This case series details 3 patients with a history of DFUs, elevated hemoglobin (HbA1c), and peripheral neuropathy.
Case 1
The first case is of a 67-year-old man with type 2 diabetes mellitus (DM; HbA1c, 8.5%), neuropathy, and gout. The patient has extensive DFU history, including several recurrent wounds. The left distal third digit most recently healed 2 years prior to receiving the mat, and the right distal second digit healed 1 year prior to receiving the mat.
Fourteen weeks after receiving the mat, the patient entered an episode with temperature asymmetry of 2.1˚C at the right hallux (Figure 2A). During a call prompted by the notification, the patient inspected his feet and denied any plantar lesions. Upon clinical exam 1 week later, no wounds were found. Accommodative insoles were dispensed. A second phone call was made during week 16 for continued elevated asymmetry of 1.8˚C at the right hallux (Figure 2B). The patient was seen in the clinic 5 days later without a DFU (Figure 2C). A callus to the distal left third digit was pared without incident. The patient’s asymmetry episode resolved during week 20 (Figure 2D).
Case 2
Case 2 is of an 80-year-old man with type 2 DM (HbA1c, 7.7%), neuropathy, and a history of a right plantar hallux wound that healed 9 months prior to receiving the mat (Figure 3A). Three weeks later, he entered an episode with temperature asymmetry of 6.0˚C and 8.2˚C on 2 consecutive days throughout the left forefoot (Figure 3B). During a call prompted by the asymmetry, the patient was instructed to decrease walking and use appropriate footwear. One week later, the patient remained in episode with asymmetry of nearly 4.7˚C, now over the right foot. The patient presented to the clinic 3 days later with a pinpoint DFU to the plantar and medial aspect of the right hallux interphalangeal joint (IPJ) postdebridement. A custom offloading orthotic was prescribed to fit his diabetic shoes.
Between weeks 6 and 7, the patient was again found to have temperature asymmetry at the right forefoot, this time exceeding 3˚C. Upon exam during a clinic visit at the end of week 7, the patient’s right IPJ wound was healed.
Despite this, the patient remained in episode through week 11, with temperature asymmetry exceeding 6.0˚C to the right forefoot and hallux (Figure 3C). The patient presented to the clinic at the end of week 11 wearing sandals without appropriate offloading. A pre-ulcerative callus to the area of concern was noted. Upon debridement, the plantarmedial area of the right hallux IPJ showed a deep tissue injury. The patient was reminded of the importance of offloading, and metatarsal bars were added to the patient’s sandals. The patient was casted for custom orthotics with an offloading accommodation at the hallux IPJ. The patient’s asymmetry episode resolved shortly thereafter, and he has remained out of asymmetry episode and free from DFUs over the following 22 weeks (Figure 3D).
Case 3
The third case is of a 69-year-old man with type 2 DM (HbA1c, 12.3%), neuropathy, and peripheral arterial disease. The patient had a history of a DFU at the right plantar transmetatarsal amputation stump, most recently healed 3 weeks prior to receipt of the mat.
The patient entered asymmetry episode on day 1 and remained in episode for the following 2 weeks (Figure 4A). He presented to the clinic on day 14 with a DFU measuring 1.2 cm x 0.8 cm x 0.2 cm upon debridement (Figure 4B). Patient denied prior knowledge of wound or lesion. Continued offloading and wound care resulted in closure about 9 months after receiving the mat.