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.