Revisiting the Total Contact Cast

Abstract

A lthough the benefits of total contact casting for healing plantar neuropathic ulcers are consistent throughout a large body of available literature, the method of cast application varies (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). Cast structure at the ulcer site provides one major variance, i.e., should the cast create total contact with the entire plantar surface of the foot or should the wound be isolated? This article aims to resolve this issue by examining the differences in plantar pressure at the wound site between total contact casting using full contact with the plantar aspect of the foot and wound isolation. RESEARCH DESIGN ANDMETHODS -A total of 10 healthy adult subjects (aged 28 Ϯ 13 years, height 1.81 Ϯ 0.1 m, and weight 92.6 Ϯ 18 kg) with focal areas of pressure (but no history of ulceration) under their metatarsal heads were recruited. For each subject, a region of interest (ROI) was selected to encompass areas of particularly high pressure. This study was approved by the Institutional Review Board of the Cleveland Clinic Foundation, and all subjects signed informed consent forms. A Pliance pressuresensitive array (Novel) was fixed directly to the subject's foot covering the ROI. The 16 ϫ 16 sensor array had a sensor size of 19.36 mm 2 and a sampling rate of 50 Hz. Subjects were timed while they walked 10 m barefoot with the sensor held in place using thin paper tape. The pace was self-selected but measured to provide reproducible speeds under the different conditions. The subjects were then cast with the sensor in place over the ROI using one of two casting methods, A or B, selected at random. Casting method A created a true total contact cast (TCC), and casting method B created a woundisolation TCC (Fig. 1). Details of casting techniques are provided in the online appendix (available at http://care.diabetes journals.org). Both methods presented here used fast-setting fiberglass cast materials (3M Health Care). All casts were applied by the same trained personnel with previous TCC experience.Once the subject was comfortable walking in the cast, he/she was timed walking 10 m in the cast while pressure data were recorded. After the data were collected, the cast was removed with an oscillating cast saw, taking care to avoid moving or damaging the embedded sensor. The second type of cast was then immediately applied with the sensor array fixed in the same position, and the data collection procedure was repeated.Five steps from the middle portion of the walk were averaged for each trial using Novel step analysis and averaging software. A 5-cm diameter circular area was identified near the center of the sensor array such that it included the ROI selected for each patient. The peak pressure and pressure-time integral in these regions were calculated. The same regions were used to examine data from barefoot walking, walking in a conventional TCC without wound foam, and walking in a wound-isolation TCC with wound foam. Time-matched trials were used for comparison to eliminate the effect...

A novel approach to mapping load transfer from the plantar surface of the foot to the walls of the total contact cast: a proof of concept study

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