Expert Insights On Offloading Lower Extremity Wounds

Clinical Editor: Kazu Suzuki, DPM, CWS

   However, Dr. Bell says the NPUAP system can become confusing when one uses it for patients with diabetes. Would it be appropriate to document a heel ulcer in a patient with diabetes using the Wagner classification, the University of Texas San Antonio system or the pressure ulcer system? Dr. Bell says it depends upon who may be doing the assessment, the mobility of the patient and the ensuing treatment plan. He also says one should consider that Stage III, IV and “unstageable” ulcers are “never events,” meaning they should never happen.

   As Dr. Suzuki mentions, clear staging is sometimes difficult as the pressure ulcer may evolve and worsen over time after the initial damage occurs from the pressure. He notes early stage skin erythema is hard to identify in darker skinned patients while deep tissue injury is a particularly hard diagnosis to make.

   Dr. Giovinco emphasizes that the wound itself is in fact the result of pressure. Many times, he says physician notes do not state that physicians are treating a “pressure ulcer.” At the Southern Arizona Limb Salvage Alliance (SALSA), he and his colleagues use digital photographs of wounds as well as indocyanine green angiography (SPY imaging technology, Novadaq).

   As far as photos go, Dr. Giovinco emphasizes the importance of being as consistent as possible in lighting and color balance to make an accurate comparison of these images in a series. He notes that many of the classic wound descriptions, such as the dimensions, wound base composition, drainage, odor and surrounding coloration, hold true. Dr. Giovinco also suggests stating whether there is reason to suspect infection as commonly, patient notes do not explain the reason not to prescribe antibiotics for an open wound.

   Dr. Suzuki notes heel ulcers are always hard to photograph because it is very awkward to take a photograph, especially if the patient is too weak to transfer to a treatment chair. If the patient is in a wheelchair, he often uses his iPhone’s “face-up camera” by sneaking the camera right behind the heel, which ensures that he takes a picture with good focus and exposure. When it comes to uploading the photos for electronic medical records, Dr. Suzuki recommends using Apple’s “photo stream” service, which pushes the photos to a computer via the cloud, or using a camera or memory card with a “wifi” function that can send the pictures to the computer wirelessly.

   Calling the documentation of pressure ulcers a “touchy subject” in a hospital setting, Dr. Suzuki says his institution’s policy is to photograph and document any pressure ulcers during the admission process.

   “Obviously, we want to avoid any ‘hospital-acquired’ pressure ulcers, which would be a medicolegal nightmare for the institution,” says Dr. Suzuki. “I do try my best to document the wound as accurately as possible while not being too quick to assign the blame, although the patient and the family may have someone in their mind to blame where the patient developed the ulcer.”

   Finally, Dr. Suzuki emphasizes that “decubitus ulcer” is an old and incorrect terminology for pressure ulcers.


What is your offloading device of choice for diabetic neuropathic foot ulcers?


Getting patients out of their favorite shoes (which are often flimsy or otherwise inappropriate) and fitting them with post-op surgical sandals, such as Med-Surg shoes (Darco International), is a good start, according to Dr. Suzuki. He may modify patients’ post-op shoes with customized insoles or a ¼-inch thick felt pad applied either to the shoe or directly to the foot. Dr. Suzuki believes one can apply walking boots like the Body Armor Walker (Darco) when desiring better offloading capability.

   All the panelists note the efficacy of the “gold standard” total contact cast (TCC). Dr. Suzuki notes there is a small learning curve to TCC applications as ill-fitting casts can easily create additional skin tears and open wounds. He notes there are several pre-made kits, including the Cutimed Off-Loader (BSN Medical) and TCC-EZ (Derma Sciences), which he says make the application easier. He notes there is a specific CPT code (CPT 29445) that pays for the applications (approximately $106 to $140 from Medicare) as well as for the supply cost (Q4037 or Q4038 codes).

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