The Charcot Patient Conservative treatment of patients with plantar deformities secondary to Charcot neu- roarthropathy is a challenging and time-consuming process.45 The typical midfoot collapse can leave a ‘rocker bottom foot’ with a midfoot prominence that becomes the only weight-bearing surface on the plantar aspect of the foot, resulting in extremely high plantar pressures. Surgery may be required to provide a plantigrade foot that can function without ulceration.46 The defor- mity will often mandate a custom-made shoe, requiring the skills of an orthopaedic shoemaker who will make measurements and a cast of the entire foot to produce a shoe that will fit the Charcot foot. A custom-moulded interface between the foot and the shoe, including special
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346 FOOTWEAR FOR PEOPLE WITH DIABETES
load relief from plantar prominences, is often built directly into the midsole of such shoes, and a custom-made orthosis is then placed inside the shoe. Traditionally, Charcot patients have often been provided with a brace , such as a patellar-tendon-bearing brace (PTB)47 , to transfer some of the load to the leg. However, patients often dislike PTBs,47 and it is not clear that load bearing is always reduced on the braced foot.48
COMPLIANCE IN WEARING THERAPEUTIC FOOTWEAR The most advanced and well-designed prescription shoe can be effective only if it is worn by the patient on a continuing basis.
However, a number of studies have shown that consistent use of such footwear is rarely the case and that poor compliance with wearing therapeutic footwear is associated with increased risk of re-ulceration.49,50 It has been suggested that to be effective, shoes must be worn for at least 60% of the time,51 but this number would seem to be low.
One study reported that only 22% of the sample ‘regularly wore’ prescribed footwear, and only 38% of the subjects wore slippers indoors.52 Another study found that only 12% of patients wore their shoes at home more than 80% of the time.
Patients can often be compliant for the majority of the time, only to fail, and ulcerate, after a holiday or special event such as a wedding at which they felt the need to wear attractive (but unsafe) footwear.53 No research has yet established the optimal approach to maximize patient compliance with footwear.
Many authorities feel strongly that when patients are given shoes that they perceive to be ‘ugly’, compliance will be poor.54 However, others believe that the key is in the patient’s perceived value of the shoe, and not in a previous history of foot complications or the aesthetics of footwear.
The role of education in compliance with footwear is not yet known.
In the absence of better evidence, it seems reasonable to attempt (1) to produce attractive therapeutic shoes; (2) to make sure that the patients know the cost of their shoes; (3) to carefully explain the reason for the shoes and the role that footwear can play in ulcer and amputation prevention; and (4) to remind the patients and their family members as frequently as possible about the need to wear the shoes at all times.
FUTURE TRENDS
The design of therapeutic footwear remains an art that is only just beginning to be influenced by science.
The early progress that Dr Brand and his colleagues made1,2 did not herald the revolutionary change that they hoped for.
Yet, the digital world is knocking at the door, and an array of tools such as contact foot digitisers, in-shoe pressure mapping, finite element method simulations and CAD-CAM55 are beginning to make contributions that will eventually change the face of footwear design and prescription.
These developments will not filter through to practice until the value of therapeutic footwear in reducing morbidity can be demonstrated and shown to be cost-effective.
NOTE The authors own stock in DIApedia LLC.