Total Contact Casting of the Diabetic Foot in Daily Practice

Abstract

OBJECTIVE -A limited number of clinical trials have shown that the total contact cast (TCC) is an effective treatment in neuropathic, noninfected, and nonischemic foot ulcers. In this prospective data collection study, we assessed outcome and complications of TCC treatment in neuropathic patients with and without peripheral arterial disease (PAD) or (superficial) infection.RESEARCH DESIGN AND METHODS -Ninety-eight consecutive patients selected for casting were followed until healing; all had polyneuropathy, 44% had PAD, and 29% had infection. Primary outcomes were percentage healed with a cast, time to heal, and number of complications.RESULTS -Ninety percent of all nonischemic ulcers without infection and 87% with infection healed in the cast (NS). In patients with PAD but without critical limb ischemia, 69% of the ulcers without infection and 36% with infection healed (P Ͻ 0.01). In multivariate analyses, PAD, infection, and heel ulcers were associated with a lower percentage healed (all P Ͻ 0.05). Median duration of cast treatment was 34 days. New ulcers, all superfical, developed in 9% and preulcerative lesions in 28% of the patients; these skin lesions healed in the cast within a maximum of 13 days.CONCLUSIONS -In comparison to pure neuropathic ulcers, ulcers with moderate ischemia or infection can be treated effectively with casting. However, when both PAD and infection are present or the patient has a heel ulcer, outcome is poor and alternative strategies should be sought. The high rate of preulcerative lesions stresses the importance of close monitoring during TCC treatment. Diabetes Care 28:243-247, 2005O ff-loading of the wound is one of the key elements in treating diabetic (neuropathic) foot ulcers (1). Several off-loading devices are available, such as walkers, half shoes, orthoses, felted foam, and the total contact cast (TCC) (2-5), which is seen as the definitive standard therapy (2,6 -8). There are three randomized clinical trials (6 -8) published on the effectiveness of TCCs in neuropathic plantar foot ulcers, in which a nonremovable TCC was compared with no offloading (6), a removable aircast walker (7), and/or a shoe modality (8). These studies concluded that a TCC healed a higher proportion of neuropathic, noninfected ulcers in a shorter amount of time, with healing rates of ϳ90%.Although a TCC seems a highly attractive off-loading modality, several disadvantages have been reported: new ulcers may occur, daily wound care is not possible, mobility is impaired, costs may be relatively high, and specialized staff seems necessary (3). In the case of prolonged casting, joint rigidity and muscular atrophy have been documented (7). Finally, the above described trials were performed in centers of excellence in patients with superficial, noninfected, nonischemic, plantar ulcers, and numbers were relatively small. When combined, these published randomized controlled trials reported on 66 patients treated with TCC. Although from a biomechanical point of view off-loading is indicated in most patients, o...

High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study

“…In the validation study of the University of Texas wound classification system [8], patients with the combination of infection and ischaemia were 90 times more likely to undergo a midfoot or higher amputation than those with less advanced wound stages. In the total contact cast study of Nabuurs-Franssen et al [13], the healing rate of patients with mild to moderate ischaemia and infection was only 36%, compared with a rate of 90% in patients with neuropathy with or without infection. Not many studies on patients with a foot ulcer report on the relative proportion of the study population with a high-risk profile.…”

“…Foot ulcers were therefore categorised into four stages according to presence or absence of infection and PAD (Table 1); these stages are similar to those of the University of Texas system [8]. Using this classification, healing rates of 90% in stage A, 89% in stage B, 69% in stage C and 36% in stage D were reported [13].…”

“…In many centres, patients with neuropathic or mildly neuroischaemic ulcers are treated in foot clinics, while patients with severe ischaemia and deep foot infections are admitted to surgical wards. From several studies there emerges a 'classic' picture of a patient with a neuropathic ulcer on the plantar surface of the foot [1,8,11,12]; with optimal therapy >80% of these 'uncomplicated' ulcers can heal within 3 months [13][14][15]. One might therefore question whether some studies provide an image of diabetic foot disease that is biased towards the least complicated foot ulcers or a specific subset of patients.…”

Chronic diabetic ulcers under the first metatarsal head treated by staged tendon balancing: A prospective cohort study

“…47 The costs and complication rates associated with such treatment can be high. [47][48][49] For these reasons we agree with Laborde's 10 opinion that to consider total-contact cast as 'the gold standard' treatment is questionable. It is obvious that in the presence of abnormal forefoot pressure associated with structural change, every offloading modality will have only a temporary effect on healing, and a high risk of re-ulceration when discontinued.…”

Effective and Economic Offloading of Diabetic Foot Ulcers in India with the Bohler Iron Plaster Cast

“…A prospective follow-up study by Marrigje et al [29] proved that in comparison to pure neuropathic ulcers, moderately ischemic or infected ulcers can be treated effectively with casting and had a median duration of 34 days of cast treatment. Our population too had a mixed etiology of neuropathy, infection, and possible moderate ischemia, and significant healing was achieved in 30 days.…”