ArcaMax

DEAR DR. ROACH: I have a diabetic nonhealing ulcer on my right heel. I was told that the blood circulation in my foot is not very good, which is why the ulcer is not healing.

Five years ago, I had a nonhealing ulcer in my left heel. It got infected, and the infection went into my heel bone. After several months, I agreed to an amputation. But this time, I was prescribed antibiotics with bandage changes that happen every two or three days. The ulcer has not healed now for over a month. Is it still possible that healing could take place? -- L.H.

ANSWER: I hope so. Most diabetic ulcers can be healed if they are treated the right way early enough. We really want to avoid amputations as they are bad for your function and cause worse outcomes later on.

One major issue is the poor blood flow to the area. People with diabetes may develop poor blood flow due to large arteries being blocked or when the small vessels are not working well. If there are blockages in large vessels, such as the femoral artery or one of its branches, then a vascular surgeon may be able to bypass the blockage. Newer techniques of angioplasty and stents may also be used and are less invasive and risky. But an angiogram is usually necessary to determine whether this approach would be useful.

If the poor blood flow is due to the small vessels, then surgical approaches are not as important as medication treatment and proper wound care. Diabetes needs to be meticulously managed, with blood sugar levels kept in the normal range as much as possible; a continuous glucose monitor can help determine if your regimen is adequate.

I cannot recommend highly enough an experienced wound care nurse, who is the expert in managing nonsurgical wounds (and postsurgical wounds, too). The pressure must come off the heel.

Nonhealing diabetic foot ulcers are one of the clearest indications for hyperbaric oxygen therapy. Not everyone has this therapy available, but it can be very useful in addition to standard therapy. Finally, antibiotics are guided by the results of wound cultures. These cultures need to be done by an expert to get the correct results.

DEAR DR. ROACH: I'm a 78-year-old white male who is a nonsmoker; I am 5 feet, 6 inches tall, weigh 135 pounds, and consider myself to be in excellent health. A diagnosis from a recent bone density scan showed that my FRAX 10-year probability of a major osteoporotic fracture was 11.6%, and my probability of a hip fracture was 7.3%. I exercise seven days a week and believe that my diet is excellent. My standard blood panel results are always normal in all categories. Would it be advisable for me to take Fosamax at a 70-mg dosage? -- C.Y.

ANSWER: The FRAX score is the easiest way of understanding the results of a bone density scan. Even though the odds are that in 10 years, you will not have had a fracture, your risk of a hip fracture is high enough that most experts would recommend treatment to lower your risk.

Generally speaking, treatment is recommended with a FRAX score above 20% for any major osteoporotic fracture or a score that is more than 3% for a hip fracture. Your risk for a hip fracture is significantly above the recommended threshold, even though your overall risk is not, which leads me to suspect that your hips are preferentially affected by osteoporosis.

If medication is recommended, a bisphosphonate such as alendronate (Fosamax) would normally be the first-line treatment for men, and 70 mg weekly is a common dosage.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.

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