Inside Insights For Offloading Diabetic Neuropathic Ulcers

Clinical Editor: Lawrence Karlock, DPM

Offloading diabetic neuropathic ulcers comes with a unique set of treatment challenges. Some consider total contact casting the gold standard but whether it’s practical in a busy practice is highly debatable. Still, how can one arrive at a solution that will enhance patient compliance? With these issues in mind, our expert panelists share their thoughts and experiences with this topic. Q: How do you initially offload the plantar diabetic neuropathic ulcer? A: Lawrence G. Karlock, DPM, says he is initially aggressive when it comes to offloading the plantar neuropathic ulceration. Noting that he is “rather stern” with patients on this subject, he gives them three offloading options: crutches, a walker or a wheelchair. Unfortunately, he says the majority of these patients ignore his advice about offloading. If necessary, Dr. Karlock says he will also employ an Ipos shoe for a plantar metatarsal head ulcerations. When dealing with a severe Charcot foot with midfoot breakdown and midfoot prominence, Dr. Karlock will use a Crow Walker. When treating plantar diabetic neuropathic ulcers, Steven R. Kravitz, DPM, will often emphasize a removable walking cast with a removable plug system in the insole of the device. He says using the Active Offloading Walker (Royce Medical) is beneficial because it prevents ankle plantarflexion and heel lift, which “significantly offloads the forefoot.” When using this device (formerly known as the DH Walker), Dr. Kravitz recommends monitoring of these patients as he cautions that the plugs around the aperture, which is designed to offload the ulcer, can shift with ambulation over a period of time. Placing moleskin over the remaining plugs around the aperture can sometimes be helpful in stabilizing this situation, according to Dr. Kravitz. David G. Armstrong, DPM, uses either the total contact cast (TCC) or an instant total contact cast (iTCC), which is the Active Offloading Walker wrapped with cohesive bandage or a single layer of plaster.1 He says converting the removable cast walker into a device that is not as easy to remove helps ensure compliance to the offloading regimen. “If we understand that certain removable cast walkers can offload the foot as well as a TCC but certain people don’t wear their removable cast walkers as much as they should, we can conclude that the key is to make the removable cast walker less easily removable,” emphasizes Dr. Armstrong.2 He adds that he recently co-authored two randomized clinical trials that reaffirm this approach. As the ulcers become more stabilized, Dr. Kravitz notes that using a surgical shoe with plastizote liners or a DH Shoe (Royce Medical) can have “significant benefit.” On the other hand, Dr. Karlock says he doesn’t offer surgical shoes with felt cutouts because he feels they just give patients “more opportunity to be noncompliant.” Q: When, if ever, do you employ TCC? A: “There is rather conclusive evidence that TCC is probably the best way to offload and heal any plantar neuropathic ulceration,” says Dr. Karlock. He points out that most of the literature says 80 percent or more of neuropathic ulcers can be healed within a short period of time with TCC. “This is a far superior success rate than any bioengineered skin substitute or topical growth factors,” emphasizes Dr. Karlock. However, all of the panelists agree that the time-consuming nature of applying a TCC often makes it difficult to use in the private practice setting. Dr. Kravitz says he does not regularly use TCC as he prefers to examine the wound and change the dressing regularly “without having to go through the removal and reapplication of the TCC.” However, Dr. Kravitz adds that the TCC is a good alternative in cases in which the removable cast walker isn’t effective. The aforementioned iTCC can be useful for the many centers and clinics that don’t have the resources to use TCCs, according to Dr. Armstrong. He also notes that some companies like MedEfficiency have put all the TCC supplies in one package (MedE-Kast). This greatly simplifies procurement and use of the TCC, notes Dr. Armstrong. Sometimes, Dr. Karlock says he’ll use a modified TCC. However, he also cautions that there are “high risks” associated with casting a neuropathic foot, especially if it is not monitored closely. Q: How do you deal with the noncompliant patient? A: Dr.

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