The Effectiveness of an Accommodative Dressing in Offloading Pressure Over Areas of Previous Metatarsal Head Ulceration

Wounds. 2003;15(2) 

In This Article

Abstract and Introduction

This study compared the effectiveness of an adhesive felt accommodative dressing (AliMed, Inc., Dedham, Massachusetts) with a short leg walker (Pacesetter II, Carapace, Tulsa, Oklahoma), a wedged-sole surgical shoe (OrthoWedgeTM, Darco International, Huntington, West Virginia), and a surgical shoe (Medical Surgical ShoeTM, Darco International) in reducing walking pressure over areas of previous foot ulceration. Pressure was measured using the F-Scan system in 12 volunteer subjects who had histories of neuropathic metatarsal head ulceration. Peak pressure over the area of previous ulceration was lower (p < 0.05) when walking in the accommodative dressing alone (235.8 ± 197.5 KPa) compared to barefoot (458.2 ± 194.4 KPa). Peak pressure was lower (p < 0.05) when walking in the accommodative dressing with a surgical shoe (176.7 ± 89.2 KPa), the accommodative dressing with the wedged-sole surgical shoe (124.1 ± 60.9 KPa), and the short leg walker (179.9 ± 98.4 KPa) compared to the wedged-sole surgical shoe alone (259.0 ± 94.8 KPa). Mean force-time integral at the area of previous ulceration was lower (p < 0.05) when walking in the accommodative dressing (23.4 ± 28.7 Nsec) compared to barefoot (63.3 ± 62.9 Nsec). Mean force-time integral was lower (p< 0.05) walking in the accommodative dressing with the wedged-sole surgical shoe (12.9 ± 9.5 Nsec) compared to the wedged-sole surgical shoe alone (32.2 ± 17.9 Nsec). This study supports the use of an adhesive felt accommodative dressing in offloading metatarsal head ulcerations. These data also show the potential benefit of a nonremovable accommodative dressing in offloading plantar ulcers in noncompliant individuals who walk barefoot.

Plantar ulceration is a common complication of diabetes and other neuropathic conditions. Nearly 15 percent of individuals with diabetes will develop foot ulceration.[1] Faulty foot ulcer healing is considered a major cause of diabetes-related lower-extremity amputations.[2]

Sensory loss and foot stress (pressure) are the primary causes of plantar ulceration.[3,4] In the absence of a protective level of sensation, repetitive walking stress leads to foot injury, ulceration, and faulty healing.[5,6,7] Plantar ulcerations develop at areas of highest foot pressure and are most commonly found over the bony areas of the forefoot.[3,8,9]

The effective reduction of pressure (offloading) is essential in the healing of plantar ulcers.[10] Individuals with insensate feet frequently have difficulty adhering to offloading recommendations because they lack the pain feedback essential to drive protective behavior changes.

The contact cast has been found to be the most effective method in healing foot ulcers.[11,12,13] The cast is effective because it provides custom offloading to the ulcer area, imposes continuous offloading, reduces edema, and limits patient activity. While considered the gold standard, the cast is not widely used because of the skills required for application and concern about secondary skin lesions.

As a result of these concerns, a variety of alternative offloading methods have been recommended.[14,15,16,17] Short leg walker boots, surgical shoes, surgical shoes with wedged soles, and accommodative felt and/or foam dressings have been found to be useful in a variety of multidisciplinary settings because they are relatively simple to apply.

Short leg walkers are rigid removable plastic walking boots that have soft foot beds and rocker soles. Walkers have been found to be as effective as a cast in reducing pressure[18,19] but not as effective as a contact cast in ulcer healing.[12]

Surgical shoes with soft foot beds have been used to accommodate the fit of wound dressings and provide pressure relief in the ulcerated foot. A surgical shoe has been found to reduce foot pressure when compared to a standard shoe.[20,21] A wedged-sole surgical shoe was found to be more effective than a surgical shoe in reducing forefoot pressure[18] and has been shown to promote foot ulcer healing.[22] The wedged-sole surgical shoe has been found to be less effective than the cast and the short leg walker in ulcer healing.[12] The wedged sole of these shoes is placed proximal to the metatarsal area to promote weight bearing on the rearfoot.

Accommodative dressings are made from felt and/or foam materials and are designed to provide customized offloading over an ulcerated area of foot.[16,17] Offloading is obtained by cutting a hole in the material under the area of ulceration. These pads are attached to the foot by tape, cement, or adhesive backing (depending on the material used) and are generally worn in combination with a surgical shoe. An adhesive felt accommodative dressing placed over the entire forefoot and worn in a wedged-soled surgical shoe was found to be an effective method of promoting forefoot ulcer healing.[23] A felt and foam accommodative dressing applied over and proximal to the ulcer and taped to the foot was found to be more effective than a surgical shoe alone but less effective than a cast, short leg walker, or half-shoe in reducing pressure.[18] An accommodative dressing attached over the entire forefoot may be more effective in offloading pressure and promoting healing than one placed directly over and proximal to the ulcer area.

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