How To Offload Lower Extremity Ulcers

In a discussion of offloading modalities, these panelists focus on offloading of pressure ulcers on the heel and ankle as well as diabetic neuropathic ulcers.

Q:

How do you initially approach offloading of lower extremity ulcers?

A:

Kazu Suzuki, DPM, CWS, emphasizes assessing the need of each individual patient. “You have to do some detective work on what, why and when the pressure is applied over the wound bed, and then figure out how to prevent or minimize it,” he explains.

Dr. Suzuki says the presence of calluses or a bruised wound bed is a sign of whether patients have received proper offloading or not. As he notes, examining the foot deformity or the wear pattern on shoes and insoles are other ways to examine the often neuropathic feet in patients with diabetes.

In her initial assessment of a plantar foot ulcer, Monica Schweinberger, DPM, evaluates the neurovascular status as well as the foot structure. If the patient has peripheral arterial disease (PAD), she says early referral to a vascular surgeon or interventional cardiologist is of utmost importance in improving the likelihood of healing. David Swain, DPM, also emphasizes the importance of checking the patient’s vascular status. He will typically start with an arterial Doppler/arterial duplex study with ankle brachial index (ABI) for patients without diabetes and a toe brachial index (TBI) for patients with diabetes. Dr. Swain says he’ll make an immediate referral to a vascular specialist if any arterial pathology is present or suspected.

Dr. Suzuki says patients with pressure ulcers tend to be more debilitated or compromised in terms of nutrition or mobility, which would prompt more investigation. Recently, he has started recommending the Ensure Enlive supplement with beta-hydroxy beta-methylbutyrate (Abbott Nutrition), saying it can increase the lean body mass and reduce mortality in debilitated patients who often have pressure ulcers. Similarly, Dr. Swain says appropriate lab testing (albumin, prealbumin and total protein) and referral to a dietician are often useful for wound patients who may be malnourished.

A head to toe assessment is vital to getting the appropriate type of offloading for a patient, says Dr. Swain. The patient may have contractures or spasticity, and he advises these issues can present challenges to traditional offloading techniques and procedures. He ensures the patient and patient’s caregivers or family are actively engaged with what needs to happen for optimum offloading. Dr. Swain also has a frank conversation with the patient about the expected duration of the ulcer as pressure ulcers can often take several months to heal, even under ideal circumstances.

Dr. Schweinberger says one may need to surgically address structural abnormalities that are causing increased pressure to prevent recurrent ulceration. One may often delay surgery until after ulcer healing but she says it may, in some cases, be necessary to achieve healing. Dr. Schweinberger generally suggests taking X-rays at the first visit to rule out bone infection. Appropriate debridement and management of infection are critical to ulcer healing, according to Dr. Schweinberger.

Offloading depends somewhat on the location of the ulcer, notes Dr. Schweinberger. With plantar metatarsal head ulcers, she will often use a metatarsal pad along with foam aperture padding around the ulcer site under a Jones compression dressing if the patient has a palpable pulse. She notes the patient will then bear partial weight on the affected heel in a surgical shoe. Her patient will receive a cane or walker to aid with ambulation and instructions to limit walking to short distances about the home. Dr. Schweinberger also instructs patients to elevate the affected extremity consistently, limiting dependency to about 30 minutes at a time.

For toe ulcers, Dr. Schweinberger will often use a combination of felt and foam aperture pads. As she notes, midfoot ulcers, similar to what one would see in a patient with a Charcot foot, may require a total contact cast. When a patient has plantar heel ulcers, Dr. Schweinberger says patients with plantar heel ulcers usually require complete non-weightbearing, whether it is via crutches, a wheelchair or a Roll-A-Bout device (Roll-A-Bout).

In all cases involving pressure ulcers, limiting patient ambulation and controlling swelling with elevation and/or compression leads to more predictable healing, notes Dr. Schweinberger.

Q:

What is your preferred offloading device for pressure ulcers on the heel and ankle?

A:

Dr. Suzuki performs two primary interventions for heel and ankle pressure ulcers. First, for prevention, for any patient admitted with a high risk for pressure ulcers (based on the Braden Scale and a frailty test), he applies Mepilex (Mölnlycke Health Care) to the posterior heels as a measure to help prevent pressure ulcers. He advises changing this dressing once a week or more frequently as needed.

Second, for the treatment and prevention of heel pressure ulcers, Dr. Suzuki frequently fits patients with Prevalon boots (Sage Products). He says these boots are bulky and soft pillow boots with a heel cutout so the patient’s heels are always “floated” off the bed surface. Dr. Suzuki also recommends these pillow boots for outpatients.

Dr. Schweinberger will often use a padded heel offloading boot for heel ulcers or a heels up pillow composed of a foam-type material with foam barriers on the sides to prevent the legs from rolling off. For ankle pressure ulcers, she says heel offloading boots that have a bar to prevent external and internal rotation of the foot can be beneficial, but the patient has to lie on his or her back.

For immobile patients with heel and ankle ulcers, Dr. Swain will ensure they have an appropriate mattress. If possible, he attempts to get them a fluid immersion simulation mattress such as the Dolphin Fluid Immersion Simulation System (Joerns Healthcare). With no other changes in the wound care regimen, he has seen stage 4 ulcers with large amounts of exposed bone heal very quickly when patients have used these sophisticated mattresses. For mobile patients, Dr. Swain usually uses felt and foam heel protectors to help with offloading.

“Education for the patient and patient’s caregivers on the need for constant offloading and maintenance of a strict offloading rotation schedule every two hours is often more important than any wound care products used for pressure ulcers,” maintains Dr. Swain. “Without active patient participation in the offloading, the ulcers will be much less likely to heal.”

Dr. Suzuki asks outpatient patients about their bed mattress and mobility issues. If patients tell him they have had the same spring mattress for the last 10 years or more, he may recommend purchasing a memory foam mattress as it may be gentler to their bony prominence (specifically, posterior heels and ankle malleoli), where the incidence of pressure ulcers is high.

Q:

What is your offloading device of choice for diabetic neuropathic foot ulcers?

A:

Depending on the mobility of the patient, the location of the ulcer, the patient’s vascular status and the drainage amount of the wound, Dr. Swain will either use a total contact cast or soft cast. He often starts with a soft cast along with more frequent dressing changes before eventual transition to a hard cast once the ulcer is more stable. Dr. Swain notes the hard cast is superior for offloading but concedes it is not always practical.

“(This is) where the use of the total contact soft cast becomes vital to healing the ulcers in a faster and safer manner,” says Dr. Swain.

Dr. Schweinberger frequently offloads with felt and foam under dressings, placing patients in a standard surgical shoe. She also uses total contact casts and occasionally cast boots, but still ensures offloading of the patient under the dressing.

When Dr. Suzuki worked in a large orthopedic department with cast technicians present at all times, he would order a total contact cast for neuropathic foot ulcers on a daily basis. As he emphasizes, total contact casting is still the gold standard in healing neuropathic foot ulcers in patients with or without diabetes. Now Dr. Suzuki will rely on a combination of a multilayer compression bandage with a long leg walking boot. He says this combination is just as effective as total contact casting based on his own experience for the past 10 years.

“I strongly believe that good and thorough education of our patients on the importance of offloading and the worst case scenario (limb loss), as well as employing the family and friends to monitor the wound patients’ activity are also crucial,” says Dr. Suzuki.

If the patient is not a candidate for casting, Dr. Swain uses a controlled ankle motion (CAM) walker or Charcot restraint orthotic walker (CROW) for patients with diabetic neuropathic foot ulcers. He often supplements offloading with a rolling knee walker for those patients for whom it is a safe option. Dr. Swain typically will not utilize crutches for offloading. He says most patients will not use them.

Dr. Schweinberger is affiliated with the Veterans Affairs Medical Center in Cheyenne, Wyoming. She is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Suzuki is the Medical Director of the Tower Wound Care Centers at the Cedars-Sinai Medical Towers. He is also on the medical staff of the Cedars-Sinai Medical Center in Los Angeles and is a Visiting Professor at the Tokyo Medical and Dental University in Tokyo. He can be reached at Kazu.Suzuki@cshs.org.

Dr. Swain is a board-certified wound specialist physician (CWSP) of the American Board of Wound Management, and a Diplomate of the American Board of Podiatric Medicine. He is the Medical Director of the St. Vincent’s Wound Care and Hyperbaric Center at St. Vincent’s Southside Hospital, and is in private practice in Jacksonville, Fla.

For further reading, see “Transitioning From Open Wound To Final Footwear: Offloading The Diabetic Foot” in the September 2012 issue of Podiatry Today or “Emerging Insights On Ex-Fix Offloading For Diabetic Foot Ulcers” in the April 2013 issue.