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...
