Football Dressing for Neuropathic Forefoot Ulcerations

Andrew J. Rader, DPM,1 and Timothy Barry, DPM2

The risk of infection and amputation related to neuropathic ulcerations in the diabetic population drives the desire for timely and optimal healing in these patients. The documented gold standard for healing neuropathic wounds is the total contact cast (TCC).1–10 Studies have consistently demonstrated the effectiveness of the TCC and, most recently, the instant total contact cast (iTCC).1–10 Barriers to physician use of TCCs are mostly concerns related to the time and complexity of application, cost of materials, and complications attributed to the TCC.11
Katz et al1 demonstrated that TCCs and iTCCs have equal efficacy; however, the iTCC is less expensive and easier and quicker to apply. The costs of the TCC and iTCC are $210.67 and $158.47, respectively.1 Half shoes, applied felted foam, and scotch cast have shown healing times inferior to TCCs and iTCCs.12–14 The MABAL shoe study had average healing rates for neuropathic diabetic foot ulcers at about 5 weeks, and although comparable to TCC, all wounds were Wagner Grade 1.15 Birke et al10 evaluated forefoot ulcer healing using a TCC, an accommodative dressing consisting of a modified surgical shoe and felt, a healing shoe, and a walking splint, and average healing times were 47.7, 36.1, 41.4, and 50.5 days, respectively. In at least 81% of the cases, these forefoot ulcers were healed within 12 weeks irrespective of the method used. All patients in this study were given instruction for partial weight-bearing using crutches or walkers.10 Recently, a prototype pressure-relieving dressing was introduced and demonstrated a reduction in pressure by 30% at individual metatarsal heads.16
Wound healing in patients with diabetes is often impaired by the loss of peripheral pressure sensation that permits painless weight-bearing on an ulcerative area leading to a chronic ulcerative process.11 Component causes of lower-extremity ulceration in patients with diabetes include peripheral neuropathy, deformity, and trauma. Peripheral neuropathy is the most common cause.17 Removal of 1 or more of the causal pathways can prevent or delay foot ulcer development.17 In neuropathic ulcerations of the plantar foot, effective offloading will lead to healing with predictable rates and patterns. In most studies, the average healing rates using TCCs range from about 4 weeks to 6 weeks.1–10 Recently, removable cast walkers (RCWs) and iTCCs have demonstrated healing rates of 51.9% and 82.6%, respectively, in 12 weeks.18 Although previous studies have demonstrated effective decreases in plantar pressure with the use of RCWs compared to TCCs, the lack of compliance with RCWs leads to lower healing rates.19–22 Armstrong et al19 demonstrated the problem of compliance when utilizing RCWs for offloading. In this study, patients wore the RCW for a minority of the steps taken during the day, utilizing the RCW only 28% of the time during daily activities.


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