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As I am inept at using Pubmed et al (usually get my daughter to help but she's just left home), I would appreciate advice / assistance re.... have any studies been published re. optimum pressure for facilitation of healing for plantar neurotrophic ulcers... 1/ use of aperture with / without cushioning and 2/ depth of aperture.
Thanks to the RPAH (Sydney) Diabetes team for organising an excellent "diabetic foot" seminar (22/10/05).............i didn't doze off at all... a first!

 

is it another myth?

in other words, is zero pressure for Rx of plantar neurotrophic ulcers for optimal healing another myth? (fully realising successful use of vacuum on non-weightbearing leg ulcers)
at least with cushioning plugs and full moulded inlays the edge effect and localised edema accumulation isnt (as much) a factor?... or is it?

 

This has always been an issue for me and there is no good data on it, but consider it this way:

1. Neuropathic ulcers DO heal with "offloading" pressure with an aperture.
2. Neuropathic ulcers DO heal with "downloading" pressure with a total contact cast (there is some pressure still on the wound, but its reduced due to the nature of the TCC)

Even though an aperture does have some theoretical disadvantages (eg increase in wound oedema; met head 'drops' down into aperature --> stress in wound; the 'edge effect', if it exists etc, etc), they do heal...

As for a TCC, it does reduce pressure on the plantar wound, but there is still some theoretically there (unless you also use an aperature) - the effect of this pressure on the wound would, theoretically, be to reduce wound oedema, prevent the metatarsal head from 'dropping' into wound, eliminate the 'edge effect', etc ---- TCC's are very effective as getting wounds healed.

The problem is testing the hypothesis, as TCC have a lot of other effects rather than just those potential theoretical local effects on the wound itself (eg eliminate propulsive phase; complinance; reduction of ankle oedema, leg of cast taking weight etc).

The premise I have always worked on is that some pressure on a wound may be good, but reduced pressure is needed for healing (I do not think it really matters if that presssure comes from a TCC or a cushioning plug in an aperture pad).

The only problem that remains, assuming this hypothesis is correct, is determining the "line in the sand" between good and bad levels of pressure .... and we just do not have the data.