Ventral Windowed Total Contact Casts Safely Offload Diabetic Feet and Allow Access to the Foot

Abstract

Background: Irremovable total contact casts (TCCs) are the gold standard to offload diabetic foot ulcers (DFUs) and to immobilize feet with active Charcot neuro-osteoarthropathy (CN). They do not allow checks of the foot and are contraindicated in people with peripheral arterial disease (PAD). Frequently, removable TCCs and other removable devices are used because they allow wound care, modifications of the inner surface of the cast, and checks of the foot. The authors propose TCCs with ventral windows (VW-TCCs) whenever patients with high-risk conditions show poor adherence to wearing a removable cast all the time and access to the foot is necessary. Methods: This retrospective study compares treatments with bivalved, removable TCCs applied prior to the introduction of the novel design (from 1 January 2016 to 1 July 2017, “ c”) to treatments in the following period ( t) with both bivalved removable TCCs and VW-TCCs in use. Results: Forty-five treatments after introduction (17 with the VW-TCC) showed a 52.8% lower median time to reach remission of the DFS than 41 controls (128/267 days, log-rank test P = .013). Reasons given for not using the novel design were: sufficient offloading with a removable TCC (16), patient preference (six), anatomical conditions (two), casts applied as a service for other facilities (three), and calf ulcers (one). Adverse effects from both designs were uncommon and not severe. Conclusions: VW-TCCs combine advantages of both removable and irremovable TCCs. Complications do not limit the use, even in patients with PAD.

Diabetes Update 2021

“…Nichtabnehmbare Vollkontaktgipse sind der Goldstandard bei der Behandlung plantarer diabetischer Druckulzera; Nachteile sind das Entfallen der Inspektion durch den Patienten und der erhebliche Aufwand der Spaltung und des Wiederanlegens des Gipses bei einer interkurrenten Ulkusbehandlung. Eine einfache, aber pfiffige Innovation hierzu kommt von den Kollegen Hochlenert und Fischer aus Köln, die in einer „proof of concept study“ einen gefensterten „total contact cast“ vorstellten [ 21 ], in welchem ein Fußulkus über ein ventrales Gipsfenster behandelt werden kann, während der Fuß fixiert bleibt (Abb. 4 ).…”

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

“…11,19 Over the past 4 years, a number of new trials have been performed in the area of offloading that add to the evidence base for treating people with DFU. [23][24][25][26][27][28][29] Ulcer healing is still recognised as the key critically important outcome for people with DFU. However, other outcomes of importance to people with DFU are receiving more attention and also require careful consideration when developing recommendations in new offloading guidelines, such as effects on plantar pressure, weight-bearing activity, adherence, adverse effects, quality of life, and costs.…”

Effectiveness of offloading interventions for people with diabetes‐related foot ulcers: A systematic review and meta‐analysis

“…Offloading interventions reported included non-removable devices, removable devices, therapeutic footwear, wheelchairs, and heel casts. However, of those, only 3 RCTs 65,67,81 and 3 other controlled studies 35,64,85 reported outcomes in plantar rearfoot DFU, while 8 non-controlled studies 100,101,[105][106][107]111,118,171 added relevant evidence. 67 One other controlled study, 35 and one non-controlled study with similar results, 171 found removable knee-high versus ankle-high offloading devices may cause large increases in proportions of ulcers healed, but evidence is very uncertain (RR 5.60, 0.87-36.22; p = 0.07;…”

“…Eleven RCTs 17,36,37,62,68,73,[75][76][77]79,82 and 8 other controlled studies 34,35,57,84,85,87,88,90 reported baseline infection or ischaemia characteristics, with only one 85…”

“…One other controlled study85 found non-removable versus removable knee-high devices may cause large increases in proportions of ulcers healed, but evidence is very uncertain (RR 5.00, 0.30-83.69; p = 0.26; N = 1; n = 10; Very low CoE). One RCT 67 found nonremovable knee-high devices versus therapeutic footwear may cause moderate decrease in proportions of ulcers healed, but again evidence is very uncertain (MD NA; 69 vs. 107 days; p = NR; N = 1; n = 16; Very low CoE).…”