Expert Insights On Offloading Lower Extremity Wounds

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Author(s): 
Clinical Editor: Kazu Suzuki, DPM, CWS

   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).

   Dr. Suzuki cites evidence that the more robust offloading methods provide the better healing rate: 90 percent for total contact casts, 65 percent for removable cast walkers and 58 percent for half shoes (surgical sandals).2

   Dr. Bell praises the total contact cast, saying it works “better than anything I have used for ulcers on the plantar aspect of the neuropathic diabetic foot.” However, he cautions that not everyone is a candidate for TCCs. Knowing when the TCC is appropriate should be based on considerations such as stability of the patient when ambulating; presence of infection; ischemia; and location of the ulcer, says Dr. Bell. For example, he says it would not make good sense to apply a TCC to the right foot of a patient who lives independently and must drive to appointments or work.

   Dr. Bell developed a “soft total contact cast,” which he has used for years on countless numbers of patients. Borrowing this from some aspects of the traditional TCC, he created a method of offloading that utilizes soft materials such as cast padding and a few others. His patients tolerate the soft total contact cast well and most importantly, they cannot remove the cast.

   Although Dr. Giovinco understands how the cast can be an inconvenience for both the patient and the care facility, he starts by offering the total contact cast as the most effective solution when speaking with patients.

   Dr. Giovinco will prescribe a TCC if the patient has a non-infected wound with mild to moderate drainage and can tolerate a cast. Some patients who are unstable in ambulation may not be good candidates for a TCC due to a risk of falling, he notes.

   The drawback of TCCs is they are much heavier than a post-op shoe and one may hear more complaints from patients about it, cautions Dr. Suzuki.

   “Some clinicians, including myself, believe that the cumbersome weight of the device actually enforces the offloading by discouraging the patient from walking too much,” notes Dr. Suzuki.

   “I have said this many times over the years that we wouldn’t send our patients home with a scalpel blade and ask them to perform their own debridement at home so why would we trust or expect them to manage the offloading of their DFU? We are the experts and must manage offloading accordingly and appropriately,” says Dr. Bell.

   Dr. Bell is a board-certified wound specialist of the American Academy of Wound Management and a Fellow of the American College of Certified Wound Specialists. He is the founder of the “Save a Leg, Save a Life” Foundation, a multidisciplinary, non-profit organization dedicated to the reduction of lower extremity amputations and improving wound healing outcomes through evidence-based methodology and community outreach.

   Dr. Giovinco is an Assistant Professor in the Department of Surgery at the University of Arizona. He is the Director of Education with the Southern Arizona Limb Salvage Alliance.

   Dr. Suzuki is the Medical Director of the Tower Wound Care Center at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. He can be reached via e-mail at Kazu.Suzuki@CSHS.org .

References

1. Available at http://www.npuap.org/ .
2. Armstrong DG, Nguyen HC, Lavery LA, et al. Offloading the diabetic foot wound: a randomized clinical trial. Diabetes Care. 2001; 24(6):1019–22.

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