Key Insights On Offloading Diabetic Neuropathic Ulcers
Offloading a wound is a critical component of facilitating optimal outcomes with healing. Accordingly, these expert panelists discuss the use of total contact casting (TCC) to offload diabetic neuropathic wounds as well as the impact of instant total contact casting (iTCC) and other offloading methods.
Q: As far as offloading devices go for diabetic/neuropathic foot ulcers, do you use total contact casting?
A: Barry Rosenblum, DPM, feels offloading is “extremely important” in treating diabetic neuropathic ulcers. Similarly, Richard Brietstein, DPM, CWS, says offloading is a “hallmark” in treating the condition and notes that TCC and Cam Walkers are options.
Dr. Rosenblum paraphrases Lawrence Harkless, DPM, who said, “It’s not what you put on a wound, it’s what you take off.” In regard to offloading, Dr. Rosenblum says pressure is what one removes from the wound.
“Any of the new (or old) topical therapies for wound care are bound to fail in the absence of sound offloading,” says Dr. Rosenblum. He uses TCCs “on a small subset of patients.”
The TCC is the gold standard for offloading neuropathic plantar foot ulcers, according to Kazu Suzuki, DPM, CWS. He cites a “large body of literature” that shows that TCC facilitates reliable wound healing of foot ulcers. When it comes to selecting patients for TCC treatment, he warns that one should carefully select those with non-infected wounds and those with leg edema under control.
However, Dr. Suzuki concedes there are downsides with cost and the time required to apply and remove a TCC. He admits he does not use TCC as often now because he does not have a full-time cast technician available in his institution. Dr. Suzuki also warns that a poorly applied cast or poor patient selection may result in more iatrogenic blisters and wounds.
Dr. Suzuki notes that MedEfficiency is one company that sells pre-packaged TCC kits, which makes applying TCCs much easier. He adds that there are reimbursement codes for the application (CPT 29445) and for the cast material (Q4038 for the physician’s office) for TCCs.
Q: Do you use instant TCC (iTCC) or other offloading devices?
A: Dr. Suzuki recalls that with iTCC, one applies a walking boot and then wraps the boot with cohesive wrap or cast material. Doing so renders the iTCC as an irremovable device. He acknowledges some criticism that iTCC cannot truly offload the wound as well as a well crafted TCC. However, Dr. Suzuki believes both TCC and iTCC are similarly effective because the heaviness of the casts will discourage patients from being too active and ambulating too much.
The iTCC has a place in the toolbox of the foot and ankle surgeon when it comes to facilitating quick offloading, notes Dr. Rosenblum. He has found the iTCC easy to apply and efficient in terms of application time.
Dr. Brietstein does not use TCC. He prefers using offloading modalities that are more portable and easy to remove so one can examine the wound. Dr. Brietstein also notes that if the patient’s edema has resolved or is resolving, the permanency of the TCC may cause pistoning if the cast becomes too long and wide for the patient. In contrast, he says one can tighten Cam Walker devices by adjusting the straps and removing or adding hexagonal plugs.
Q: What other offloading devices do you use in your clinic for neuropathic foot ulcers?
A: Dr. Suzuki frequently uses regular surgical shoes with rigid soles such as the Med-Surg shoe (Darco), sometimes with replacement “pegged” insoles that add more cushioning and offloading. He will also use a roll of ¼-inch adhesive felt, which he cuts out in different shapes and applies either to the insoles or directly to the patient’s plantar skin. Dr. Suzuki has often discovered that this method facilitates wound healing and works well in thinner and lighter geriatric patients with shuffling gait.
For many forefoot plantar ulcerations, Dr. Rosenblum uses felted foam dressing, which he says is cost-effective without being labor intensive. When it comes to other offloading techniques, he cites the VACOped line of offloading devices, which he calls user-friendly and very effective.
In regard to the classic rocker bottom foot type, Dr. Brietstein says there are little offloading options other than TCC or Cam Walkers. He rarely uses offloading types of shoes.
Dr. Suzuki’s patients have found Roll-A-Bout devices (Roll-A-Bout) easier to use than a pair of crutches. Although the electric scooters may cost more, Dr. Suzuki says they are nice alternatives to crutches, walkers or wheelchairs for many of his geriatric or morbidly obese patients.
Q: Do you have any additional pearls on offloading neuropathic foot ulcers?
A: Dr. Brietstein suggests being judicious about cast use for a period of a week due to potential complications such as infection. He will instead use Cam Walker types of offloading devices since he finds it is much easier to examine the ulcer when patients use Cam Walkers.
Dr. Rosenblum supports approaching wounds from the vantage point that if something is not working within a fixed period of time, then one should reevaluate the strategy. With that said, he notes many of the advanced wound healing product companies would have the practitioner switch to their product as a more “aggressive” approach.
Dr. Rosenblum says one can make the same argument for a more “aggressive” approach to offloading. His approach includes a low threshold for recommending surgical offloading via osteotomy, bone resection or Achilles lengthening.
Dr. Rosenblum says his armamentarium may also include the application of external fixation in order to offload the plantar surface, especially when he is dealing with some difficult-to-treat conditions.
Dr. Suzuki advises clinicians to be patient and understanding as it can be frustrating to see patients who do not adhere to offloading regimens. It is important for clinicians to build a rapport with patients and explain why offloading is essential in wound healing “rationally, logically and in plain language,” according to Dr. Suzuki. He says it may take more than a few visits for the patient to understand the importance of offloading.
Dr. Suzuki adds that it is crucial, if not obligated from a medicolegal perspective, to inform the patient of the worst possible outcomes of foot ulceration (namely the loss of limb and the loss of life). For patients who are clearly not adhering to his offloading instructions, he will ask a family member to visit with the patient to help facilitate patient adherence.
“From my experience, I have had the worst outcome in diabetic foot ulcers (bilateral leg amputations) when a bipolar patient had a manic episode and walked for miles until his heel ulcer wore down to his calcaneus,” recalls Dr. Suzuki. “Ever since, I have raised my awareness on psychiatric illness and its possible impact on wound care.”
Dr. Brietstein is a Clinical Professor in the Department of Geriatrics at Nova Southeastern College of Osteopathic Medicine in Davie, Fla. He is the Clinical Director of the University Hospital Wound Healing Center in Tamarac, Fla. He is a member of the Editorial Advisory Boards of WOUNDS and Ostomy/Wound Management.
Dr. Rosenblum is the Director of Podiatric Residency Training at the Beth Israel Deaconess Medical Center in Boston. He is an Assistant Clinical Professor of Surgery at Harvard Medical School.
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, Japan.
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