Preparing to Repair: Improving Outcomes Through Offloading

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My name is Matthew Regulski. I have practiced in Toms River, New Jersey for almost 20 years. I run the Wound Institute of Ocean County, New Jersey. Offloading, as we talk in my prepare to repair paradigm is critical for any ulceration on the lower extremity. Not only when we talk about total contact casting for the plantar foot, but I also use it for ankle, heel, dorsal foot, hallux and interphalangeal joint ulcerations. There's lots of things you can do. You have to take the pressure off the wound. I prefer to use total contact casts. Total contact casting has five RCTs behind it to show that has a 90% healing rate, when you do a good standard of care with it. I'm not just saying we put the cast on and don't worry about anything else. You still have to do all those good things.

Why is it only used in two to 6% of all diabetic foot ulcers? It's one of the few things where we have major evidence base behind it to utilize. And I think two things. I think one is that people are afraid of causing another problem. So we counter that by saying, listen, when you talk to these companies, they will come to your facility. They will come to your office just like they did for me. And they train your whole staff and they come every year. They were just in our, one of our one centers last week training our resident physicians how to do it. So they will come and spend the time with your staff and with you to make sure that you are doing it correctly. So do not be afraid of it at all because it's one of the best things that you can do for your patients.

I think the second thing is sometimes people get caught up in the weeds of reimbursement because there's great reimbursement on total contact casts. You can't use one code for two procedures. Some people would just take the diabetic foot ulcer or whatever ulcer they're doing. And then the, the, the procedure code will be debridement and casting. You will not get paid for both of those. The debridement code has to go with the ulcer. When you use a total contact has bill an equinus code, a difficulty walking, a contracture code. Now you have to describe and reflect that (evidence) in your note. So I usually like to say, “A total contact cast was used. Patient has equinus at six degrees dorsiflexion with the knee straight,” something of that nature. And then we talk, I have a little blurb on my auto text of how it's has level one evidence in multiple randomized controlled trials.

If we don't use it, the wound could erode bone, can get exposed infection and so forth. So remember that you have to use two different codes for those two different procedures. If you keep the ulcer code with your debridement and your casting will not get paid for it. I try to get everybody I can in a total contact cast who has the need for it. Now granted it could be their driving foot or, I've had people that get claustrophobic. And when you start with the casting and I highly recommend you bring them back in two to three days and change it again because you're going to put them in a position that will stretch that Achilles because it's tight. I will suggest to them to use a cane for a little bit.

And some people, when you put them in a cast, they try to walk as fast as everybody else and you can't. You have to tell them to temper their expectation by taking it easy. And what's great about the total contact has is now they're protected. Go ahead, go to the store, go to the mall, go out to church, go to dinner. You're protected. Because if you don't have that on, then they have to stay off the foot. If I can't get them into a total contact cast, I do like to use Foot Defender. Foot Defender also has, it has multiple studies behind its use. It's almost as good as a total contact cast, but you can take it off. Okay. It's very easy to get. It's reimbursed by Medicare. There's codes for it. Um, I've even told people in the beginning to just who weren't Medicare, to go to the website and acquire that.

It's easy, very easy. The front opens up, slip in, it has a MAFO in the back. It has a MAFO in the front to stop translation of the tibia. And then with that, Dr. Hanft developed that really incredible inlay that has incredible offloading, uh, power, almost as good as a total contact cast. So we try to use those two things each and every time. We want diabetics to walk and move. It reduces their plaque formation in their body, reduces their sugar level. They can go and do stuff when you're in the cast. That's why I don't understand why it's not used more often. Highest level of evidence, people will come and train you to how to put it on and do those things with it highly reimbursable when it's coded correctly, five RCTs behind it. I don't understand why more people are not utilizing that. I can't figure it out. But please, it has the evidence, it has the reimbursement. Use it when it is appropriate to be used.