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Offloading - Management of DFUs

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In a 2014 literary review compiled by world leading medical practitioners and researchers, "Evidence consistently demonstrated that when offloading is integrated into the patient encounter process and provided at each visit, the likelihood of healing a DFU is greater and the chance for complications is reduced". Offloading is an etiologic therapy of neuropathic diabetic foot ulcers. When correctly applied, it has been proven not only to interrupt the pathogenic chain that produces the ulceration, but also to induce modifications in the histology of the ulcer, shifting it from a chronic inflammatory state to a much more evolutive condition. Offloading is also confirmed to be a cost-effective treatment for DFUs.


Total Contact Casting is recognized as the Gold Standard of Care for a diabetic foot ulcer. The cast is used to heal diabetic foot ulcers by distributing weight along the entire plantar aspect of the foot. It is applied in such a way as to precisely contour the foot.

A study by Piagessi et al (2007) showed no differences in healing rates at 12-week follow-up between TCC and the Optima Diab. They found that rendering a boot irremovable was the largest influencer of successful management. 

Non-removable devices healing rate > 80%

Removable devices healing rate < 60%

TCC-EZ® is a unique and versatile total contact cast system designed to reduce application time while providing improved healing rates for the diabetic foot ulcer, and increased stability and comfort for the patient. TCC-EZ® offers a one-piece, roll-on, light weight, woven design that is faster and easier than traditional total contact cast systems.
  • TCC-EZ® can be applied in under 10 minutes
  • Enforced patient compliance
  • Takes less than ¼ of the amount of time of traditional total contact casting
  • Requires minimal training time
  • Lightweight woven design offers a more comfortable fit
  • Allows for customized fit on every application

Alternative to Total Contact Casting

While TCC is the gold standard for offloading DFUs, it is not always practical or indeed possible to implement. Research has shown Instant Total Contact Cast Boots (ITCC) to be the next best alternative to TCC. These non-removable walker boots are easier to fit and less expensive than traditional TCC.

Optima Diab®

The Optima Diab is a lightweight, thermo-formable walker boot with a full foot high rocker sole, facilitating an efficient and consistent gait. It features four adjustable Velcro fasteners ensuring easy application. The 3x3 Puzzle Insole allows for further customisation of offloading. This boot can be made into an instant total contact cast boot by the use of the locking mechanism provided.

  • rigid full foot high rocker sole
  • shock attenuating and durable Polyurethane sole unit
  • universal fitting suitable for left and right
  • heat mouldable shell
  • 4 adjustable Velcro fasteners
  • locking mechanism to convert to an instant total contact cast boot
  • 3 layered (soft, medium, hard) puzzle insole for additional customisation

 

Conclusions

  1. Offloading devices should be used more
  2. Improve patient education and compliance levels
  3. TCC / iTCC’s are Gold Standard (Non Removable)
  4. Walker boots with suitable insole are 2nd choice
  5. If TCC & Walker Boots are not appropriate use offloading shoe and suitable insole
  6. Consider foot shape & mechanics when fitting & selecting any offloading device

References

  1. Snyder, J. et.al (2014). The Management of Diabetic Foot Ulcers through Optimal Off-loading. Building Consensus Guidelines and Practical Recommendations to Improve Outcomes. JAPMA. Vol 104. No. 6.
  2. Hingorani, A. et. al (2016). The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. Journal Vascular Surgery.
  3. Piaggesi A, et al. (2016). Comparison of removable and irremovable walking boot to total contact casting in offloading the neuropathic diabetic foot ulceration. Foot Ankle Int. 2016; 37(8):855–61

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