Given that offloading is critical to healing wounds in the lower extremity, these panelists discuss assessment techniques for wounds, favored modalities for offloading diabetic neuropathic ulcers and how to document pressure wounds.
Kazu Suzuki, DPM, CWS, suggests putting on “an investigator hat” and figuring out exactly when and how the ulcer developed from the pressure. As he notes, the answer may be simple. For example, Dr. Suzuki cites a textbook case of a diabetic pressure ulcer under the metatarsal head along with a periwound callus. He says these are very easy to identify.
For Nicholas Giovinco, DPM, the initial assessment of a wound for offloading starts with palpating the local anatomy. He looks for bony prominence areas in which mobility is limited and shear stresses are not well accommodated. If this area is supple, Dr. Giovinco would suspect shoe wear as the cause of the ulcer.
When looking inside of the shoe or boot, Dr. Giovinco looks for edges or areas where excessive wear may be taking place. Many times, this is not obvious but he says it only becomes clear when looking at how the patient walks within the shoe gear. Dr. Giovinco adds that dressings and the gait pattern will have an effect on the shoe’s wear pattern.
Dr. Giovinco also notes that the shoes patients wear to the office are sometimes not the ones they wear the other six days of the week. If one is dealing with an actual pressure ulcer, he says shoes are frequently not the culprit. More commonly, he notes the wound is secondary to low pressure (i.e. from a bed, a wheelchair or an appliance of some kind) over a prolonged period of time, such as after a more proximal procedure or if the patient is otherwise systemically unwell.
Similarly, Dr. Suzuki notes lower extremity pressure ulcers in a patient with a spinal cord injury may be difficult to figure out as the patients are often completely insensate and cannot indicate how they injured themselves. He recalls seeing foot ulcers that came from the wheelchair foot plate as well as from the side frames and various hardware attached to the chairs.
For neuropathic diabetic foot ulcers, Desmond Bell, DPM, CWS, will first assess the patient’s structural deformities and then analyze his or her gait. He notes one must determine if the structural deformity of the foot is causing the issues with gait that have led to ulceration, or if there are issues with gait that have manifested with the formation of the ulcer. As Dr. Bell advises, gait and location of the ulcer are “critical” in determining what type of offloading one can utilize.
In addition, Dr. Bell says one should consider whether a structural deformity is the major factor in the ulcer formation. Will its presence result in re-ulceration of the foot at a later date, assuming that the ulcer can heal in the first place? He stresses that appropriate surgical intervention may be the best offloading method to implement when recurrence is a strong concern.
Drs. Bell and Suzuki suggest a starting point of utilizing the classification of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Bell notes that the NPUAP says pressure ulcer documentation should be “complete, accurate and legally defensible.”1 After determining that an ulcer is a result of pressure, he says one should utilize the NPUAP staging system based on the extent of tissue damage or loss (Stage I-IV).
However, Dr. Bell says the NPUAP system can become confusing when one uses it for patients with diabetes. Would it be appropriate to document a heel ulcer in a patient with diabetes using the Wagner classification, the University of Texas San Antonio system or the pressure ulcer system? Dr. Bell says it depends upon who may be doing the assessment, the mobility of the patient and the ensuing treatment plan. He also says one should consider that Stage III, IV and “unstageable” ulcers are “never events,” meaning they should never happen.
As Dr. Suzuki mentions, clear staging is sometimes difficult as the pressure ulcer may evolve and worsen over time after the initial damage occurs from the pressure. He notes early stage skin erythema is hard to identify in darker skinned patients while deep tissue injury is a particularly hard diagnosis to make.
Dr. Giovinco emphasizes that the wound itself is in fact the result of pressure. Many times, he says physician notes do not state that physicians are treating a “pressure ulcer.” At the Southern Arizona Limb Salvage Alliance (SALSA), he and his colleagues use digital photographs of wounds as well as indocyanine green angiography (SPY imaging technology, Novadaq).
As far as photos go, Dr. Giovinco emphasizes the importance of being as consistent as possible in lighting and color balance to make an accurate comparison of these images in a series. He notes that many of the classic wound descriptions, such as the dimensions, wound base composition, drainage, odor and surrounding coloration, hold true. Dr. Giovinco also suggests stating whether there is reason to suspect infection as commonly, patient notes do not explain the reason not to prescribe antibiotics for an open wound.
Dr. Suzuki notes heel ulcers are always hard to photograph because it is very awkward to take a photograph, especially if the patient is too weak to transfer to a treatment chair. If the patient is in a wheelchair, he often uses his iPhone’s “face-up camera” by sneaking the camera right behind the heel, which ensures that he takes a picture with good focus and exposure. When it comes to uploading the photos for electronic medical records, Dr. Suzuki recommends using Apple’s “photo stream” service, which pushes the photos to a computer via the cloud, or using a camera or memory card with a “wifi” function that can send the pictures to the computer wirelessly.
Calling the documentation of pressure ulcers a “touchy subject” in a hospital setting, Dr. Suzuki says his institution’s policy is to photograph and document any pressure ulcers during the admission process.
“Obviously, we want to avoid any ‘hospital-acquired’ pressure ulcers, which would be a medicolegal nightmare for the institution,” says Dr. Suzuki. “I do try my best to document the wound as accurately as possible while not being too quick to assign the blame, although the patient and the family may have someone in their mind to blame where the patient developed the ulcer.”
Finally, Dr. Suzuki emphasizes that “decubitus ulcer” is an old and incorrect terminology for pressure ulcers.
Getting patients out of their favorite shoes (which are often flimsy or otherwise inappropriate) and fitting them with post-op surgical sandals, such as Med-Surg shoes (Darco International), is a good start, according to Dr. Suzuki. He may modify patients’ post-op shoes with customized insoles or a ¼-inch thick felt pad applied either to the shoe or directly to the foot. Dr. Suzuki believes one can apply walking boots like the Body Armor Walker (Darco) when desiring better offloading capability.
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  .
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.