Happy 4^th of July to all of our PRESENT e-Learning Systems readers! I hope your Independence Day is full of fun and relaxation.

This year’s holiday has me thinking about my patients’ independence. Working in Pomona, California exposes me to a lot of diabetic patients, so obviously I’m going to be treating a lot of wounds, infections, and amputations. These patients often go through some very difficult life decisions, and these situations have a significant impact on their quality of life.

Take for example a recent diabetic patient of mine who in the past underwent several toe amputations on one foot. As a result of the biomechanical imbalances, she had clawtoe deformities of the remaining 2^nd and 3^rd toes (she had half of her great toe). Her 3^rd toe now has a bone infection and will require surgery soon.

Apparently I am a much more aggressive surgeon than the prior doctors who whittled away at her toes, since I recommended a transmetatarsal amputation and Achilles tendon lengthening. We had a serious conversation about her options, and we decided together to go down this route.

The rub of this situation is that the affected side is the right foot. What does this bring to mind? You got it: driving. For several weeks after the surgery, she will not be able to drive, which as she told me, is a significant challenge. She takes care of her brother and works a full time job. Here we are talking about limiting her mobility in addition to removing the remaining part of her forefoot. Her independence will be sorely reduced, at least for the initial recovery, before she returns to prescription shoes.

This is an unfortunately too common occurrence, especially for those of us treating patients with lower extremity issues. One of podiatric medicine and surgery’s biggest challenges is the fact that the feet are so necessary for simple mobility. Undergoing shoulder surgery, for example, might limit the use of an arm, but it doesn’t stop one from walking. Try maintaining your independence when you have one good foot and have to use crutches or a walker to ambulate. There go the hands too! Couple this with the fact that the foot often takes longer to heal than the rest of the body, and we have a recipe for complete loss of autonomy.

Want to make it even more challenging? I commonly offweight diabetic foot ulcerations with instant total contact casts (iTCC). For those of you not familiar with this, you put your patient in a walking boot and then prevent the patient from removing it by wrapping fiberglass cast tape around the boot. If you don’t use this method, I highly recommend it. Without getting into a whole conversation, I’ll tell you that Armstrong has shown this method is as effective in treating diabetic neuropathic forefoot ulcers as the classic total contact cast.^1,2 It’s also much faster to apply and easier for the patient to walk. I’ve written about this method in the past, so feel free to peruse the PRESENT Podiatry archives for more information.

Offweighting: What Does The Evidence Show? Part 1: The Options

Offweighting: What Does The Evidence Show? Part 2: The Consensus

Anyway, after applying the iTCC, patients have a harder time ambulating and if on the right extremity, cannot drive. Their balance (poor to begin with due to neuropathy) puts them at increased risk for falls and may require a cane. Autonomy down the drain!

It is incumbent upon all of us taking care of patients to remain cognizant of the challenges involved. We need to be more creative in creating avenues to help our patients increase their independence.

One way to do this is to increase their autonomy in the decision-making process.³ I have found that providing patients with reasonable choices and fully discussing the issues surrounding those choices empowers patients to be part of the decision, which provides a sense of control and emotional autonomy.

Some interesting new work with lower extremity amputee veterans undergoing rehabilitation is applicable to our non-veteran patients in similar situations.

Conclusions from this work are:⁴

Ideas to improve autonomy:

It’s often difficult for those of us not dealing with these limitations to lose sight of how significant the lack of autonomy can be. Consider applying some of these ideas to your patients, and maybe you will be responsible for making their July 4^th holiday a true independence day.