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Care and prevention

Managing the diabetic foot:


treatment, wound care and
offloading techniques
y Stephanie Wu and David Armstrong

Foot ulcers are caused by an imbalance between excessive Debridement


Any dead tissue should be removed
pressure on the sole of the foot and repetitive stress from
from the wound, as required, using
walking. It does not take much pressure to provoke an a sharp tissue nipper or scalpel or
a curette. Finger pressure may be
ulcer, so the skin has a built-in protection system. Normally,
applied to the wound to help control
harmful pressure or motion against the skin will set off a bleeding. The wound may then be
protective pain alarm. Unfortunately, in people with diabetes probed to check for underlying tissue
and infection. Following adequate
nerve damage (neuropathy), this pressure goes undetected debridement, the wound can be
and can cause serious injury. Having lost the ‘gift of pain’, dressed and pressure offloaded as
required. At follow-up, the absence
people with diabetes neuropathy often do not notice the
of undermining of the wound edges
problem until an ulcer has formed. Stephanie Wu and is a good sign that the wound has
been appropriately offloaded.
David Armstrong provide an update on the latest optimum
treatments for people with diabetes foot damage.

>>
When a person’s feet receive an
adequate supply of blood, the treatment
force is spread over a wide area using
devices such as a total-contact cast.1
( )The absence of
undermining of the
wound edges is a good
sign of appropriate
offloading.
to heal a diabetes-related foot ulcer An infection-free wound environment
is centred on relieving repetitive is provided using a technique called Wound healing
pressure and managing the area of the debridement. The following section A wound repairs as a result of an
foot affected by the ulcer (optimizing provides instructions for the surgical orchestra of highly integrated cellular
the wound environment). Pressure debridement of diabetes foot ulcers and biochemical responses to an
reduction is commonly known as that are not infected and receive an injury. Integrating bio-engineering
‘offloading’. This is most successful when adequate supply of blood. with advances in our understanding

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November 2005 Volume 50 Special Issue
The close fit of the plaster shoe
helps to distribute pressure to
the plantar foot as a whole.
Care and prevention

of the complex mechanisms of the stimulates cell growth and wound of the foot and the lower leg. The
wound healing process have led to healing. This appears to be potentially close fit of the cast material to the
the development of various products, effective in improving healing in plantar surface of the foot increases
such as new wound dressings, growth complex diabetes foot lesions.2 the plantar weight-bearing surface area
factors, negative-pressure wound to help distribute the pressure from
therapy, and living skin equivalents. Offloading one or two distinct areas to the plantar
Negative-pressure wound therapy is Common methods to offload pressure foot as a whole.3 Most importantly, the
one of the most promising of these. on the foot include: bed rest, the total-contact cast is not removable.

( )
use of a wheel chair, crutches, total-
Negative-pressure wound therapy contact casts, felted foam, half shoes, Total-contact casting
Negative-pressure wound therapy therapeutic shoes, custom splints, is considered the
is the controlled application of and removable cast walkers. ‘gold standard’ in
sub-atmospheric pressure to a achieving pressure
wound using an electrical pump and Removable cast walkers redistribution.
specialized wound dressings. Studies Removable cast walkers can be
have suggested that the effects of taken off to allow self-inspection Unfortunately, however, there are
applying negative pressure include: and treatment of a wound. People also a number of potentially negative
the optimization of the flow can bathe and sleep comfortably, attributes that may discourage some
of blood and because they can be taken off, health-care professionals from using
the reduction of swelling in removable cast walkers can be this modality. The application of total-
local tissue used for infected wounds as well as contact casting is time-consuming
the removal of potentially superficial ulcers. Removable cast and often associated with a learning
damaging wound fluid. walkers limit propulsion by keeping curve. A poorly fitting cast can provoke

( )
o
the ankle at an angle of 90 and skin irritation and in some cases
Negative-pressure thereby help to reduce pressure on ulceration; most medical centres do
wound therapy the sole (plantar surface) of the foot. not have a health-care professional
stretches cells, or cast technician available with
which stimulates The best feature of the removable cast adequate training or experience to
wound healing. walker is also paradoxically its potential safely apply a total-contact cast. In
downfall. The ability to remove the addition, total-contact casts do not
These physiological changes give device eliminates the element of allow assessment of the foot or wound
rise to a moist environment for ‘forced adherence’ that is the finest on a daily basis and are therefore
healing and facilitate the removal of attribute of the total-contact cast. often contraindicated in cases of
bacteria from the ulcer. Additionally, infections in soft tissue or bone.
the application of sub-atmospheric Total-contact casting
pressure may help to increase the Of the numerous offloading devices, Removable cast walkers
rate of cell division and subsequent total-contact casting is considered A similar degree of success in terms
formation of granulation tissue. by many to be the ‘gold standard’ in of reducing plantar pressure has
achieving the redistribution of pressure been seen with some removable cast
Although the exact effect of negative- and healing. The use of a plaster cast to walkers (walking braces).4 However, in
pressure wound therapy on wound treat neuropathic foot lesions has come a study that compared the effectiveness
healing is not clear, it has been to be known as total-contact casting of total-contact casts, removable
suggested that the application of micro- because it employs a well-moulded, cast walkers, and half-shoes, this did
mechanical forces to wounds deforms minimally padded cast that maintains not translate into equivalent time to
or stretches individual cells, which contact with the entire plantar surface healing: when compared with the two

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November 2005 Volume 50 Special Issue
Care and prevention

other modalities, a significantly higher instant total-contact cast. The study y Stephanie Wu and
proportion of people with diabetes concluded that the instant total- David Armstrong
foot ulcers were healed after 12 contact cast, when compared with Stephanie Wu is an assistant professor in the
weeks wearing a total-contact cast.1 the total-contact cast, is not only Department of Surgery at the William A Scholl
equally efficient in healing diabetes College of Podiatric Medicine at the Rosalind
The reason people do not heal well foot ulcers, it is quicker and easier Franklin University School of Medicine,
in removable devices is precisely to use, and more cost-effective.5

( )
Chicago, USA. She is a Fellow at the Center
because they are removable. In the for Lower Extremity Ambulatory Research
absence of pain, people with diabetes The instant total- in Chicago, USA.
neuropathy generally do what feels contact cast is easy
best. A heavy boot does not feel like to use, and cost- David Armstrong is a professor of surgery,
the best option to many people – even effective. Chair of Research and Assistant Dean at the
when there is an open wound present. William M Scholl College of Podiatric Medicine
A parallel study that compared the at the Rosalind Franklin University of
Instant total-contact casting effectiveness of a removable cast Medicine, Chicago, USA. He is also a member
It would be ideal to be able to take walker and an instant total-contact of the National Board of Directors of the
the clinical efficacy of the total-contact cast showed comparable results in American Diabetes Association.
cast and combine it with the relative the healing of diabetes foot ulcers.6
ease of application of the removable The study found that a significantly
cast walker. The instant total-contact higher proportion of people healed
cast is an innovative approach which in the instant total-contact cast
attempts to do just this. The instant group, when compared with those
total-contact cast involves simply using the removable cast walker;
wrapping a removable cast walker of the people whose healed, those References
1 Armstrong DG, Nguyen HC, Lanegatvery LA, van Schie CH,
with a single layer of cohesive bandage, who used the instant total-contact Boulton AJM, Harkless LB. Offloading the Diabetic
elastoplast or casting tape. This cast healed significantly faster. Foot Wound: A Randomized Clinical Trial. Diabetes
Care 2001; 24: 1019-22.
forces a person to adhere to advice
to immobilize their foot – ensuring Conclusion 2 Armstrong DG, Lavery LA. Negative Pressure Wound
Therapy Heals Wounds Faster than Standard Wound
pressure redistribution – while There is a high occurrence and Care Following Partial Diabetic Foot Amputation:
allowing for ease of application and recurrence of foot ulcers in people Results from a Randomised Multicentre Clinical Trial.
Lancet 2005 (In press).
examination of the ulcer when needed. with diabetes. In order to reduce the
negative consequences associated with 3 Mueller MJ, Diamond JE, Sinacore DR, et al. Total
Two additional studies were conducted these ulcers, a consistent standard of contact casting in treatment of diabetic plantar ulcers.
Controlled clinical trial. Diabetes Care 1989; 12: 384-8.
to test the wound-healing efficacy of care must be provided. This standard
the instant total-contact cast. The first should combine common sense with 4 Baumhauer JF, Wervey R, McWilliams J, Harris GF,
Shereff MJ. A comparison study of plantar foot
randomized controlled study compared newer technologies: appropriate
pressure in a standardized shoe, total contact cast,
the standard total-contact cast with wound care, debridement, and patient and prefabricated pneumatic walking brace.
an instant total-contact cast.5 No adherence to pressure reduction Foot Ankle Int 1997; 18: 26-33.

differences were found in healing rates have been and will continue to be 5 Katz IA, Harlan A, Miranda-Palma B, et al. A
and average healing time. Furthermore, the cornerstones of treatment to randomized trial of two irremovable off-loading
devices in the management of plantar neuropathic
there were also no differences in avoid lower-limb amputations.
diabetic foot ulcers. Diabetes Care 2005; 28: 555-9.
complications between the two groups.
6 Armstrong DG, Lavery LA, Wu S, Boulton AJ.
Evaluation of removable and irremovable cast walkers
However, the cost in materials and in the healing of diabetic foot wounds: a randomized
personnel was much lower for the controlled trial. Diabetes Care 2005; 28: 551-4.

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November 2005 Volume 50 Special Issue

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