Status of peripheral circulation
Clinical assessment is ideal, but in the absence of palpable distal pulses further investigation is necessary. Positive Doppler auscultation is encouraging and, when accompanied by signs of satisfactory skin nutrition, such a hair growth on the toes and warm feet of normal color, the Proxiderm procedure may proceed. If doubt still exists plethysmography and if necessary imaging studies may be necessary. The doubtful results occasioned by calcification of vessels that lead to incompressible vessels leave the reliance on ankle/brachial indices (ABI) open to question. However, using ancillary parameters, it is our experience that an ABI above  0.7 with satisfactory signs of skin nutrition have not led to problems.
The Proxiderm is contra indicated for ischemic ulcers

Inflammation and Infection
It is common to culture a variety of organisms, especially in diabetics who are prone to poly-microbial infection, the knowledge that many organisms are merely contaminants is well known and contaminated wounds can be approximated with the Proxiderm. There are also times where a dominant organism is present which would require coverage, such as a methicillin resistant staphylococcus aureus and some species of streptococci.

In the presence of inflammatory changes (as evidenced by erythema, edema or increased heat) or of a persistent discharge, the cause must be ascertained, treated and the application of the devices delayed until the condition has subsided. For example the inflammation may be due to necrotic material such as a deep tendon with the organisms playing a secondary role. If the inflammation is due to the pathogenic presence of bacteria, antibiotic treatment is indicated and identification of the responsible organism/s may be helpful; in these circumstances a tissue biopsy is desirable. After the inflammation or discharge has been effectively controlled the Proxiderms may be applied.

Patient Compliance
Non-weight bearing is essential during the Proxiderm procedure for wounds on the sole of the foot. It has been found that patients often visit the toilet at night, without offloading, considering that ``a few steps will due no harm".

While the Proxiderm closes the wound quickly, approximated wounds of the lower extremity, especially in diabetic patients need at least an additional 14 days to heal; elevation of the extremity, the administration of the appropriate antibiotics and intensive wound care are essential in achieving a satisfactory result. It may take approximately 3-6 weeks to bear the weight of a 180 to 200 lb. patient while walking. Earlier weight bearing can be destructive. During this time period, the patient must off load the weight by crutches or wheel chair.

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