Offloading in diabetic foot

offloading is an important aspect in Diabetic foot ulcer patients.There are two major aspects of offloading. Offloading is immensely useful in helping ulcers heal and secondly in prevention of recurrence of ulcers.

1. Offloading Dr Sumita Shankar M.Ch (Plastic Surgery) FICS (USA, Barcelona) Carl Zeiss Fellow in Hand & Microsurgery Managing Director & Senior Consultant Plastic & Cosmetic surgeon

2. My Experience Wounds :   Diabetic Wounds: 42 Varicose Ulcers: 10 Burn Wounds: 10 Trauma: 10 Tumours : 10 (Benign & Malignant) Iatrogenic: 3 Infective Wounds: 4 Miscellaneous: Filariasis : 2 Fungal: 1 Hansen’s: 2 Foreign Body: 2 Axillary Hydradenitis : 1 Faciotomy Wounds:3

3. OffLoading ‘ Boulton ’ has repeatedly stated that it is not what you put on a DFU that heals it but rather what you take off the wound

4. What is Offloading? Offloading is defined as any measure to eliminate abnormal pressure points to promote healing or prevent recurrence of DFUs. .. . Total contact casts reduce plantar pressure by increasing the weight bearing surface area

5. Learning Objectives Forces applied on foot Principles of Offloading Methods of Offloading- Basics TCC importance

6. Learning Objectives Offloading for DFU Treatment Offloading for Prevention of recurrence Surgical aspects in Offloading Take home message

7. Forces applied to the foot There are four main types of force that are applied to the soft tissues of the foot, whether at rest or during activity: Shear force: when a material is moving in two or more directions at the same time due to single or multiple loads Compressive force: when a material is squashed or squeezed between two or more opposing loads Frictional force: when a force moves over the surface of a material while in contact with it, creating a ‘drag’ across the material’s surfaces Tensile force/strain : when a material is stretched by two or more opposing forces The Diabetic Foot Journal Vol 19 No 4 2016

8. Forces applied to the foot The Diabetic Foot Journal Vol 19 No 4 2016 Types of force: (a), (b) compression, (c) frictional, and (d) tensile force/strain

9. Combined forces The Diabetic Foot Journal Vol 19 No 4 2016

10. Essential factors regarding the forces include : Forces applied to the foot Magnitude : the size of the applied forces Direction : which way the forces are entering and exiting Velocity : the speed at which forces are applied and dissipated Duration : the amount of time any given force is in contact with the foot. The Diabetic Foot Journal Vol 19 No 4 2016

11. Concept of Off-Loading Off-loading is use of devices or surgeries that remove pressure or reduce the “load” at the site of ulceration This is to improve healing of the ulcers DFUs often occur on the sole of the foot at sites of repetitive injury that are unrecognized by patients with diabetic sensory neuropathy. The ulcers are usually at a pressure point on the bottom of the foot where a callus has formed. If a neuropathic patient continues to walk on an ulcer, every step “crushes” new tissue that is attempting to organize and fill the soft-tissue void. Diagnosis and Management of Diabetic Foot Complications. 2018 by the American Diabetes Association, Inc.

12. How does Off-Loading work? The Diabetic Foot Journal Vol 19 No 4 2016 Off-loading is one of the most important interventions to facilitate the healing of foot ulcers This allows healing tissue to bridge the wound without continual damage. Reduce pressure and shear forces at the site of ulceration. Reduce motion of the joints of the foot Decreases the number of steps or loading cycles per day

13. Diabetic F oot changes Small muscle atrophy with corresponding muscle weakness and deformity   This muscle atrophy may lead to increased plantar pressure , Motor impairment, shortening of the Achilles tend on (due to glycosylation) and possible rupture of the plantar fascia have the potential to produce equinous deformity D iabetes are prone to a non-enzymatic glycation of their soft tissues, which can in turn lead to tightening of the periarticular structures around the joints causing joint immobility

14. Peak pressure profile for a diabetic foot Notes : (A) Two-dimensional (2D) depiction of plantar pressure and (B) 3D depiction of plantar pressure (note the abnormal spikes along the lateral forefoot ).

15. DFU

16. DFU

17. DFUwith Club foot

18. Diabetic Foot Ulcer Debriding the hyperkeratotic and callused skin surrounding the wound edge is the first step of offloading. 

19. Diabetic Foot Ulcer Coaptation of the wound edges is the next step of DFU healing

20. Diabetic Foot Ulcer Total C ontact Cast is the Ultimate step of Offloading for DFU healing

21. Total Contact Cast Total contact casts are the gold standard for offloading diabetic neuropathic wounds yet are quite cumbersome for patients and take significant time and expertise to apply properly in the clinical setting.

22. Total Contact Casts - TCCs The Diabetic Foot Journal Vol 19 No 4 2016 TCC is a below-knee cast that incorporates the whole lower limb, encasing the whole foot. Gold standard for the offloading of mid- and forefoot lesions and there is a body of evidence to support its use. Gold standard form of offloading for neuropathic non-infected plantar ulcers The technique is not widely used in clinical practice, possibly due to a lack of education, training, and resources. Reportedly healing between 72 and 100% of ulcers within 5–8 weeks.

23. Diabetic Foot Ulcer   Facilitating a short, shuffling gait offers yet another simple means of offloading the foot

24. Removable heel casts Removable heel casts can fit into ordinary footwear or cast sandals and should be replaced when soiled. Make a cavity within this area to accommodate thin dressings and enable additional offloading. The Diabetic Foot Journal Vol 19 No 4 2016

25. Below-knee walking cast The Diabetic Foot Journal Vol 19 No 4 2016 Similar to the cast used for setting lower-leg fractures, with some additions. Accommodative padding is applied to the contours of the foot and some under-cast padding to the leg Bony prominences before the cast tape is applied. The ulcerated area can be left totally enclosed or a window cut for inspection and redressing. Not considered as effective as a TCCs; however, both immobilise the foot and ankle, thus reducing shear and activity levels

26. Removable cast walkers/instant TCCs The Diabetic Foot Journal Vol 19 No 4 2016 The instant total contact cast renders this type of device non-removable due to the application of a resin cast bandage around the leg section of the cast.

27. Removable cast walkers (RCWs) are one alternative to the TCC in that they are rapidly applied and equally efficacious, are easily removed to wash and inspect wounds, and allow patients to ambulate with adequate plantar offloading via the rocker bottom sole. RCWs are also an excellent alternative to TCCs for patients with vascular diseases like critical limb ischemia.20 The advantage of the easily applied and removed RCW is also its weakness in that patient adherence to the walker is a major factor in nonhealing ulcers and frequent recurrence in those who do not continually wear their RCWs. A hybrid device known as the “instant TCC” utilizes the frame of the RCW alongside the semipermanent binding of TCCs. By wrapping the RCW with a cohesive bandage (Figure 3), patients benefit from the forced compliance of a TCC while enjoying the more tolerable offloading capability of an RCW.21

28. Bohler’s Iron with TCC

29. Samadhan System of Offloading Diagnosis and Management of Diabetic Foot Complications. 2018 by the American Diabetes Association, Inc. Samadhan unit: a foam cylinder Retainer: a piece of elastocreppe bandage Fastners : metallic hooks provided with the elastocreppe bandage or safety pins. Samadhan System has 3 components Very simple to manufacture It needs only a small space to accommodate a small table with a shelf to keep raw material and prepared Samadhan Units.

30. Samadhan System of Offloading Piece of foam measuring 6 inches × 4 inches is cut from the big sheet . Applying liquid adhesive Rolling in to a cylinder Pile of samadhan units and retainer bandage

31. Samadhan System of Offloading Cutting samadhan unit to size Placing samadhan unit on plantar surface Wrapping retainer bandage Going for work with sandals

32. Offloading Crutches Walker Wheelchair

33. Offloading Prevention of recurrence of DFU

34. Characteristics of preventive foot wear Broad toe box Soft insole Rigid outsole Extra depth Non traumatic lining

35. Footwear The Diabetic Foot Journal Vol 19 No 4 2016 Representative offloading devices a Extra depth shoe b Custom-made orthotic c Prefabricated orthotic

36. Half shoe Molded insole Rocker Bottom shoe Customised footwear Plantar metatarsal pads

37. Monitoring strategies and technological innovations Wearables The emergence of “smart” technologies and W earable electronics paves the way for the integration of both in the context of providing patients and clinicians with objective data about patient health that is easily accessible ..

38. At-home monitors A 2007 study found that those who did not use a system for temperature monitoring system quadrupled their chances of developing foot ulcer recurrence than those who did, emphasizing the major impact this technology could have on global health if implemented ubiquitously .

39. SmartSox uses fiber optic cables embedded within socks to warn the patient of peaks in plantar pressure Warning messages are sent to the patient’s wristwatch, instructing them to offload the areas of high pressure.

40. Offloading by Surgery Callus Removal Condylectomy PAN Condylectomy Achilles Tendon lenghthening Surgical correction of skeletal abnormalities P lantar fat pad augmentation Single Metatarsal head All Metatarsal heads removed

41. Offloading by Callus removal Reduces plantar pressure by 29%

42. The instant total contact cast. The instant total contact cast. Note: A removable cast walker rendered irremovable due to wrapping of the upper portion with a layer of fiberglass.

43. Achilles tendon lengthening Achilles tendon lengthening is an effective method to reduce the recurrence of plantar diabetic neuropathic ulcers of the forefoot in patients with limited ankle range of motion.

44. Surgical correction of skeletal abnormalities Deformities of the foot’s natural osseous architecture is highly linked to ulcer recurrence; therefore, surgical debridement of the abnormal bones is often necessary to aid in prolonging ulcerative remission .

45. Plantar fat pad augmentation Silicone injection treatment indicated its safe utility in prevention and maintenance of wound remission . Autologous fat transfer

46. The role of the multidisciplinary team (MDT) A coordinated team approach has also been shown to decrease the frequency of limb loss in diabetic patients worldwide . A n MDT should comprise doctors with a particular interest in diabetes, podiatrists, trained nurses, vascular surgeons, orthopedic surgeons, infection specialists, orthotists , social workers, and psychologists

47. Patient friendly technique is key Offloading principles should have the advantage of being widely accepted by patients. They should not require expertise, special training, or special equipment (Simple) These should be relatively inexpensive. Do not interfere with normal walking, driving, or bathing. ( daily activities) This will lead to more patient adherence. Diagnosis and Management of Diabetic Foot Complications. 2018 by the American Diabetes Association, Inc.

48. Take Home Message DFU: Infection Vasculopathy Foot Hygiene local wound management ( callus removal, debridement & coaptation of wound edges ) Offloading Prevention of recurrence Offloading Hygiene /smoking Infection/ glycemic control & Early detection

49. Education Bottom line: Educating Patient / Family Health care Providers