Offloading: The Comprehensive Guide Editorial Summary Foot complications are one of the most serious and debilitating consequences of Diabetes Mellitus. With global predictions of the number of diabetic patients near doubling by 2030, this condition is likely to be at the forefront of our clinical caseload. Aside from the morbidity and global healthcare burden in a diabetic patient with foot ulcers and amputations there is a significant financial implication. Early detection and active management can delay or even prevent the onset of adverse outcomes. Protocols reflect the need for regular foot evaluations in every diabetic patient should have foot evaluation at yearly intervals. The cornerstone of the management are a multidisciplinary approach to prevention, including prevention of infection, appropriate wound care and management of non-viable tissue, and pressure reduction. The Triad of peripheral neuropathy, foot deformity and minor trauma have been found as risk factors in majority of cases of diabetic foot ulcers. Offloading the affected foot is a pivotal management strategy dispersing pressure away from the affected part. This article provides a concise overview of a variety of offloading techniques and their pros and cons.
Figure 1: Bohler Iron Walking Cast. 6
Introduction
I Dr Anthony Tickner Medical Director, Saint Vincent Hospital Wound Healing Center Vice President, Massachusetts Foot & Ankle Society President & CEO-Associated Foot Specialists, P.C.
n patients with diabetes, 12-25% develop a diabetic foot ulceration (DFU) in their lifetime. This is a leading cause of diabetesrelated hospitalization and non-traumatic lower extremity amputation. DFU’s may lead to an increase in global morbidity, mortality, healthcare costs from hospitalizations, surgical and nonsurgical interventions, and amputations. Excessive pressure contributes delayed healing in up to 94% of these ulcerations. Pressure offloading can arguably be the most important principle implemented in treating diabetic foot ulcerations.1,2,3,4,5
Offloading Around the World
Westford MA, United States
There are many different offloading techniques used around the world. Although Total contact casting (TCC) is the gold standard for offloading, it requires resources that may not be available in various countries. Fortunately, physicians are innovative and resourceful when it comes to caring for their patients and alternatives have been found.
Bohler Iron Walking Cast
Dr Lee Rogers Chief-Podiatric Services, UT Health San Antonio President, American Board of Podiatric Medicine Associate Editor, Journal of The American Podiatric Medical Association San Antonio TX, United States
Images available from open access article: Venkatakrishnan S, Zachariah K, et al. A Description of a Modified Bohler Iron Walking Cast in the Management of Plantar Ulcers. J Foot Ankle Surg (Asia-Pacific) 2019;6(1):10–12.
Mandakini Offloading System The Mandakini offloading system is also discussed in Indian literature as an effective and cost-effective offloading technique. First, a pair of gloves is rolled together. The number of gloves used is dependent on the patient size. The gloves are then placed in an adhesive dynoplast, which is then applied to the foot. For distal lesions, it is applied proximally, and for rearfoot lesions, it is applied distal to the lesion. The device is then secured with a dressing. This technique is recommended to be changed every week for 4-6 weeks and authors noted complete healing without patient complaints with over 2 years of regular uses of the technique.7 Figure 2: Mandakini Offloading System. 31
In India, the Bohler iron walking cast has been discussed in recent literature as a more effective offloading method because the entire plantar surface is off the ground. In this method, a lower leg cast is applied followed by an iron rod with a plantar platform. The iron rod is then applied with a clamp proximally and secured with more casting material. A modification is also utilized with roads and a distally placed hinge, to allow for a posterior platform for heel ulcerations.6 Images available from open access article: Kari SV. The economical way to off-load diabetic foot ulcers [Mandakini off-loading device]. Indian J Surg. 2010 Apr;72(2):133-4. doi: 10.1007/s12262-010-0042-3. Epub 2010 Jul 1. PMID: 23133224; PMCID: PMC3452512.
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Wound Masterclass - Vol 1 - December 2022
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