Evaluation of Removable and Irremovable Cast Walkers in the Healing of Diabetic Foot Wounds

Abstract

OBJECTIVE -The purpose of this study was to evaluate the effectiveness of a removable cast walker (RCW) and an "instant" total contact cast (iTCC) in healing neuropathic diabetic foot ulcerations. RESEARCH DESIGN AND METHODS -We randomly assigned 50 patients withUniversity of Texas grade 1A diabetic foot ulcerations into one of two off-loading treatment groups: an RCW or the same RCW wrapped with a cohesive bandage (iTCC) so patients could not easily remove the device. Subjects were evaluated weekly for 12 weeks or until wound healing.RESULTS -An intent-to-treat analysis showed that a higher proportion of patients had ulcers that were healed at 12 weeks in the iTCC group than in the RCW group (82.6 vs. 51.9%, P ϭ 0.02, odds ratio 1.8 [95% CI 1.1Ϫ2.9]). Of the patients with ulcers that healed, those treated with an iTCC healed significantly sooner (41.6 Ϯ 18.7 vs. 58.0 Ϯ 15.2 days, P ϭ 0.02).CONCLUSIONS -Modification of a standard RCW to increase patient adherence to pressure off-loading may increase both the proportion of ulcers that heal and the rate of healing of diabetic neuropathic wounds. Diabetes Care 28:551-554, 2005A melioration of pressure, shear, and repetitive injury to the sole of the foot are principal tenets of neuropathic ulcer care. Total contact casts (TCCs) are considered the gold standard in redistribution of pressure over the plantar aspect of the diabetic foot (1-7). TCCs have been shown to reduce pressure at the site of ulceration by 84 -92% (8), and there is a large body of work that supports the TCC's clinical efficacy. In two randomized controlled trials comparing the proportion of healed ulcers treated with a TCC compared with other readily available and popular devices (removable cast walkers [RCWs], half-shoes, and therapeutic depth inlay shoes) TCCs, healed a higher proportion of wounds compared with other modalities (7,9). This was an interesting finding because certain types of RCWs, including one used in one of the above-mentioned trials, often reduce pressure on the plantar aspect of the foot as well as TCCs (9). If patients do not heal as well in the RCW and yet it off-loads pressure about as well as the TCC, then a logical explanation for their less effective clinical performance is that these devices are being removed by the patients that use them (10).In an effort to make the RCW more efficacious, we have modified it slightly by merely wrapping the traditional RCW in a layer of cohesive or plaster bandage. This technique has been termed the "instant" TCC (iTCC) (11). It has been our initial experience that this technique is clinically successful. If clinical results are superior to those with the RCW, we believe it could potentially auger a significant shift in the current standard of care in pressure reduction (off-loading) of diabetic wounds. We are unaware of any reports in the literature that have compared a standard RCW with the iTCC. The purpose of this project was to evaluate the effectiveness of a traditional RCW and the iTCC to heal neuropathic foot ulcerations in pa...

An Off-the-Shelf Instant Contact Casting Device for the Management of Diabetic Foot Ulcers

“…Previous studies emphasize how the rate of healing at 12 weeks is Ͼ80% in patients treated with irremovable devices, while it drops to Ͻ60% in patients treated with removable devices (21).…”

The Diabetic Foot in End Stage Renal Disease

“…[91] Recent evidence suggests that good results may also be achieved by use of the "instant Total Contact Cast," a removable cast walker rendered irremovable by wrapping in a layer of cohesive or plaster bandage. [89] In case casting facilities are not available, alternative offloading modalities include temporary ready-made shoes with a cushioning insole, special half shoes for forefoot ulceration, or other orthotic devices. [10,13,90] Additionally, crutches, wheelchairs, and Zimmer frames aid in the reduction of weight-bearing.…”

“…[10,13,15] This is accomplished by bedrest to reduce further weight-bearing on the ulcerated foot and by the immediate application of some form of cast. [10,13,15,89] Casts include removable cast walkers, such as the Aircast walker (a bivalved cast, lined with four air cells and inflated by a hand pump to ensure a close fit) and the Scotch cast boot (a simple removable boot, made of stockinette, felt, and fiberglass tape), and the irremovable total contact cast. [10,13] The Total Contact cast is an irremovable cast, generally regarded as the "gold standard" in off-loading techniques.…”

Reconsidering Nerve Decompression: An Overlooked Opportunity to Limit Diabetic Foot Ulcer Recurrence and Amputation

“…5 Most nonischemic initial DFUs can be healed with offloading pressure concentrations via total contact casting or cast boot walkers rendered irremovable. 6 Sadly, such proven treatment is used a minority of the time. There is very high risk of recurrence after initial DFU healing, reported to be 25-35% at 1 year, 50% by 3 years, and near 100% by 10 years.…”