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.
For a minor pressure ulcer of stage 1 or 2, Dr. Suzuki will use Calmoseptine ointment (Calmoseptine, Inc.), a 20% zinc oxide ointment with a small amount of menthol as an anti-itch ingredient. It is an over-the-counter formulation available in most pharmacies and he frequently gives patients the manufacturer’s sample packets. Dr. Suzuki will apply a liberal amount over the wound and cover it with a gauze dressing to keep it from smearing.
Dr. Giovinco uses padding protection for pressure wounds, saying wounds will continue to worsen with sustained pressure. He notes this protection is likely to include foam or cotton cast padding.
Are there any new studies or emerging modalities in the treatment of pressure ulcers?
Dr. Suzuki’s institution uses Mepilex (Molnlycke Health Care), a bordered foam dressing with a silicone adhesive, on the buttocks of the intensive care patients — even before the pressure ulcer arises — and replaces the dressing once a week. He cites a study to back up this practice to prevent pressure ulcers.2 In a similar fashion, for elderly and frail patients with a history of pressure ulcers, Dr. Suzuki may recommend that they apply soft foam dressings over the “pressure points,” such as the posterior heel or lateral and medial malleolus, as a proactive preventive measure for pressure ulcers. He notes patients can purchase most wound dressings from Web sites like Amazon.com.
Dr. Giovinco notes some intriguing research for offloading modalities, such as exoskeletons and wearable offloading braces. He says there is a “huge influx of interest” and financial investment in wearable offloading braces as the technology can allow management of wounds and ulcers while keeping the patient in motion.
“Overall, there is still very little substitute for a total contact cast,” notes Dr. Giovinco.
When it comes to pressure ulcers for immobile or bedbound patients, Dr. Bell emphasizes that prevention is still the key. He cites new pressure sensing technologies such as the Mattress Sensing MAP System (Wellsense), which can determine focal pressure areas for bedridden patients. Dr. Bell also cites PressureStat and TempStat (Visual Footcare Technologies), which allow patients and physicians to monitor foot pressure in a proactive manner.
“Undeniably, we need more research into the daily practice of pressure ulcer care,” asserts Dr. Suzuki. “When I see patients who come from skilled nursing facilities, I often see the patients treated with flimsy heel cups and trypsin spray, which have no clinical evidence to justify their use.”
Do you have any other pearls regarding offloading methods?
While in training, Dr. Suzuki learned that in the 1970s, DPMs used to admit diabetic foot ulcer patients and keep them in the hospital bed until the wound healed completely as a way of forced adherence to non-weightbearing, which was effective. He shares that story all the time with patients, explaining why he needs their awareness and adherence to heal the wound as part of a “team effort.”
“I strongly believe that patient education is the most important factor in effective offloading and, consequently, effective wound healing of pressure ulcers,” asserts Dr. Suzuki.
Dr. Bell notes that for any kind of offloading to be effective, whether it is total contact casting, a specialized bed or a device that offers mobility with wheels (Roll-a-Bout or a wheelchair, for instance), one must consider the patient’s overall status. As offloading is not “one size fits all,” he says the patient should not dictate to the physician what is the best option.
“Don’t rely on patients to do their own offloading at home,” says Dr. Bell. “You wouldn’t send your patients home with a scalpel and instruct them to do their own debridement so why would you expect them to be proficient (or adherent) when offloading is left up to them? Be the expert and be consistent when it comes to offloading wounds.”
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. Bell practices at the First Coast Cardiovascular Institute in Jacksonville, Fla.
Dr. Giovinco is an Assistant Professor in the Department of Surgery at the University of Arizona. He is the Director of Education of the Southern Arizona Limb Salvage Alliance (SALSA).
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. Dr. Suzuki can be reached via e-mail at Kazu.Suzuki@CSHS.org .
1. Rose JF, Giovinco N, Mills JL, et al. Split-thickness skin grafting the high-risk diabetic foot. J Vasc Surg. 2014 Feb 8 (epub ahead of print).
2. Black J, Clark M, Dealey C, et al. Dressings as an adjunct to pressure ulcer prevention: consensus panel recommendations. Int Wound J. 2014 Mar 3 (epub ahead of print).