Football Dressing for Neuropathic Forefoot Ulcerations
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A number of studies have evaluated the healing time of diabetic foot ulcers when treated properly. Sheehan et al23 defined good clinical care of diabetic foot ulcers as offloading, frequent sharp debridement, and moist wound healing. Sheehan et al23 demonstrated that diabetic foot ulcer wound healing at 12 weeks can be predicted by the percentage change in area during the first 4 weeks of treatment. A wound that fails to decrease in size by 50% by 4 weeks is unlikely to heal in a reasonable time.23 Margolis et al24 also illustrated expected healing times for diabetic foot ulcers by demonstrating the change in area of a wound at 4 weeks predicts healing at 12 to 20 weeks. Wound size, duration, and grade are associated with likelihood of healing at 20 weeks.25 Margolis et al26 stated healing benchmarks for diabetic foot ulcers allow healthcare professionals to provide patients with a realistic assessment of their chances of healing and provide information that can be used in designing clinical trials. These studies have provided benchmarks for expected healing times for neuropathic diabetic foot ulcers. For Wagner grade 1 or 2 diabetic foot ulcerations, the expectation is the wound should be healed in 12 weeks with effective offloading. Moreover, significant healing should be noted within the first 4 weeks of treatment with a 50% reduction in ulcer area.
Rearfoot and forefoot pressures are increased in patients with diabetes and peripheral neuropathy.27 Both forefoot and rearfoot plantar pressure ratios are increased in patients with severe diabetic foot ulcerations.27 The quality and variability of activity may be more likely to lead to ulceration even in patients who are less active.28 Sudden changes in activity and routine loading of plantar tissues may result in tissue injury as compared to absolute value of peak plantar pressures or number of steps with regard to plantar ulcer recurrence.29
A semiquantitative analysis of histopathological features of neuropathic ulcers performed by Piaggesi et al30 demonstrated decreased inflammatory and reactive components and accelerated healing with TCC utilization. This helps confirm the importance of offloading neuropathic ulcerations. Birke et al31 demonstrated no difference in healing time between patients with leprosy and patients with diabetes. Their findings support loss of protective sensation and mechanical stress as the primary etiology for plantar ulceration in both groups.31 Appropriate wound care, debridement, and pressure reductions are the keys to successful treatment of neuropathic foot ulcers.32
The key to a wound dressing and offloading modality is the effectiveness, ease of application, availability of materials, cost, and the likelihood of compliance. The cost and ambulation problems associated with iTCC and TCC use make these options unsuitable for some patients. In an effort to develop alternatives for patients with neuropathic ulcerations where TCCs, iTCCs, and RCWs are not good choices, the authors developed the “football” dressing. In order to evaluate this dressing, the authors compared the healing rates to that of TCCs and iTCCs. Most healthcare professionals can easily apply the football dressing, and the materials are widely available and inexpensive.
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