Adequate off-loading with nonremovable casts or fixed ankle walking braces is the optimum modality for treating diabetic foot ulcers, but clinicians aren't always meeting this standard of care, a consensus statement found.
The consensus statement appeared in the November/December Journal of the American Podiatric Medical Association. A panel developed 8 evidence-based consensus guidelines and core recommendations, citing the level of evidence and the strength of each recommendation.
- 1. Vascular management, infection management and prevention, and pressure relief are essential to ulcer healing (high level of evidence/strong recommendation). Vascular assessment requires a combination of physical examination and laboratory tests or screenings, which can include palpation of pulses, ankle or toe brachial index, skin perfusion pressure, and transcutaneous oximetry. Infection should be diagnosed by the clinical presence of at least 2 symptoms of inflammation, or by purulent secretions. The panel concluded that the Infectious Diseases Society of America clinical practice guideline for diagnosing and treating diabetic foot ulcers was one of the most comprehensive in the literature. Patients who are at high risk for ulceration or who have a healed ulcer should be provided with protective footwear to help relieve pressure and prevent ulcer recurrence.
- 2. Adequate off-loading increases the likelihood of healing (moderate/strong). Off-loading devices and techniques include nonremovable devices, surgical techniques, wheelchairs, crutches, and bed rest. Insoles and custom-made footwear are helpful in off-loading pressure if patients adhere. Surgical off-loading such as surgical correction of foot deformities may also be appropriate.
- 3. For guidance on off-loading the Charcot foot, the panel endorsed a diabetes consensus report published in 2011 (low/strong).
- 4. Total contact casting is the preferred method for off-loading plantar diabetic foot ulcers because it has most consistently demonstrated the best outcomes and is cost-effective (moderate/strong). Total contact casting is indicated for ulcers associated with neuropathy, Charcot's foot, and postoperative off-loading. Inappropriate application of this therapy may result in new ulcerations or other complications, so proper training is paramount. Total contact casting is contraindicated in the presence of untreated infection, osteomyelitis, and severe peripheral arterial disease. It should be used with caution in deep or heavily draining wounds and in ataxic, blind, or severely obese patients.
- 5. There is a gap between the evidence supporting the efficacy of off-loading and clinical practice (moderate/strong). For clinicians, casting can be perceived as a technically difficult, complex, and time-consuming procedure. Also, there can be reimbursement and cost issues. Patients often prefer removable devices. Newer techniques that approximate the effect of traditional total contact casting, such as a removable cast walker wrapped in a nonremovable bandage, may be easier to use and faster to apply and may help patients comply.
- 6. The likelihood of healing increases with the level of adherence to off-loading (moderate/strong). A one-time ‘‘prescription’’ of off-loading is not enough, the statement said. Clinicians must ensure adequate off-loading at each encounter and during the entire treatment process. Clinicians should ensure that patients never leave the clinic wearing the shoe that allowed the ulcer to occur.
- 7. Advanced therapeutics are unlikely to succeed in improving wound-healing outcomes unless effective off-loading is done (moderate/strong).
- 8. Per-visit off-loading quality measures are needed to address the gap between evidence for off-loading and its current use in clinical practice (low/strong).