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.
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.