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Board Review Wound Care

The ConSENSEus for Offloading Diabetic Foot Ulcers

David Pougatsch, DPM

David A Pougatsch, DPM discusses the consensus statement in support of offloading and total contact casts. Dr Pougatsch will examine why total contact casts are not utilized in the treatment of diabetic foot ulcers in the vast majority of clinics around the United States.

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Goals and Objectives
  1. Discuss the financial and personal cost of diabetes in the United States
  2. Understand why offloading is so effective and when to initiate it
  3. Discuss the Consensus statement on diabetic foot ulcers
  4. Identify why total contact casts are underutilized
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  • CPME (Credits: 0.5)

    PRESENT eLearning Systems, LLC is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine.

    PRESENT eLearning Systems, LLC has approved this activity for a maximum of 0.5 continuing education contact hours.

    Release Date: 03/16/2018 Expiration Date: 12/31/2018

  • Author
  • David Pougatsch, DPM

    Associate Medical Director
    Amputation Prevention Center at Sherman Oaks Hospital
    Los Angeles, CA

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  • Lecture Transcript
  • Male Speaker: Alright, good morning everybody. Diabetic foot ulcers and offloading, everyone knows about it but the problem is just nobody does it. A little bit of disclosures there. The purpose of this talk, I think, is more to discuss about the use of offloading modalities. Not necessarily show you what offloading does. I think we all know that offloading diabetic foot ulcers reduces plantar pressures and eventually heals the wound. But more to discuss why we should do it. Just a little bit of background, we all know diabetes is getting worse and worse in this country, leading to outrageous medical costs. It also is the leading cause of heart disease, blindness, stroke, renal failure. All these patients are hypertensive. It’s a very complex problem. These patients are very complex. They have multiple specialties following them. It’s not just the wound. I think a lot of us know this. It’s not just the wound. You have to treat the entire patient. Again, in terms of studies, a lot of funding has been going to diabetes, but really not much with the diabetic foot ulcer research, as you can tell. A lot of this is a product of our environment. We’re surrounded by lots of good food and the problem has just been getting worse and worse. One of my favorite slides. How does this amputation occur? My good friend, Dr. Rogers, put this together. It’s basically a combination of things. We all know diabetes could lead to neuropathy if it’s uncontrolled. This neuropathy leads to ulceration. Whether or not patient has vascular disease, plus or minus vascular disease infection often lead to an amputation. We all know that a lot of our patients, I mean, by show of hands, everyone treats diabetic foot ulcer patients. Even if it’s one patient a week, we’re going to see them in our practice. We’re basically the de facto specialty for diabetic foot ulcers. Again, we all know the statistics that 50% of this end up with proximal limb amputations will probably be dead within five years, another graph demonstrating that. Again, and the sheer cost, the cost of treating diabetic foot ulcer is through the roof. In terms of diabetic patients being admitted to the hospital, this is the number one reason, it’s a complication due to a diabetic foot ulcer. I’m here and I’m not in Los Angeles, so that’s good. What exactly causes diabetic foot ulcers? What’s the combination of things? Obviously, you have decreased mobility, some sort of deformity. It could have muscle stiffness, equinus is very common on these types of patients, some ligament laxity. In the end, they all lead to increased plantar pressures and that’s the cause. An interesting slide here is that you see this, the diabetes raising the amputations are waking up the prosthetic industry. The interesting part is that this is in the business section, not the health section. It’s also a big money. A little bit of question must be brought forward there. Where does offloading fit in? When you have an infection? When your patient’s avascular? When you debride it? The answer is that offloading has to be done throughout the continuum of wound care, regardless of what stage it’s in. Any type of wound essentially can be offloaded. Again, why offloading? We know that it reduces the plantar pressure as well as the strain. There are many modalities of offloading available. You can’t say every patient is getting one modality of offloading. It’s just not possible. We all know that. It’s like saying I’m going to do an Austin bunionectomy for every patient and we all know that that’s not possible. You have to tailor the type of offloading modality to the patient. This is what Dr. Frykberg was alluding to earlier. There was a group of podiatric and medical leaders that came together and basically came up with certain statements. Some are opinions. Some are backed by randomized trials. Discussed what level of evidence these recommendations do have in terms of offloading. Again, we all know that DFUs can severely hinder quality of life for a lot of these patients. At this time, I think a lot of the patients with diabetic foot ulcer are also quite depressed, if you’ve actually had the chance to talk to them.

    [04:59]

    It really hinders their quality of life. Taking the basic premise of not being able to walk away from a human being is very tough. Again, what did the panel do? They looked at different articles from PubMed and they basically looked at higher quality studies to determine what the recommendations would be in terms of offloading diabetic foot ulcers and they graded them, appropriately named the Grade Approach. They looked at the level of evidence, which is on the left, and as well as the recommendation level from the group. Is it a strong recommendation, which means that treating physicians should follow it? Or is it more of a weak recommendation where it needs to be looked at a little bit more? There’s eight consensus statements. I’m going to harp on a few of them, which I think are very important. Obviously, number one, we all know, vascularity, taking care of the infection as well as taking off the pressure, the VIPs are important in treating diabetic foot healing. We all know that. We also know that offloading will increase the likelihood of diabetic foot ulcer healing. We know that. Charcot foot, I won’t harp on too much. Number four, total contact casting is the preferred method for offloading a diabetic plantar foot ulcer. Has the best outcomes and is the most cost effective. That, you cannot argue with that using a total contact cast is the primary method. We also know that adherence with total contact casting is quite important. How many times have you given a patient a postoperative shoe or a CAM boot to offload the diabetic foot ulcer and they come back next week and the boot or the shoe are MIA. There’s a lot of compliance issues with removable types of offloading devices that are obviously not there with the total contact cast. I’m going to allude earlier what Dr. Bromley said in his lecture where you can put whatever product, whatever biologic product to try to heal the wound. Unless you’re able to offload the wound effectively, no amount of product is going to work. You have to reduce that pressure in combination with the biologic tissues. With some key outcomes, the likelihood of the healing is increased with offloading adherence, as we know. Again, the total contact cast was determined by the consensus group to be the most effective method to relieve pressure. We all know that if it’s done consistently, it will heal the ulcers in a more timely fashion. There’s a lot of offloading modalities available to us. Again, you have to tailor to your patients. Some patients, they’re not going to be able to tolerate a total contact cast. Some patients are going to be too wobbly in a postoperative shoe. You have to basically adapt the modality to the patient. My favorite one nowadays are patients who want to get around actually is a new walker. I think those are great. I love giving my young active patients new walkers. Essentially, when it comes to offloading the actual wound, the best method is the total contact cast. Here’s a couple of different products available. Total contact cast are actually quite simple to put on. I’m going to talk about this in a second. A lot will say, well, they’re difficult to put on. They’re too time consuming. They’re actually not. Especially now with the new roll on cast, this one on the left that you can see is a nice slip on roll on total contact cast. These things take about five minutes once you have all the supplies out. They’re very simple to use. They’re very comfortable. I’ve actually had it applied on my leg and they worked out very well. As you can see, a total contact cast on the left is the modality that will reduce the plantar peak pressures the most. Here’s another study also that basically looks at total contact cast versus a CAM boot versus a postoperative shoe. Basically, what you see is that in the same amount of time, you have a higher percentage of wounds healed. If you want to look at in terms of days of healing, you actually heal faster as well. Another little bit of evidence from Dave Armstrong in terms of using the total contact cast to heal. Exactly, why aren’t we doing this? My good friend, Stephanie Wu in Chicago looked at this and basically sent out a letter to multiple centers. Looked at, what’s the percentage of people using total contact cast? Shoe modifications are the most common, whether that’s the actual shoe or orthosis removal shoe walkers being CAM boot. This is scary. Less than 2% of these centers stated that total contact cast are the primary offloading technique.

    [09:47]

    That is scary. The total contact cast has been known for a long time now that it reduces pressures the most and is the most effective way to heal. Yet, only 2% of these centers are using total contact cast as their primary offloading techniques. I think what’s even scarier is that about half these centers don’t even use total contact cast at all. Not only that, about 60% who refute the consensus documents and refute the previous evidence that say total contact cast is not the gold standard. I don’t know how to answer that. I really don’t. The literature is out there. The studies have been done. We all know that total contact cast is the gold standard in offloading diabetic foot ulcers. Why? The one advantage to total contact cast that I think trumps a lot of other modalities is compliance. Patients can take this off. Dave Armstrong did a little quirky study down in Tucson where they basically took a pedometer and they hid it inside a CAM boot and let patients walk in it and then put a pedometer on their hip. What they noticed that in all reality, the two number should be close to each other. What they found out is that the pedometer and the CAM boot was about 30% of the total number of steps taken for the day. These patients were taking them off. Compliance is absolutely huge. Also, we know that it reduces sheer forces quite a bit. Some cons, but some of these are actually missed. Tolerance is always an issue with cast. We all know that. Like I said, you have to pick the right patient. Time to apply supplies. A lot of these are now in easy kits, which take about five minutes to put on. I think time to apply is a complete myth, especially now with these wonderful roll on total contact cast that we have. People say that it’s difficult in monitoring a wound. You can always window the cast, so that’s also not an excuse. It’s easy. Once you put the cast on, you let it harden, and you take your cast pattern, you window where the ulcer is. Again, there are multiple randomized controlled trials including metaanalyses that have shown that diabetic foot ulcers are most effectively offloaded using a total contact cast. Here is some of them. This is basically looking at seven randomized controlled trials put together where the average healing rate was 88% utilizing a total contact cast. The days to healing were actually significantly less than not using a total contact cast. I skipped on this earlier. I’ll just mention it briefly. In terms of Charcot foot, I’ve had quite a bit of Charcot referrals come in and they’re wearing no more than a postoperative shoe, maybe a CAM boot. We all know that this is also ineffective. Charcot foot needs to be immobilized, initially nonweightbearing. Once it’s into the chronic stage and you start to weightbear them a little bit, weightbearing them in a total contact cast is the ideal situation. If you’re even immobilizing them, it should be in a total contact cast. Looking at Caroline Fife’s article, more recently, this is 2010. Wu’s study was in 2008. Again, minimal use of total contact cast even though the overall treatment cost associated with treating DFUs with total contact cast is significantly less. The larger retrospective series also came from Caroline Fife in 2014. This is about 20,000 DFUs. Again, they looked at the characteristics of different wound centers and try to evaluate what they’re doing. They looked at percentages healed, percentages amputated, those that are offloaded, those that are offloaded with total contact casting, as well as the infection rate. Again, what they found was the offloading was documented about 2%. Those 2% number just lingers and it really bothers me, how only about 2% of these visits, 2% of these wounds overall are essentially being offloaded, utilizing a total contact cast. Again, most common offloader is a postop shoe. I understand patients are happy with the postop shoe. It’s very comfortable. It’s much more comfortable than a cast but we’re doing them a disservice. We are doing these patients a disservice by not placing them in a total contact cast. We’re delaying their care. We’re delaying their healing. We’re increasing cost. Like a lot of speakers have mentioned, we’re going to be measured down the road in terms of costs, in terms of healing, time to healing. Why aren’t we using that most ideal modality out there? I got to say, it’s very scary. Again, infection rates were even higher with those non-TCC treated. Only about 60% of clinics were even using the TCC as an option. I know this is a little bit of a busy slide, but I still want to drill you that even six years after Stephanie Wu’s study, we’re still minimally offloading these diabetic foot ulcer with total contact cast. Again, so their conclusion was that it’s vastly underutilized.

    [15:04]

    However, I think a lot of us who treat diabetic foot in over 95% of our patients, about 95% of my patients are diabetic foot ulcer type patients, these newer easy to apply TCC kits I think work really well. They’re very simple to use. They take very little time. You can even train nurses to do it as well. It’s a very simply process. They’re very quick. Like I said, anybody can use it. Attending physician can use it. Now, in terms of patients, again, ideally noninfected neuropathic ulcers. I usually like to stop if there’s muscle exposed. If there’s bone exposed, I don’t really like to offload with a total contact cast until I treat that issue. A lot of times, they need surgical debridements, significant bone debridements. Once you’re able to address that, I would go ahead and use the total contact cast. Even preulcerative conditions, venous leg ulcers, or even a reason to use a total contact cast for the reasons that the compression they provide. Again, you have to have an adequate blood supply. Ulcers having sign of infection might be a relative contraindication. Anecdotally, I should say, some people still use it as long as someone is being effectively treated for the infection. Draining wounds can also be an issue, but then again, windowing the cast becomes an option. A lot of times, my contraindication is essentially psychologically unable to have a cast on. That’s my main reason. Some people I know just cannot handle being in a cast for prolonged period of time. Some pathways to healing, it’s again a little bit of a busy slide. I don’t know how it came up on the screen. Essentially, once you debride, once you have the infection under control and once you have adequate vascular supply, there’s absolutely no reason not to offload these patients in a total contact cast. Again, only 2% of centers are doing it. Two percent of patients are being offloaded with TCC regularly and I think that number needs to increase. Again, I said that the application is quite simple. This is a video but I’m going to run short on time. It’s basically one of my patients who has minimal motion on his knee and his back and we’re actually placing this supine. We can do it in five minutes. Typically, when doing total contact cast, ideally you have the patient prone. I know some patients are difficult getting prone position, but at least that way you can have gravity work for you instead of against you. Again, it’s very easy to put on. If you kind of forward that a little bit and we can kind of see the cast go on. This is just the stockinette initially. Again, so patient in minimal motion. It’s basically three layers. You have the stockinette layer. You have the cotton layer. This protects the pressure prominences along the anterior tibia as well as the malleoli. You follow this with a layer of a cotton roll and then followed by the cast. Essentially, that’s how it looks at the end. It does go over close very easily. Again, this was on supine where ideally, you’d have the patient in a prone position. Even in a difficult patient, patients with limited range of motion, it’s quite easy. Another question always comes up with total contact cast with negative pressure. We use total contact cast with negative pressure all the time. It does work out very well especially with the bridge dressings that are available for negative pressure. This is the patient right here has a posterior heel ulcer that we want offload because the patient has been noncompliant with other modalities of offloading. As you can see, we can easily put on a total contact cast and have the negative pressure working quite well. Again, very easy to remove also. You go right down the middle where the cotton layer was and you take them right off. I’ll end with this. I know it’s affecting all of us a little bit. Any conclusion? When it comes to offloading, you got to find the correct patient, find the correct type of wound. It’s not difficult. It might be a little time consuming, five minutes or so. I did it in about five minutes, might take the average clinician maybe six to seven minutes once you have everything ready. Again, it’s reimbursed. I’m not going to go into that at this point. It’s effective with ancillary treatments such as negative pressure, such as biological tissues. Ultimately is this, it is the gold standard. I don’t know how much more. I feel like I’m spending a lot of energy here saying it’s the gold standard. It is the gold standard. It will get your patients healed. It will get the patients heal faster. These are comfortable. They’re not uncomfortable by any means.

    [20:00]

    Some of these actually come with a boot that can be applied with the total contact cast to make it a walking cast, which is very helpful. It’s also supported by the consensus document. We had multiple leaders from podiatric and other medical specialties come together, look at all the research and put out this consensus statement in December of 2014. I don’t see a reason not to use it. Welcome to Vegas. I hope everyone has a great time out here. For my partner, Dr. Lee Rogers and Dr. Karen Shum, thanks for having me.