Tag: offloading

Take A Load Off: Offloading Tips And Pearls In Wound Care

Diabetic foot ulcerations (DFUs) affect approximately 26 million people worldwide, with a staggering 2.5 times increased risk of death at five years.1-3 While many etiologies and conditions contribute to a wound, offloading is crucial to solving the wound healing puzzle.

In some literature, offloading is the most important aspect of DFU treatment in patients with neuropathy.4-6 The thought behind offloading is relief of mechanical and abnormal stresses that the foot experiences from a loss of protective sensation. This combination results in tissue damage, thought to lead to many DFUs.1,4,7 Specifically, mechanical stress is due to increased plantar pressure and shearing forces during the gait cycle, causing repetitive microtrauma … read more

A Novel Method to Offload Neuropathic Ulcers of the Distal Phalanges in the Presence of First Ray Metatarsal Hypermobility

The standard practice to heal neuropathic ulcers on the toes is to offload the affected areas with special types of therapeutic footwear including shoes and boots to reduce the amount of pressure on the wound. Once healed, the individual wears custom insoles to prevent the development of new wounds. In our practice, we found that some newly healed wounds will reulcerate despite wearing therapeutic footwear. We devised a method to prevent and offload neuropathic foot ulcers on the distal phalanges in the presence of first ray metatarsal hypermobility, a common problem associated with the development of wounds … read more

The industry’s BEST TCC Kit is Now Available on Amazon. M-Med provides the most versatile total contact cast on the market with the TCC-Mobility Series. 60% more padding for patient comfort and safety. Click here for more information on TCC-Mobility Series.

 

You can order as many or as few kits based on your need- there’s no minimum order quantity. And, we have the Best Price in the marketplace allowing your practice to maximize value per procedure. M-Med’s TCC kits are fully customizable.

 

Sample Request Form

Dr. Michael Miller

As an advanced wound care specialist for almost 20 years full time, I am a relentless devotee of best practices and the wound care literature. While there are many wound care practices that allow some personal latitude, there are one or two “definites”. The literature has recently become very vociferous in the use of Total Contact Casting as the “Gold Standard” for offloading plantar based Diabetic Neuropathic Foot ulcers. As a non-hospital affiliated wound care specialist, I have no deep pocket entity to support me as I trial device after device searching for ease of use, facilitated patient compliance, and more, best pricing.

 

I found your devices in a search for an equally efficacious TCC that had better pricing than the many on the market. Since no two patients are alike, the many components in your kit allowed me to configure the final product, controlling the height, thickness, weight and even the configuration/position of the walking gasket. More, the pricing for needed large orders made this a less painful expenditure for me. Of course, the rapid shipping came in handy when my staff opened a closet door to discover two casts and four patients on the schedule in 48 hours.

 

I wanted to take the time to let you know how much I appreciate the products you have available for those of us who strive to provide best care using the best products, at what I have found to be best service and pricing.

 

Respectfully yours

 

Michael S. Miller DO, FACOS, WCC
CEO and Medical Director – The Miller Care Group
Indianapolis, IN

A Total Offloading Foot Brace for Treatment of Diabetic Foot Ulcers

     Results From a Halted Randomized Controlled Trial

 

Introduction. Foot offloading is the mainstay treatment for plantar diabetic foot ulcers (DFUs). Objective. This multicenter, single-blinded, randomized controlled trial evaluates the efficacy of a total offloading foot brace for healing plantar DFUs. Materials and Methods. Seventeen patients were randomized to standard therapy (ie, reducing stress and pressure via mechanical offloading) or offloading foot brace. Comparison of plantar pressures was performed using digital pressure sensing films. The ulcers were assessed by physical inspection and digital planimetry of photographs. Results. Reductions in peak plantar pressures ranged from 67.3% to 89.4% (P = .09). Healing at weeks 12 to 15 had minimal differences (brace vs. control: 71.7% vs. 80.3%, respectively). Although not significant, earlier periods of the brace versus the control demonstrated faster wound healing in weeks 2 to 5 (36.0% vs. 6.8%, respectively) and weeks 6 to 9 (50.7% vs. 17.0%, respectively). Conclusions. The total offloading foot brace minimizes plantar pressure, allowing for early healing of DFUs, and optimizations in brace design may enhance healing of plantar DFUs … read more

Total Contact Cast Offloading Real Treatment For All Plantar Based Wounds

 

Patient is a 49 year old male with a history of Charcot Marie Tooth Disease (CMT) who presented with a a plantar ulcer of the Left Foot. CMT is an inherited neuropathy which directly damage nerves fibers resulting in both sensory and motor neuropathy causing significant foot deformities. His medical history included an unknown type of reconstructive surgery to the left foot in 2007 for his CMT. The presenting plantar ulcer had been there for 7 months and treated continuously by a local podiatrist with Iodine dressings only. The patient had never been prescribed any offloading devices and presented wearing canvas sneakers. Our Initial treatment consisted of aggressive debridement of the ulcer to 100% bleeding surfaces including all skin margins. Hemostasis was achieved rapidly using Scion CLO-SURPLUS PADTM Chitosan Hemostatic dressing. M-Med’s Mobility Series Total Contact Cast Kit was used to allow for modification for his unusual foot configuration. He underwent total contact casting weekly with complete healing in 5 weeks. The multi-component TTC system allowed for modifications by adding, subtracting or modifying components for the desired fit needed at that time. He was placed in a custom molded shoe with inserts and has had no recurrence to date … read more

Treating Hard-to-Heal Wounds

An Evidence-Based Approach for DFU and Chronic Wounds

 

This is a brief summary of a presentation given at the annual conference of Wounds Canada, in Mississauga, Ontario, on November 16th, 2017. It has been produced with the financial support of Integra Life Sciences. The presenter was Robert Fridman, DPM FACFAS CWSP, a fellowship-trained podiatric surgeon at the Department of Orthopaedic Surgery at New York-Presbyterian Columbia University Medical Center and the Department of Surgery at New York-Presbyterian Weill-Cornell Medical Center.

 

Normal Wound Healing
For health-care professionals, standard wound management consists of preparing the wound bed to support the healing process. When treating diabetic foot ulcers (DFUs), health-care professionals must work toward controlling infection, correcting ischemia, optimizing nutrition, correcting hyperglycemia and offloading of the wound.

 

Offloading
Offloading is one of the cornerstones of effective management of a diabetic foot ulcer, as it helps to minimize repetitive trauma to the area. Total contact casting (TCC) has been established as the gold standard to achieve offloading while enabling patients to ambulate. TCC enables pressure to be transmitted to the cast wall or rearfoot, resulting in decreased forefoot pressure. The device also reduces gait speed and shortens stride length, resulting in reduction of pressure. Ankle movement and the propulsive phase of gait are reduced, resulting in a reduction in vertical loading forces (see Figure 1). Ninety percent of DFUs have been shown to heal within six weeks when treated with a TCC … read more

$70,000 Amputation or $250 Offloading Procedure

Please choose one

Easy choice right? Not for the Government of Ontario Canada. The vast majority of the 2,000 amputations that occur per year in that country would be preventable with common offloading practices (total contact casting*). Doris Grinspun, CEO of the Registered Nurses’ Association of Ontario was assured three years ago by government ‘premieres’ that they would begin to cover such procedures … that’s three years or 6,000 legs or $420,000,000 ago. “We’re willing to pay for the amputations but we’re not willing to pay for the prevention,” offered Grinspun.

Cost and human suffering aside, mortality rates jump significantly after an amputation especially in older patients, diabetes further increases mortality rates. In one rather grim study** 390 patients that had undergone lower extremity amputations were reviewed, of the patients with diabetes “the median time to death was 27.2 months“.

So if you are suffering from diabetic neuropathy and experience a diabetic foot ulcer and happen to be living in Ontario Canada you need to get your affairs in order. But there is hope as The Ontario Health Technology Advisory Committee is currently assessing total contact casting to treat foot ulcers, check back in three years.
original article

*total contact casting is considered “The Gold Standard of off-loading”. A comparison of the three major off-loading methods (total-contact casts (TCCs), removable cast walkers (RCWs), and half-shoes) reinforces this point. The proportions of healing for patients treated with TCC, RCW, and half-shoe were 89.5, 65.0, and 58.3%, respectively. A significantly higher proportion of patients were healed by 12 weeks in the TCC group when compared with the two other modalities.

**Mortality and Hospitalization in Patients After Amputation
http://care.diabetesjournals.org/content/29/10/2252.full 

Off-Loading the Diabetic Foot Wound
A randomized clinical trial
http://care.diabetesjournals.org/content/24/6/1019.long

A Journey of a Thousand Steps to #ActAgainstAmputation

Diabetes is the sixth leading cause of death in North America. By 2020, an estimated 4.2 million Canadians will be living with the disease and its devastating complications. People with diabetes have an increased risk of developing diabetic foot ulcers (DFUs) as a result of the loss of protective sensation in their extremities. Twenty five percent of individuals with diabetes will have a DFU in their lifetime, increasing their risk of amputation and pushing their five-year mortality rate to surpass that of patients with Hodgkin’s disease, breast cancer or prostate cancer.1,2,3 The direct cost of diabetes in Canada now accounts for about 3.5% of public health-care spending, and this figure continues to rise.4 The cost of DFUs is an enormous strain on health-care systems: about $12.2 billion in 2010. Care for people living with diabetic foot ulcers needs to be holistic and requires addressing all factors that contribute to ulceration, including repeated trauma and pressure. For years, the Canadian wound-care community recognized and understood the importance and value of pressure … read more (pdf)

A peek under the Cast a Total Contact Casting Primer

a Total Contact Casting Primer with Dr. Michael Miller
(A diatribe in four verses)

 

Okay fans, let’s talk about the science behind Total Contact Casting. But before we talk about the science, what is a Total Contact Cast? Well, before we talk about Total Contact Casting, let’s talk about the key to not just healing wounds but preventing them. But before we talk about preventing and healing them, we need to talk about them … wounds that is.

 

Wound is a term that usually means a defect in the epithelium, which is a five syllable word for skin. Another term you might hear is the word “ulcer”. The simplest way to differentiate these two is to remember that an ulcer arises from the inside and comes out whereas a wound starts on the outside and progresses inside. The key to understanding this is by example’s…

 

The ill equipped robber whose gun fired while he was walking into the store did not receive a gunshot ulcer, he got a gunshot wound. The bullet caused the damage from the outside, in. 

 

The person who took too many aspirin every day and started to have terrible stomach pain did not develop a gastric wound, he developed a gastric ulcer. The lining eroded from the inside out.

 

The beautiful model who could not have her picture taken had a herpes ulcer of her lip, not herpes wound. This ulcer developed from the inside of her lip to the outside

 

The patient who had his hernia fixed and then bumped the incision causing it to open, does not have a stomach ulcer, they have a stomach wound. The incision opened up from the outside exposing the inside.

 

Now that we have the definitions done, back to prevention and treatment. Of course the most obvious question that you need to ask is, what is our diagnosis (diagnoses) for either why this wound developed or what is specifically keeping it from healing?

read more

 

How To Ensure Effective Offloading With Total Contact Casting

I recently had the opportunity to speak at a dinner meeting to a group of wound care clinicians. During a question and answer session, the topic of discussion drifted toward the use of total contact casting (TCC). I asked the meeting participants to indicate, with a show a hands, how many of them were using this modality regularly in their practice. I was shocked to see that the number was less than 10 percent.

 

Numerous authors have described the underlying pathology in the development of lower extremity ulcerations. Perhaps one of the greatest difficulties in managing complex lower extremity ulcerations is offloading the wound site effectively. A review of the literature demonstrates that TCC is the “gold standard” for offloading non-infected, non-ischemic plantar foot ulcerations.1,2

 

There are several mechanisms that combine to provide the reduction of peak plantar pressures via the use of TCC. Studies have established that the use of TCC decreases altered gait mechanics with shortened stride length and an overall reduction of walking velocity, both of which contribute to the reduction of plantar pressures.3 Furthermore, given the “cone effect” provided by the physical structure of the patient’s leg (an inverted cone), the TCC (a conical receptacle) also allows more even distribution of the patient’s weight read more

Total Contact Cast Use in Patients With Peripheral Arterial Disease

As the majority of diabetic foot ulcerations (DFUs) occur on the plantar foot, excessive pressure is a major contributing factor to delayed healing. The gold standard for offloading is the total contact cast (TCC); yet, TCC use is contraindicated in patients with ischemia. Lower extremity ischemia typically presents in the more severe end stages of peripheral arterial disease (PAD). As PAD exists on a severity spectrum from mild to severe, designation of a clear cutoff where TCC use is an absolute contraindication would assist those who treat DFUs on a daily basis. Objective. The aim of this study is to determine if a potential cutoff value for PAD where TCC use would be an absolute contraindication could be ascertained from a retrospective case series and a systematic literature review of patients with PAD in which treatment included TCC use … read more

Diabetic Foot Ulcer Off-loading: The Gap Between Evidence and …

 

Diabetic Foot Ulcer Off-loading: The Gap Between Evidence and Practice. Data from the US Wound Registry

 

Off-loading was documented in only 2.2% of 221,192 visits from January 2, 2007, to January 6, 2013. The most common off-loading option was the postoperative shoe (36.8%) and TCC (16.0%). There were significantly more amputations within 1 year for non-TCC–treated DFUs compared with TCC-treated DFUs (5.2% vs 2.2%; P = .001). The proportion of healed wounds was slightly higher for TCC-treated DFUs versus non-TCC–treated DFUs (39.4% vs 37.2%). Infection rates were significantly higher for non-TCC–treated DFUs compared with TCC-treated DFUs (2.6 vs 1.6; P = 2.1 × 10−10). Only 59 clinics used TCC (61%) … read more

Reexamining The Gold Standard For Offloading Of DFUs

Although the total contact cast can be effective for offloading diabetic foot ulcers, it is not in wide usage. These authors assert the gold standard for offloading lies in the non-removability of the device and offer a closer look at the merits of transitional offloading.

 

According to the American Diabetes Association, there are approximately 29.1 million Americans, or 9.3 percent of the population, who suffer from diabetes.1 Twenty-one million of these people have already been diagnosed with the disease and 8.1 million remain undiagnosed.

 

This number, although large, pales in comparison with the 86 million Americans who have been classified as “pre-diabetic” and who are at risk of having diabetes in the near future.1 Each year, 1.7 million Americans 20 years of age or older add to this number. This amounts to 4,660 people per day or one new patient with diabetes every 19 seconds. A full 25.9 percent of Americans age 65 or older suffer from diabetes and its complications. Almost twice as many American Indians (15.9 percent) and African-Americans (13.2 percent) develop the disease as Caucasians (7.6 percent) with Hispanics close behind (12.8 percent). Asian-Americans are not spared as 9 percent of this population will develop the disease and its many complications.

 

Glycosylation affects all organ systems and leads to complications such as dyslipidemia with an increased incidence of hypertension, and systemic vascular disease. It also leads to the development of a progressive ascending peripheral neuropathy with a loss of sensation and sweat gland function. This in turn leads to ulceration and, in some cases, amputation when infection of the wounds goes unchecked by an immune system that is also compromised by the process …
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How to apply a Total Contact Cast


This video demonstrates the application of the 901MF-WH Total Contact Casting Kit. Instructional dialog extends the length of the application considerably, actual application time of the Total Contact Casting Kit once comfortable with the process is approximately 5 minutes. For more information on the total contact casting kits being used visit: http://m-medusa.com