What is the recommended dressing change frequency and weight-bearing status for a 2 cm diameter and 1 cm deep plantar diabetic foot wound treated with hydrogel and Hydrofera (polyurethane foam) ready dressing, and should a cam (controlled ankle movement) boot be used during ambulation?

Management of Plantar Diabetic Foot Wound: Dressing Changes and Weight-Bearing Protocol

Dressing Change Frequency

Change the hydrogel and Hydrofera foam dressing at least daily to allow careful wound inspection and prevent maceration from exudate. 1

• Daily dressing changes are essential for monitoring infection signs and ensuring proper wound assessment, particularly for plantar ulcers that are prone to pressure-related complications 1
• The foam component (Hydrofera) is appropriate for managing exudate from this wound, while hydrogel maintains moisture balance 1
• More frequent changes may be necessary if the wound produces heavy exudate that saturates the dressing or causes maceration of surrounding skin 1

Weight-Bearing Status and Offloading

This patient requires strict non-weight-bearing or minimal weight-bearing with mandatory offloading using a non-removable knee-high device (total contact cast or irremovable fixed ankle walking boot). 1, 2

Primary Offloading Recommendation

• A non-removable knee-high device with appropriate foot-device interface is the gold standard for healing neuropathic plantar forefoot ulcers (strong recommendation, high-quality evidence) 1
• The non-removable nature prevents patient non-adherence and ensures consistent pressure relief, which is critical for plantar wound healing 1
• Total contact casting or irremovable fixed ankle walking boots provide superior outcomes compared to removable devices 1, 2

Alternative if Non-Removable Device Contraindicated

• If the patient cannot tolerate a non-removable device, use a removable knee-high walker only if the patient demonstrates reliable adherence (weak recommendation, moderate-quality evidence) 1
• Removable devices have significantly lower effectiveness due to poor patient compliance with wearing them consistently 1

CAM Boot Usage

Yes, a CAM boot should be used, but it must be rendered non-removable (irremovable fixed ankle walking boot) for optimal healing. 1, 2

• Simply providing a removable CAM boot without making it non-removable is inadequate for plantar ulcer healing 1
• The boot should be worn at all times during ambulation, including pivoting and any weight-bearing activities 1
• Instruct the patient never to walk barefoot, in socks only, or in thin-soled slippers, even at home (strong recommendation) 1

Essential Concurrent Wound Care Measures

Sharp Debridement

• Perform sharp debridement of any callus, necrotic tissue, or wound debris at each visit, as this is fundamental to healing plantar diabetic ulcers (strong recommendation) 1, 3
• Debridement removes bacterial colonization, facilitates granulation tissue formation, and reduces pressure at callused sites 1

Monitoring for Complications

• Assess for signs of infection at each dressing change (erythema, warmth, purulence, increased pain) 1
• Evaluate for underlying osteomyelitis if the wound fails to improve, using probe-to-bone test and imaging 2
• Ensure adequate arterial perfusion, as ischemia will prevent healing regardless of offloading 1

Critical Pitfalls to Avoid

• Never allow the patient to bear weight on the ulcer without proper offloading, as continued pressure will prevent healing and may worsen the wound 1, 2
• Avoid using removable offloading devices unless you can ensure strict patient adherence, as non-compliance leads to treatment failure 1
• Do not apply total contact casts if infection is present or uncontrolled, as this prevents wound visualization and monitoring 1
• Avoid using topical antimicrobials for clinically uninfected wounds, as they provide no benefit (strong recommendation) 1
• Do not rely on dressings alone without addressing offloading and debridement, as these are the cornerstones of diabetic foot ulcer management 1, 3