1. Offloading Diabetic Foot Ulcers Andrew Bernhard Class of 2013

2. Diabetic Foot Ulcers Chronic wound caused by neuropathy and pressure Sensory, motor, and autonomic neuropathies possible Often seen over boney prominences or in areas of increased pressure, sometimes due to shoe pressure Generally painless Hyperkeratotic rim with moist base

3. Staging of Ulcers Wagner System – Grades 0–6, No open lesion – gangrene UTHS – Two parts based on grade (0-3) and stage (A-D) PEDIS – Perfusion, Extent, Depth, Infection, Sensation NPUAP – Most common classification, Stages 1-4

4. Ulcer Examples

5. Ulcer Examples

6. Ulcer Examples

7. Ulcer Examples

8. Ulcer Examples

9. Ulcer Treatment Aggressive debridement is key to helping wound Surgical debridement, or incision and drainage, are often required Correcting blood sugar correlates with decreased ulcer incidence Offloading the foot will also decrease recurrence and speed up recovery

10. Offloading of Diabetic Ulcers Various devices are available to offload the foot The gold standard is the Total Contact Cast Removable Cast Walkers are also a possibility Diabetic shoes are generally good for healed ulcers

11. Total Contact Cast Gold standard for ulcer treatment Transfer weight of lower extremity from foot to lower leg, by 1/3 45% reduction in forefoot loading Contraindicated in heel ulcers, infection, poor skin quality, arterial insufficiency Changed weekly for 6 weeks Very rarely used (1.7% of ulcers)

12. Removable Cast Walkers Alternative to Total Contact Cast Cheaper More attractive to patient Better visibility of wound Poor patient compliance, due to removability

13. CAM Walker More used to control ankle motion Not necessarily designed for ulcer treatment Can provide offloading, similar to an RCW or TCC Still removable, so compliance is decreased

14. CROW Walker Good choice – Charcot Restraint Orthotic Walker Fully padded interior with hard, immobile exterior Covers entire foot and lower leg Patient needs to acclimate to the boot, one hour at a time

15. CROW Walkers

16. Other options Orthowedge – unloads forefoot completely Heelwedge – good for unloading heel Medsurg / Surgical Shoe Wound Care Shoe System Darco products

17. References Wu, Stephanie, et. al. “Use of Pressure Offloading Devices in Diabetic Foot Ulcers: Do we practice what we preach?” Diabetes Care. 2008 November; 31(11): 2118–2119 Kushner, Donald. “The Diabetic Foot.” OCPM Lecture Cavanagh, Peter, et. al. “Treatment for diabetic foot ulcer” Lancet. 2005; 366: 1725–35 Darco Products - http://www.darcointernational.com/off-loading-wound-care