Pertinent Insights On Offloading For Ulcerations
The location of an ulcer can make prevention and management particularly challenging. Accordingly, these expert panelists discuss surgery for plantar diabetic foot ulcers, dressings and emerging treatments for pressure ulcers, and key offloading principles.
What kind of surgical procedures do you perform for diabetic ulcers on the plantar foot?
Nicholas Giovinco, DPM, performs a variety of procedures on the plantar foot, his favorite being either a primary closure or a split thickness skin graft. His skin grafting technique involves a negative pressure wound therapy (NPWT) treatment for several days after the procedure to improve the adherence of the graft. He cites a recent study showing the plantar surface to be a consistently viable region of the foot to receive a skin graft.1
For Kazu Suzuki, DPM, CWS, this is a case-by-case decision. He has performed numerous flexor tenotomies for the correction of flexible hammertoes, calling the procedure one of the simple and highly effective procedures for reducing the retrograde pressure on the metatarsal head. For more persistent foot ulcers under the metatarsal heads, Dr. Suzuki may prefer metatarsal head resections or panmetatarsal head resections to shorten the foot leverage and remove the pressure points at the same time.
Although some have advocated tendo-Achilles lengthening (TAL) for recalcitrant forefoot wounds, Dr. Suzuki says that would be his last resort for forefoot ulcers as it may take longer time for recovery than the other procedures mentioned. He has also seen a few cases of TAL overcorrection, which results in recalcitrant heel ulcers. Dr. Suzuki notes these are “extremely tough” ulcers to heal unless one surgically shortens the previously treated Achilles tendon.
Desmond Bell, DPM, CWS, notes that it is rare that surgery on his patients is elective or involves what would be considered normal anatomy as most of his cases involve the diabetic foot. The circumstances or the “hand you are dealt” will often determine the extent of the procedure, he suggests. Ideally, Dr. Bell says one should always consider the involved biomechanics but says this is often a secondary or tertiary concern for surgeons in general. Metatarsal head resections, digital and partial ray resections, and Keller procedures (in which a sub-hallux or first metatarsophalangeal ulcer are present) are all procedures he has used throughout his career.
What kind of dressings do you like for pressure ulcers?
For Dr. Bell, the answer depends on the issues beyond pressure. His key concerns when deciding on a dressing are the presence of infection, perfusion or lack thereof, patient tolerance and adherence to offloading. He has used NPWT for many pressure ulcers, regardless of the surface of the foot (including the heel). One must consider the ambulatory status of the patient and select the most appropriate way to offload, according to Dr. Bell.
“In all honesty, the dressing is the last consideration. There are many excellent dressings available. Most are useless if sound wound healing principles are not employed,” adds Dr. Bell.
Dr. Suzuki quotes a wound care motto: “It is not what you put on (meaning dressings) but it is about what you take off (meaning pressure).” He thinks any sterile non-adherent dressings would be appropriate for pressure ulcers, given that the pressure is adequately controlled and eliminated. Dr. Suzuki personally likes antimicrobial non-adherent dressings, such as Cutimed Sorbact (BSN Medical), and chooses a secondary dressing to match the drainage amount.