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Observational Study
. 2024 Sep;17(3):e70001.
doi: 10.1002/jfa2.70001.

A mouldable fibreglass backslab device as a novel approach to offload chronic plantar foot ulcers: A retrospective observational audit

Melissa Ting  1   2 , Ivana Ferreira  1   2 , Jonathan Hiew  1   2 , Mahalia McEvoy  1   2 , Gabrielle Tan  1   2 , Priyal Shah  1   2 , Eugenie Nicolandis  1   2 , Emma J Hamilton  1   3   4 , Jens Carsten Ritter  1   5   6 , Michael Nicolaou  1   7 , Laurens Manning  1   4   8
Affiliations
Observational Study

A mouldable fibreglass backslab device as a novel approach to offload chronic plantar foot ulcers: A retrospective observational audit

Melissa Ting et al. J Foot Ankle Res. 2024 Sep.

Abstract

Background: Pressure offloading is a critical component of plantar foot ulcer management, including diabetes-related foot ulcers (DFU). Conventional offloading options such as total contact casting and removable knee-high walkers may be unsuitable or unsuccessful in patients with morbid obesity, intermittent lower limb oedema, high exudative wounds or poor mobility. A mouldable fibreglass backslab device (BSD) may be a practical alternative to be considered in these situations.

Methods: Data were retrospectively collected on 28 patients (29 foot ulcers) with non-healing ulcers who received a BSD to offload their foot ulcer as an extension to standard offloading care. Baseline data included: patient demographics, type of offloading prior to BSD application, date of ulcer onset, days ulcer present prior to BSD application and ulcer size at BSD initiation. Measures of success included ulcer size reduction 12 weeks post-BSD application, time to complete ulcer healing in BSD, time to 50% reduction in ulcer size post-BSD application and total number of days ulcer present.

Results: The median (IQR) ulcer area and ulcer duration at baseline for 19 patients (20 ulcers) who used the BSD was 1.65 (0.4-3.8) cm2 and 531 (101-635) days. At 12 weeks, the median (IQR) ulcer area was 0.3 (0-0.55) cm2 with a median (IQR) reduction of 97 (80-100) %. Nine (45%) ulcers achieved complete wound healing (100% reduction in wound size) at 12 weeks post-BSD application, and the remaining 11 (55%) ulcers achieved at least 50% reduction in wound size. The median (IQR) time to complete wound healing and 50% reduction in wound size was 71 (35-134) days and 24 (15-44) days, respectively. Nine patients ceased use of the BSD and reverted to conventional offloading before their wounds had healed. Of these, four patients achieved a 50% reduction in wound size at the 12-week mark with conventional offloading.

Conclusion: Our preliminary data suggests that a mouldable fibreglass BSD may be a practical offloading option in the management of DFUs, especially when conventional offloading methods are unsuccessful, unsuitable or unacceptable to patients. Higher level evidence is required to demonstrate suitability or efficacy of the BSD compared to current evidence-based recommended offloading methods.

Keywords: diabetic foot; foot ulcer; offloading; retrospective studies; ulcer healing.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

FIGURE 1
FIGURE 1
A step‐by‐step guide to apply a moldable fibreglass BSD is pictured above. The foot ulcer should be appropriately dressed prior to BSD application (A). A tubular stockinette is placed over the foot and leg (B). A strip of fibreglass is measured from the plantar forefoot/sulcus to the middle of the calf, taking note of where the heel is located on the splint (C and D). Edges of the splint should be trimmed and rounded off to approximately half an inch within the cotton padding (E). Edges of the splint (where the heel is) are folded inwards, the splint is sprayed with water for activation and the cotton padding replaced (F). This is then placed against the patient's foot and leg, ensuring that any folds are placed away from the skin and secured with crepe bandages pulled under medium to high tension (G–I). During this process, the patient's foot and leg should be relaxed and the ankle held at 90° (J). When the splint has set, the patient is fitted with a Darco® APBTM All Purpose Boot (DARCO (Europe) GmbH), Darco® SlimlineTM Cast Boot (DARCO (Europe) GmbH) or a removable cast walker (K and L). BSD, backslab device.
FIGURE 2
FIGURE 2
Patient offloading flowchart prior to BSD application and outcomes at 12 weeks post‐BSD application. BSD, backslab device.
FIGURE 3
FIGURE 3
Change in wound area from application of backslab device. Data shown are hindfoot (red), midfoot (blue) and forefoot (grey ulcers). A linear regression line is also shown (black, dashed line).
FIGURE 4
FIGURE 4
Successful wound healing with a mouldable fibreglass BSD in a patient with a plantar neuropathic heel ulcer (A), in context of Type 2 diabetes mellitus, peripheral neuropathy and morbid obesity (body mass index 41.3 kg/m2). This patient was optimised from a diabetes, infection and vascular point of view (palpable pedal pulses and toe pressures of >120 mmHg, not requiring vascular intervention), but effective offloading was a challenge. This patient was unable to tolerate a removable knee‐high walker due to falls, despite the use of a contralateral shoe raise. A TCC or i‐TCC was not feasible due to heavy wound exudate that required daily dressing changes. This patient's only option was to use a pair of custom insoles in removable ankle‐high devices to offload his wound, but this was not successful as the wound remained static for many months. In January 2021, the patient was fitted with a mouldable fibreglass BSD (Dynacast® Prelude, BSN Medical) which was fitted inside a Darco® APBTM All Purpose Boot (DARCO (Europe) GmbH) (B). The patient reported no immediate discomfort or perceived instability when trialled in clinic post‐BSD application. A 50% reduction in wound size was achieved after 3 weeks (C) and complete wound healing occurred in 6 weeks (D and E). Following complete healing the patient was fitted into a WalkOn® AFO (Ottobock SE & Co. KGaA) and a custom insole into off the shelf footwear. This patient has since remained ulcer free. BSD, backslab device; i‐TCC, instant total contact cast; TCC, total contact cast.
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