Offloading the diabetic foot: toward healing wounds and extending ulcer-free days in remission

Abstract

Management of the diabetic foot is multifaceted and requires constant monitoring from patients and health care providers. The alarmingly high rate of recurrence of ulcerations in diabetic foot requires a change in our approach to care and to the vernacular in the medical literature. With its high rates of morbidity and recurrence, care of the complex diabetic foot may be aptly comparable to many forms of cancer. Therefore, our efforts should be not only in rapid healing of open wounds but also in maximizing ulcer-free days for the patient in diabetic foot remission. One facet of the multidisciplinary approach in managing wounds is achieved by reducing peak plantar pressures by offloading the foot with various conservative and surgical techniques aimed at reducing areas of stress caused by ambulation and improper shoe gear. Evidence supports the use of total contact casts as the gold standard for offloading open wounds; however, other methods have gained popularity as well. Novel approaches in surgical techniques and advances in wearable technology appear to show promise in measuring and modulating dangerous pressure and inflammation to extend remission and improve quality of life for these most complex patients. Keywords: diabetic foot, ulcer, remission, amputation, offloading, wearables Diabetes and other noncommunicable diseases of decay are now the leading cause of global mortality in the developed and developing world.1 As the continuously growing epidemic of diabetes further expands, it inflicts affected patients with a myriad of subsequent diabetic complications and comorbidities that necessitate further financial investments in managing these patients in a multidisciplinary setting to save limbs from amputation. There are several well-known guidelines for prolonging remission from ulceration in the diabetic foot with the mind-set of "active prevention", including having a heightened awareness of these risk factors associated with ulceration, patient education, staying active, frequent inspection of the feet, reducing friction by wearing diabetic socks and proper footwear, avoiding self-injurious behavior such as walking barefoot, and long-term management of the various comorbid systemic diseases associated with diabetes. 2,3 Due to the economic, physical, and psychological cost of diabetic foot ulcers (DFUs), efforts to delay or prevent their development are a prudent use of medical resources. Remarkably, people with DFUs have a risk of hospitalization that is comparable to or exceeding heart failure, pulmonary disease, renal disease, and most cancers. 4 Patients with diabetes mellitus (DM) undergoing treatment of DFUs often present with confounding factors and subsequently experience high rates of recurrence. Of the individuals who successfully heal a DFU, the risk of ulcer recurrence within

Building a scalable diabetic limb preservation program: four steps to success

“…After resolution of sequelae from wounds and complete healing is obtained, the patient should be referred to a remission clinic [17,18]. Regardless if the patient was managed as an inpatient or an outpatient, the remission clinic serves as an integral part of a limb preservation program to maximize ulcer-free, hospital-free, and activity-rich days [2,18].…”

“…Regardless if the patient was managed as an inpatient or an outpatient, the remission clinic serves as an integral part of a limb preservation program to maximize ulcer-free, hospital-free, and activity-rich days [2,18]. Individualized patient self-care and monitoring education is a key function of the remission clinic, along with home-based monitoring program coordination, as they have shown to reduce ulcer recurrence [2,19–22].…”

Wounds : an overlooked burden (Part 2) - Wound treatment : a daunting decision

“…10 Where there is poor blood circulation, compression stockings or bandages should be utilised, and in the case of diabetic foot and pressure ulcers, offloading strategies must be employed to eliminate abnormal pressure points. 66 Most importantly, clinicians should determine the vascular status of the patient before choosing any treatment modality. 67 Further elaboration on chronic wounds and their treatment options will be expanded on in part 3 of this series.…”

On the Cutting Edge: Wound Care for the Endovascular Specialist

“…Given exceptionally high rates of ulcer-related morbidity and recurrence, caring for diabetic patients with ulcers has been compared to caring for cancer patient. 99 Diabetic patients have higher peak plantar pressures than the general population, with concomitantly higher rates of neuropathy and PAD. [100][101][102] Repetitive pedal stress in the setting of these pathologies can result in osseous and structural abnormalities of the foot, which can be some of the strongest predictors of ulcer development.…”

“…102,103 Therefore, the goal in these patients is to shift or redistribute plantar pressures by offloading the foot in order to maintain ulcer remission. 99 Traditional total contact casts (TCCs) are the gold standard for offloading open wounds (►Fig. 14).…”