Offloading diabetic neuropathic ulcers comes with a unique set of treatment challenges. Some consider total contact casting the gold standard but whether it’s practical in a busy practice is highly debatable. Still, how can one arrive at a solution that will enhance patient compliance? With these issues in mind, our expert panelists share their thoughts and experiences with this topic. Q: How do you initially offload the plantar diabetic neuropathic ulcer? A: Lawrence G. Karlock, DPM, says he is initially aggressive when it comes to offloading the plantar neuropathic ulceration. Noting that he is “rather stern” with patients on this subject, he gives them three offloading options: crutches, a walker or a wheelchair. Unfortunately, he says the majority of these patients ignore his advice about offloading. If necessary, Dr. Karlock says he will also employ an Ipos shoe for a plantar metatarsal head ulcerations. When dealing with a severe Charcot foot with midfoot breakdown and midfoot prominence, Dr. Karlock will use a Crow Walker. When treating plantar diabetic neuropathic ulcers, Steven R. Kravitz, DPM, will often emphasize a removable walking cast with a removable plug system in the insole of the device. He says using the Active Offloading Walker (Royce Medical) is beneficial because it prevents ankle plantarflexion and heel lift, which “significantly offloads the forefoot.” When using this device (formerly known as the DH Walker), Dr. Kravitz recommends monitoring of these patients as he cautions that the plugs around the aperture, which is designed to offload the ulcer, can shift with ambulation over a period of time. Placing moleskin over the remaining plugs around the aperture can sometimes be helpful in stabilizing this situation, according to Dr. Kravitz. David G. Armstrong, DPM, uses either the total contact cast (TCC) or an instant total contact cast (iTCC), which is the Active Offloading Walker wrapped with cohesive bandage or a single layer of plaster.1 He says converting the removable cast walker into a device that is not as easy to remove helps ensure compliance to the offloading regimen. “If we understand that certain removable cast walkers can offload the foot as well as a TCC but certain people don’t wear their removable cast walkers as much as they should, we can conclude that the key is to make the removable cast walker less easily removable,” emphasizes Dr. Armstrong.2 He adds that he recently co-authored two randomized clinical trials that reaffirm this approach. As the ulcers become more stabilized, Dr. Kravitz notes that using a surgical shoe with plastizote liners or a DH Shoe (Royce Medical) can have “significant benefit.” On the other hand, Dr. Karlock says he doesn’t offer surgical shoes with felt cutouts because he feels they just give patients “more opportunity to be noncompliant.” Q: When, if ever, do you employ TCC? A: “There is rather conclusive evidence that TCC is probably the best way to offload and heal any plantar neuropathic ulceration,” says Dr. Karlock. He points out that most of the literature says 80 percent or more of neuropathic ulcers can be healed within a short period of time with TCC. “This is a far superior success rate than any bioengineered skin substitute or topical growth factors,” emphasizes Dr. Karlock. However, all of the panelists agree that the time-consuming nature of applying a TCC often makes it difficult to use in the private practice setting. Dr. Kravitz says he does not regularly use TCC as he prefers to examine the wound and change the dressing regularly “without having to go through the removal and reapplication of the TCC.” However, Dr. Kravitz adds that the TCC is a good alternative in cases in which the removable cast walker isn’t effective. The aforementioned iTCC can be useful for the many centers and clinics that don’t have the resources to use TCCs, according to Dr. Armstrong. He also notes that some companies like MedEfficiency have put all the TCC supplies in one package (MedE-Kast). This greatly simplifies procurement and use of the TCC, notes Dr. Armstrong. Sometimes, Dr. Karlock says he’ll use a modified TCC. However, he also cautions that there are “high risks” associated with casting a neuropathic foot, especially if it is not monitored closely. Q: How do you deal with the noncompliant patient? A: Dr. Kravitz says noncompliance is problematic not only due to the lack of consistent use of a removable cast walker, but is the “leading cause” of non-healing ulcers, according to much of the literature on the subject. “Very few patients will adhere to an offloading regime if the offloading device is removable,” reemphasizes Dr. Armstrong. Citing a recent study involving sophisticated activity monitors that he co-authored in 2003, Dr. Armstrong notes that people with open plantar wounds only wore their removable cast walkers for 28 percent of the total activity they engaged in per day.3 However, he says this is not necessarily the fault of the patients but is more due to the fact that they don’t have the “gift of pain.” Whether you are stern or take a more compassionate approach with noncompliant patients, it unfortunately doesn’t make much difference either way, according to Dr. Karlock. Dr. Kravitz says it’s important to get a patient’s family members or his or her caregiver involved. “I explain to them the urgency of compliance and the need to follow instructions,” notes Dr. Kravitz. “I emphasize to the family members the possibility, if not probability, of total loss of the patient’s limb if he or she doesn’t comply (with the offloading regimen). I have found this to be the most effective way, by far, to deal with noncompliance.” In his experience, Dr. Kravitz says if a family member or caregiver is not available, noncompliance will often continue to be a problem that compromises the patient’s long-term prognosis. Dr. Karlock encourages thorough documentation of patient noncompliance. Q: What “surgical offloading” procedures (i.e. osteotomies, etc.) do you employ? A: While there are a variety of approaches, Dr. Kravitz emphasizes that surgical offloading is very dependent on ulcer location and the structure of the foot. He adds that the patient’s long-term prognosis “is always improved when the surgeon has a thorough understanding of the biomechanics and the transfer of weightbearing forces that occur with any partial foot resection.” Dr. Armstrong says he employs a number of prophylactic and curative procedures for this patient population. The most common “bread and butter” procedures include first MTPJ arthroplasties, panmetatarsal head resections, first metatarsal osteotomies and Achilles tendon lengthenings. Dr. Kravitz says one should consider tendo-Achilles lengthening for recurrent forefoot ulcers or mid-foot Charcot, and in conjunction with transmetatarsal amputation and similar procedures. “Reactive equinus is common among a significant number of these patients,” maintains Dr. Kravitz. “When this not addressed, it often leads to exacerbation of a Charcot problem and/or recurrent forefoot ulceration.” Dr. Karlock commonly performs metatarsal basilar osteotomies for the plantar forefoot ulceration. He also emphasizes that he is a “big proponent” of midfoot exostectomies on the medial or lateral side in combination with a posterior Achilles/gastroc release for the broken down Charcot foot. “I find that the success rate in curing these severe Charcot feet with midfoot exostectomies and appropriate custom-molded shoes and/or shoes attached to an ankle-foot orthosis (AFO) is highly rewarding,” claims Dr. Karlock. He adds that this approach also doesn’t have the risk of major midfoot and rearfoot reconstruction. Dr. Karlock says the only justification for reconstruction would be the “truly unbraceable foot” that is highly unstable with recurrent breakdown and ulceration. In the realm of diabetic foot surgery, Dr. Armstrong adds that the emerging availability of a variety of traditional and hybrid external fixation devices in recent years has also helped in “temporarily or permanently holding positional correction.” Dr. Armstrong is a Professor of Surgery, Chair of Research and Assistant Dean at the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine in Chicago. He is a member of the National Board of Directors of the American Diabetes Association. Dr. Kravitz is a Fellow of the American College of Foot and Ankle Surgeons, and the American Professional Wound Care Association. He is an Assistant Professor in the Department of Orthopedics and is on the clinical faculty for the Advanced Wound Healing Center at the Temple University School of Podiatric Medicine. Dr. Karlock (pictured) is a Fellow of the American College of Foot and Ankle Surgeons and practices in Austintown, Ohio. He is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.
References 1. Armstrong DG, Short B, Nixon BP, Boulton AJM: Technique for fabrication of an “instant” total contact cast for treatment of neuropathic diabetic foot ulcers. JAPMA 2002; 92:405-408. 2. Lavery LA, Vela SA, Lavery DC, Quebedeaux TL: Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations. A comparison of treatments. Diabetes Care 1996; 19(8):818-21. 3. Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJM: Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure offloading regimen. Diabetes Care 2003; 26(9):2595-2597