Offloading Diabetic Foot Ulcers Andrew Bernhard Class of 2013

 Chronic wound caused by neuropathy and pressure  Sensory, motor, and autonomic neuropathies possible  Often seen over boney prominences or in areas of increased pressure, sometimes due to shoe pressure  Generally painless  Hyperkeratotic rim with moist base Diabetic Foot Ulcers

 Wagner System – Grades 0–6, No open lesion – gangrene  UTHS – Two parts based on grade (0-3) and stage (A-D)  PEDIS – Perfusion, Extent, Depth, Infection, Sensation  NPUAP – Most common classification, Stages 1-4 Staging of Ulcers

Ulcer Examples

 Aggressive debridement is key to helping wound  Surgical debridement, or incision and drainage, are often required  Correcting blood sugar correlates with decreased ulcer incidence  Offloading the foot will also decrease recurrence and speed up recovery Ulcer Treatment

 Various devices are available to offload the foot  The gold standard is the Total Contact Cast  Removable Cast Walkers are also a possibility  Diabetic shoes are generally good for healed ulcers Offloading of Diabetic Ulcers

 Gold standard for ulcer treatment  Transfer weight of lower extremity from foot to lower leg, by 1/3  45% reduction in forefoot loading  Contraindicated in heel ulcers, infection, poor skin quality, arterial insufficiency  Changed weekly for 6 weeks  Very rarely used (1.7% of ulcers) Total Contact Cast

 Alternative to Total Contact Cast  Cheaper  More attractive to patient  Better visibility of wound  Poor patient compliance, due to removability Removable Cast Walkers

 More used to control ankle motion  Not necessarily designed for ulcer treatment  Can provide offloading, similar to an RCW or TCC  Still removable, so compliance is decreased CAM Walker

 Good choice – Charcot Restraint Orthotic Walker  Fully padded interior with hard, immobile exterior  Covers entire foot and lower leg  Patient needs to acclimate to the boot, one hour at a time CROW Walker

CROW Walkers

 Orthowedge – unloads forefoot completely  Heelwedge – good for unloading heel  Medsurg / Surgical Shoe  Wound Care Shoe System  Darco products Other options

 Wu, Stephanie, et. al. “Use of Pressure Offloading Devices in Diabetic Foot Ulcers: Do we practice what we preach?” Diabetes Care November; 31(11): 2118–2119  Kushner, Donald. “The Diabetic Foot.” OCPM Lecture  Cavanagh, Peter, et. al. “Treatment for diabetic foot ulcer” Lancet. 2005; 366: 1725–35  Darco Products - loading-wound-care References