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DPM,FACFAS
Offloading Devices
Section:  Biomechanics

 

Considering the necessity for appropriate offloading in patients with lower extremity ulcerations, what are your "go to" offloading devices to provide a reduction in both shear and direct forces to the ulcer site? Cam-Walker, DH Walker, etc?

 

MEMBER COMMENTS
Non-weight-bearing TCC

 

 

IMG_0023

 

 

 

 

 

 

 

 

Total Contact Cast with the following:  DVT prophylaxis (enoxaparin) Strict NWB, Bedrest, Bedpan, Bed-side commode, Walker, Wheelchair, PM&R Consult, PT training, SS/Case Management consult.

 

 

 

I do not allow my patients to bear weight in their TCCs. My TCCs are constructed with at least 1 inch of circumferential webril around the entire foot, ankle, and leg followed by at least 9 rolls of 4 inch fiberglass.

 

 

 

A NWB TCC requires DVT prophylaxis based on risk factors, and most of the patients requiring a TCC are going to have a few of these risk factors, in addition to being immobilized.

 

 

 

 

Bedrest, Bedpan, Bed-side Commode, Walker, and Wheelchair all help the patient with compliance.

 

 

 

A good PM&R doc can also help ensure compliance by writing a program to facilitate these goals.

 

 

 

PT training will help the patient learn how to transfer effectively while remaining NWB.

 

 

 

I try to get these patients into a SNF while they are NWB in TCC, as this too will help ensure compliance. In addition, things like tight control on blood glucose levels can also be better achieved in this environment. 

 

 

Re: Offloading Devices

I generally use TCC or DH Removable Cast Walkers (CAM type boot).  For patients with wounds that can tolerate weekly dressing changes, then I prefer TCC in general.  For wound types that are still highly exudative or for those that you are using a specialized dressing that needs daily dressing changes, then a DH Walker is certainly an option.

Below is a photo of a plantar forefoot / midfoot ulceration for which I am currently applying TCC.  This patient's wound has been present for over 2 years and has not effectively been offloaded (mostly because of the patient removing devices).  He presented to us with this non-compliance history and we have made great progress with TCC over the past 4 wks.

Plantar Forefoot Ulceration

Re: Non-weight-bearing TCC
Quote:

 

Total Contact Cast with the following:  DVT prophylaxis (enoxaparin) Strict NWB, Bedrest, Bedpan, Bed-side commode, Walker, Wheelchair, PM&R Consult, PT training, SS/Case Management consult.

 

 

Personally, I don't see the point of using a NWB TCC.  The purpose of a TCC is to offload the weight-bearing pressure.  If they are going to be completely NWB anyway, then they won't need a TCC.

My preference is an instant Total Contact Cast (iTCC) and allow the patient to weight-bear.  As Dr. Steinberg mentioned above, the main problem with removable cast walkers (RCWs or CAM boots) is that they are removable.  One can render it non-removable with plaster, fiberglass, or a zip tie and achieve similar healing outcomes to the TCC.

Re: Re: Non-weight-bearing TCC
Quote:

 

Personally, I don't see the point of using a NWB TCC.  The purpose of a TCC is to offload the weight-bearing pressure.  If they are going to be completely NWB anyway, then they won't need a TCC.

 

A NWB TCC serves the following purpose:

 

 

1) Edema control

 

 

2) Strict NWB = 0 Newtons of applied force to the wound (Alternatively WBAT = The force of Earth's gravity on a human being with a mass of 70 kg is approximately 687 N)

 

 

3) The large bulky NWB TCC is a constant reminder to the patient that they have a limb threatening plantar wound and they absolutely must stay off this for it to heal.

 

 

 

In practice, we have found ~2-3 weeks in a NWB TCC is sufficient to close the soft tissue envelope.

 

Re: Offloading Devices

When I rotated with Dr. Steinberg, his clinic used the EZ-TCC system. It is a single layered meshed cast supported by an outer shell that provides additional stability for the patient. It is faster and easier to apply than other TCC's and the pt can be WB. Although I do not know if it offloads as well as the traditional TCC, the fact that it is so much quicker to apply and more stable for the patient to weight bear with does make it beneficial for the right patient.

 

MED_0148a-46

RE: OFF LOADING

HAS  ANYONE ELSE TRIED CROW WALKERS

RE:

 

 

There is no question that the importance of off-loading the diabetic pressure ulcer is well documented, understood and appreciated. My concern is that the effects of our off-loading techniques may need to be improved on.  The literature outlines the strategies and methods of doing so in great detail.  But are these procedures enough? We all accept that the gold standard off-loading modality is the total contact cast (TCC) or a variation of that.  Although a patient is immobilized and off-loaded to a certain degree with these devices they do not address the pressures within.  While walking in these devices the patient will still exert a habitual plantar flexion effort during gait.  This will cause increased pressure at the wound sight inside the device and negate your efforts to a degree.

 

My approach to address this oversight is to include a Total Contact Orthoses.  I am not talking about just any orthotic, although which ever one you use will still be better than no orthotic at all.  When making an orthotic most literature you read employ the Root method of casting and most orthotic labs will produce a root based orthotic. I have modified my casting procedure by significantly exaggerating the amount of correction to the hind foot intrinsically within the device.  I cast the patient with maximal hind foot supination and plantar flexion of the first ray. This will transfer weight posteriorly, prevent pronation and forefoot pedal pressures greater than can be achieved with conventional Root based orthotics.  Now when the patient walks and attempts to plantar flex the foot inside your off-loading device the foot is met much earlier by the orthotic preventing the transfer of forefoot plantar pressures.  I am experiencing extremely good results with my patients by this method.  A study is underway.