Transitioning From Open Wound To Final Footwear: Offloading The Diabetic Foot
- Volume 25 - Issue 9 - September 2012
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Are There Viable Alternatives To The Total Contact Cast?
If the clinician is not comfortable with the application of the TCC or if the patient has one or more of the established contraindications to its use, research has shown prefabricated removable cast walkers (RCWs) and non-removable cast walkers or the iTCC to be comparable to the TCC in their ability to offload the diabetic foot and close wounds in a similar timeframe.28,29 Armstrong and colleagues have been the pioneers in the use of the iTCC. Lavery, Pollo and Lawless have studied pressure redistribution in commercially produced removable walkers for patients with diabetes and found them to be comparable to the TCC and superior to other offloading devices in their ability to reduce pressure on specific areas of the foot.32-34
The key to healing with any of the offloading devices is the clinician’s ability to improve patient adherence by making it impossible to remove the devices without his or her approval. Knowles and Boulton found that when patients got specialized footwear free of charge, only 20 percent of the patients actually wore the shoes.35 Armstrong and co-workers found that when patients had the ability to remove offloading devices, they only wore RCWs 28 percent of the time during activities of daily living.36
We can make removable walkers non-removable by wrapping the devices with cast material or Coban, or by applying a simple cable tie connector to prevent patients from taking off the devices.1,2 There are also certain dressing techniques that can protect the foot with a non-removable dressing housed within the RCW, thereby allowing the patient to remove the RCW before sleeping. Researchers have demonstrated the effectiveness of felted foam and football dressings in helping to heal diabetic foot wounds.29-31,37
Non-removable devices, whether they are TCCs or non-removable dressings housed in an RCW or a surgical shoe, have been able to improve healing rates and the clinician’s ability to close wounds within the 12-week standard window.29-31,37 Removable devices allow easy access to the wound at any time during the healing process, making it easier to apply advanced wound products in the manner they were designed to be employed. Unfortunately, this removability may also tempt the patient to remove the devices for comfort.38 A number of RCWs are made of patellar tendon-bearing uppers or calf attachments in an effort to remove more weight from the foot. These RCWs are available as custom or prefabricated devices. They may have a slight edge over a standard RCW in their ability to offload the foot but clinical trials have yet to prove this.
In my hands, I have found non-removable devices very effective when they are new and the Velcro uppers have yet to stretch out. Once this happens or the clamshell upper loosens from edema reduction in the leg, the devices are no better than a standard walker.
For many years, trained practitioners have used felted foam dressings. One would apply 1/4-inch adhesive felt directly to the foot around the ulcer to reduce pressure on areas of ulceration. Then have the patient use a modified surgical shoe or prefabricated walker during ambulation. Clinicians can change the dressings and apply advanced wound treatments, leaving the protective pads in place. Reapply the pads weekly or biweekly until the wound heals.
Birke and colleagues compared felted foam dressings with a TCC, healing shoe and a walking splint with regard to healing times for forefoot ulcers.31 The authors found that 93 percent of the ulcers treated with the felted foam dressings healed within 12 weeks (mean time to healing of 20.9 days) in comparison to 92 percent (31.7 days) in those treated with the TCC.31