Working Under Pressure is Not Always. a Good Thing. Kathya M. Zinszer, DPM, MPH, MAPWCA. Geisinger Hospital System Orthopedics Department Danville, PA

Transcription

1 Working Under Pressure is Not Always a Good Thing Kathya M. Zinszer, DPM, MPH, MAPWCA Geisinger Hospital System Orthopedics Department Danville, PA

2 Disclosures No relevant financial relationships to disclose. 9/8/2018

3 Foot Deformities and how we offload and protect them

4 Wound care professionals often say: It s not what one puts on a wound that heals it, but what one takes off. Appropriate wound care, debridement, and pressure reduction have and will continue to be the cornerstones of treatment. The key to successful pressure reduction possibly lies more in patient adherence than in the prescribed offloading devices. Individuals with diabetes who have lost the gift of pain may not always adhere to the offloading regimen. Combining an effective, easy-to-use offloading device that ensures patient compliance with advanced wound healing modalities may form a formidable team in healing ulcers and potentially averting lower-limb amputations. Armstrong et al., WOUNDS, 2014

5 So Many Options, how do you choose?

6 Wounds in the diabetic population represent a significant medical and economic burden. If foot pressures are to be reduced, healing to progress, and prevention of ulceration to be a realistic goal, offloading is imperative. Synder & Lanier, 2009

7 A Variety of Standard Offloading Boots and shoes $20-25

8 Darco Forefoot & Heel Offloading Shoe & GlobalPed Forefoot Offloader Rearfoot Heel Offloader $20-25 Posterior Heel and Achilles Tendon offloader

9 Diabetic foot ulcer off-loading: The gap between evidence and practice. Data from the US Wound Registry. Fife, et al. (2014) Advances in Skin & Wound care Disconnect as to what is seen in the literature and what is actually done in the clinical setting Findings: CONCLUSION Total contact casting is vastly underutilized in DFU wound care settings, suggesting that there is a gap in practice for adequate offloading. There is a gap between evidencebased guidelines and current practice, particularly regarding the use of nonremovable off-loading devices to heal uncomplicated neuropathic ulcers. Between Fife, et all looked at DFU offloading in practice. Findings: total number of charts reviewed with diabetic foot ulcers only yielded 2.2% of population that offloaded. The n= 4,896 where only 16% of patients or 781 total were placed into a TCC while other options were used 47.2%.

10 Total Contact Cast: Gold Standard for Plantar Diabetic Foot Ulcers? $20-25

11 Removable Cast Walker Boots yield greater forefoot off-loading than Total Contact Casts Clinical Biomech ( Bristol, Avon). July: 26 (6): Gutekunst, et al Findings: Both TCC & RCWB result in significant reductions in peak pressure with the RCWB produced even greater reductions in FOREFOOT OFFLOADING than the TCC with patient compliance. TCC showed increased healing rates over REMOVABLE CWB s but once the CWB s were rendered IRREMOVABLE through application of a layer of Fiberglass Casting material (Armstrong, et al 2005), studies showed that the IRREMOVABLE CWB yielded statistically EQUIVALENT healing rates compared to a standard TCC ( Katz et al. 2005)

12 Bledsoe & Pneumatic Walking Boots $20-25

13 International Working Group on the Diabetic Foot: Guidance on Footwear and Offloading interventions to prevent & heal foot ulcers in patients with diabetes (2015) Findings: To effectively heal plantar foot ulcers, the TCC is no longer the gold standard treatment option. Pre-fabricated Removable walkers that are rendered irremovable have been shown to be as effective as the TCC. The paradigm shift is now comparing: Non-removable VS Removable offloading Little to no data is available on the value of offloading in healing complicated plantar foot ulcers, midfoot, and heel ulcer or non-plantar ulcers, even though these ulcers are more common in specialized settings.

14 Felted Foam: Lower risk for Plantar Diabetic Foot Ulcers with severe PDN $20-25

15

16 Charcot Restraint Orthotic Walker (CROW) This device is also known as a clamshell or bivalved AFO (BAFO). It is composed of a polypropylene material, lined with plastizote, incorporates a total contact custom molded orthotic, and utilizes a rocker bottom sole. The CROW is the treatment of choice for many clinicians during the quiescent second and third Eichenholtz stages of the arthropathy process where joint stability and alignment must be maintained. 23 Armstrong et al. Offloading Foot Wounds in People with Diabetes. WOUNDS, 2014

17 New off-loading consensus guidelines with device review JAPMA, December Armstrong, Snyder, Applewhite

18 33yo Male T2DM, presents with wart on Right Heel 9/8/2018

19 9/8/2018 August 2016 Mild changes Midfoot Baseline

20 9/8/2018 August 2017: 1 year later Notice MidFoot Drop

21 April /8/2018

22 July 2018 Mid Foot dislocation and collapse 9/8/2018

23 9/8/2018 July 2018 Right Foot Wound started with a Blister

24 September: Right foot wound progression 9/8/2018

25 Sept. 4, /8/2018

26 9/8/2018 Left Limb now starting to progress, no wounds yet

27 It takes a village to offload a foot!! Likelihood of healing is INCREASED with Offloading adherence The key to successful pressure reduction possibly lies more in patient adherence than in the prescribed offloading devices. Take Home pearls: Start the conversation early about offloading abnormal high pressure areas, midfoot collapse Get to know a GREAT pedorthist and orthotist Discuss the risks and signs of Charcot at initial visit with your patients with DM and neuropathy Trust your index of suspicion and guide the patient in OFFLOADING

28 Thank you! 9/8/2018

29 Working under pressure is not always a good thing Kathya M. Zinszer, DPM, MPH, MAPWCA

30 Working Under Pressure is Not Always a Good Thing Kathya M. Zinszer, DPM, MPH, MAPWCA Geisinger Hospital System Orthopedics Department Danville, PA