Football Dressing for Neuropathic Forefoot Ulcerations
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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.
1. Katz IA, Harlan A, Miranda-Palma B, et al. A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care. 2005;28(3):555–559.
2. Lavery LA, Armstrong DG, Walker SC. Healing rates of diabetic foot ulcers associated with midfoot fracture due to Charcot’s arthropathy. Diabet Med. 1997;14(1):46–49.
3. Matricali GA, Deroo K, Dereymaeker G. Outcome and recurrence rate of diabetic foot ulcers treated by a total contact cast: short-term follow-up. Foot Ankle Int. 2003;24(9):680–684.
4. Sinacore DR, Mueller MJ, Diamond JE, Blair VP 3rd, Drury D, Rose SJ. Diabetic plantar ulcers treated by total contact casting. A clinical report. Phys Ther. 1987;67(10):1543–1549.
5. Mueller MJ, Diamond JE, Sinacore DR, et al. Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care. 1989;12(6):384–388.
6. Myerson M, Papa J, Eaton K, Wilson K. The total-contact cast for management of neuropathic plantar ulceration of the foot. J Bone Joint Surg Am. 1992;74(2):261–269.
7. Helm PA, Walker SC, Pullium G. Total contact casting in diabetic patients with neuropathic foot ulcerations. Arch Phys Med Rehabil. 1984;65(11):691–693.
8. Walker SC, Helm PA, Pullium G. Total contact casting and chronic diabetic neuropathic foot ulcerations: healing rates by wound location. Arch Phys Med Rehabil. 1987;68(4):217–221.
9. Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care. 2001;24(6):1019–1022.
10. Birke JA, Pavich MA, Patout Jr CA, Horswell R. Comparison of forefoot ulcer healing using alternative off-loading methods in patients with diabetes mellitus. Adv Skin Wound Care. 2002;15(5):210–215.
11. Rathur HM, Boulton AJ. Pathogenesis of foot ulcers and the need for offloading. Horm Metab Res. 2005;37(Suppl 1):61–68.
12. Chantelau E, Breuer U, Leisch AC, Tanudjaja T, Reuter M. Outpatient treatment of unilateral diabetic foot ulcers with ‘half shoes.’ Diabet Med. 1993;10(3):267–270.
13. Zimny S, Schatz H, Pfohl U. The effects of applied felted foam on wound healing and healing times in the therapy of neuropathic diabetic foot ulcers. Diabet Med. 2003;20(8):622–625.
14. Knowles EA, Armstrong DG, Hayat SA, Khawaja KI, Malik RA, Boulton AJ. Offloading diabetic foot wounds using the scotchcast boot: a retrospective study. Ostomy Wound Manage. 2002;48(9):50–53.
15. Hissink RJ, Manning HA, van Baal JG. The MABAL shoe, an alternative method in contact casting for the treatment of neuropathic diabetic foot ulcers. Foot Ankle Int. 2000;21(4):320–323.
16. van Schie CH, Rawat F, Boulton AJ. Reduction of plantar pressure using a prototype pressure-relieving dressing. Diabetes Care. 2005;28(9):2236–2237.
17. Reiber GE, Vileikyte L, Boyko EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999;22(1):157–162.
18. Armstrong DG, Lavery LA, Wu S, Boulton AJ. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. Diabetes Care. 2005;28(3):551–554.
19. Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJ. Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen. Diabetes Care. 2003;26(9):2595–2597.
20. Pollo FE, Brodsky JW, Crenshaw SJ, Kirksey C. Plantar pressures in fiberglass total contact casts vs. a new diabetic walking boot. Foot Ankle Int. 2003;24(1):45–49.
21. 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):818–821.
22. Baumhauer JF, Wervey R, McWilliams J, Harris GF, Shereff MJ. A comparison study of planar foot pressure in a standardized shoe, total contact cast, and prefabricated pneumatic walking brace. Foot Ankle Int. 1997;18(1):26–33.
23. Sheehan P, Jones P, Caselli A, Giurini JM, Veves A. Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care. 2003;26(6):1879–1882.
24. Margolis DJ, Gelfand JM, Hoffstad O, Berlin JA. Surrogate end points for the treatment of diabetic neuropathic foot ulcers. Diabetes Care. 2003;26(6):1696–1700.
25. Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. Diabetic neuropathic foot ulcers: the association of wound size, wound duration, and wound grade on healing. Diabetes Care. 2002;25(10):1835–1839.
26. Margolis DJ, Kantor J, Berlin JA. Healing of diabetic neuropathic foot ulcers receiving standard treatment. A meta-analysis. Diabetes Care. 1999;22(5):692–695.
27. Caselli A, Pham H, Giurini JM, Armstrong DG, Veves A. The forefoot-to-rearfoot plantar pressure ratio is increased in severe diabetic neuropathy and can predict foot ulceration. Diabetes Care. 2002;25(6):1066–1071.
28. Armstrong DG, Lavery LA, Holtz-Neiderer K, et al. Variability in activity may precede diabetic foot ulceration. Diabetes Care. 2004;27(8):1980–1984.
29. Lott DJ, Maluf KS, Sinacore DR, Mueller MJ. Relationship between changes in activity and plantar ulcer recurrence in a patient with diabetes mellitus. Phys Ther. 2005;85(6):579–588.
30. Piaggesi A, Viacava P, Rizzo L, et al. Semiquantitative analysis of the histopathological features of the neuropathic foot ulcer: effects of pressure relief. Diabetes Care. 2003;26(11):3123–3128.
31. Birke JA, Novick A, Patout CA, Coleman WC. Healing rates of plantar ulcers in leprosy and diabetes. Lepr Rev. 1992;63(4):365–374.
32. Armstrong DG, Lavery LA, Nixon BP, Boulton AJ. It’s not what you put on, but what you take off: techniques for debriding and off-loading the diabetic foot wound. Clin Infect Dis. 2004;39(Suppl 2):S92–S99.
33. Frykberg RG. Diabetic foot ulcers: pathogenesis and management. Am Fam Physician. 2002;66(9):1655–1662.