Poster session 26: TCC and orthoses
P26.01
Outcomes using weight bearing total contact casts, for diabetic foot disease
Elizabeth Perry, Alfred Health, Melbourne, Australia
Gavin Burchall, Alfred Health, Melbourne, Australia
Naomi Rowlings, Alfred Health, Melbourne, Australia
Background: Our organisation runs a total contact casting clinic for patients with diabetic
foot complications including ulceration and Charcot neuroarthropathy. This study, was
conducted to determine outcomes, including healing rates and, resolution rates, using a
weight bearing total contact cast (WBTCC) for the treatment of diabetic foot problems.
AIM
1. To determine ulcer healing rates in WBTCC’s.
2. To determine resolution of acute Charcot foot in WBTCC’s.
3. To assess complications caused by WBTCC’s.
Methods: A retrospective audit was undertaken of all diabetic patients treated with a weight
bearing total contact casting in the last 2 years at an acute hospital outpatient clinic (TCC
Clinic).
Data collected included demographics, diabetes history, type of foot problem and length of
treatment in a TCC.
Charcot results were divided into different classifications based on location of the active
sites.
Ulcer results were collected regarding site of ulcer and weeks to resolution.
Results: The average time to acute Charcot resolution in a weight bearing TCC was 41.8
weeks.
The average time to healing of diabetic foot ulcers in a weight bearing TCC was 18.1 weeks
with a range between 3 - 48 weeks.
A number of complication were associated with weightbearing contact casts including
contralateral limb trauma, nail avulsions and blisters.
Conclusions: Our experience of using a weight bearing total contact cast is effective for the
treatment of acute diabetic foot problems with ulcer healing rate and Charcot resolution rates
comparable to other international studies. The weight bearing TCC has the advantage of
improving patient safety, in regards to falls risk when compared to non-weight bearing with
gait aids. Also, patient compliance, is improved when ambulating in a WBTCC despite some
complications experienced.
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P26.02
Treatment of chronic plantar ulcer of the diabetic foot using an irremovable
windowed, cast boot: prospective study of 177 patients
Georges Ha Van, Diabetic Foot Unit Service De Diabetologie Pr Hartemann, Paris, France
Agnes Hartemann, Hopital Pitie Salpetriere, Paris, France
0.6
0.4
0.0
0.2
Cumulative proportions
0.8
1.0
Objective: To evaluate the level of healing of chronic neuropathic plantar ulcers (NPU),
using an irremovable windowed fiberglass, cast boot (WCB) which is only opened after
healing.
Method: A single center prospective study of a cohort of 177 diabetic patients with chronic
NPU,
Results: Duration of NPU was 604 ± 808 days, with a mean surface area of 4.6 ± 6.5 cm², a
mean depth of 1.04 ± 1.08 cm, and a mean volume of 5.9 ± 17.7 cm3. After a mean of 96
days of wearing a WCB (min 9D, max 664D, median 68D) the level of healing was 83.6%
and 29 patients did not heal (16.4 %). The compliance was excellent (95%). NPUs at the
heels (p=0.004) as well as NPUs with bigger volumes (p=0.037) have significantly lower
healing levels.
Twenty one patients had moderate Peripheral Arterial Disease (PAD) (12%), and 24 patients
were ostectomized for underlying osteomyelitis (14%), before inclusion. Moderate PAD
(p=0.970) or operated osteomyelitis (p=0.128) did not modify the level of healing
significantly, which were of 81% and 70.8% respectively.
Complications: 12 ulcers due to the WCB (i.e. 7%) and 2 other ulcers being moderately
infected, 2% of toe amputation, no major amputation nor phlebitis.
Conclusion: The treatment of old and deep NPUs of the diabetic foot by wearing a WCB
without opening the boot, provides a good ulcer healing level. We only changed the WCB in
26 cases (14.6%). Compliance was excellent: 95% Moderate PAD or a recent osteoctomy
did not affect the efficacy of WCB.
0
100
200
300
400
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600
Days
Figure 2: Kaplan Meier estimate of complete healing rate at study completion
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P26.03
The MABAL cast shoe for offloading plantar neuropathic diabetic foot ulcers: results
from a 5-years retrospective analysis
Erik Manning, Ziekenhuisgroep Twente, Almelo, Netherlands
Adriaan Bril, Ziekenhuisgroep Twente, Almelo, Netherlands
Sicco Bus, Academic Medical Center, University of Amsterdam, Amsterdam, The
Netherlands
Background: For more than a decade the MABAL cast shoe is used in our center for
offloading treatment of plantar foot ulcers in diabetic patients. The MABAL cast shoe is an
ankle-high combicast shoe worn with a walker sole. The aim of this study was to evaluate
retrospectively the efficacy of the MABAL cast shoe in offloading plantar neuropathic foot
ulcers in diabetic patients.
Methods: Medical files of identified diabetic patients who were treated with a MABAL cast
shoe in the period 2004 to 2009 were retrieved and analysed. A total of 125 ulcers in 74
patients with diabetes and peripheral neuropathy were included. All ulcers were grade 1, 2,
and 3 ulcers according to the University of Texas ulcer classification system. The plantar
location of the ulcer was identified. Severe peripheral ischemia or Charcot's osteoarthopathy
were excluded. Primary outcome measure was the proportion of healed foot ulcers.
Secondary outcomes were the percentage healed ulcers at 12 weeks and at 20 weeks
treatment.
Results: In total 88% (110 of 125) of foot ulcers healed in the MABAL cast shoe. In 12
weeks, 64% of ulcers healed, in 20 weeks 85% of ulcers healed. The mean time to complete
ulcer healing was 75 days (range of 6 to 442 days). Of all healed ulcers, 42% concerned a
grade 1 ulcer of which 94% healed in a mean 58 days. Of grade 2 ulcers 84% healed in a
mean 97 days. Of grade 3 ulcers, 88% healed in a mean 48 days. Of all hallux ulcers, 83%
healed in a mean 60 days. All ulcers located at the first metatarsal heads healed in a mean
81 days. Of the lesser metatarsal head ulcers 81% healed in a mean 77 days.
Conclusion: This retrospective analysis show that the MABAL cast shoe may be an
effective modality for offloading small as well as large plantar neuropathic foot ulcers in
patients with diabetes. With an overall healing rate of 88%, the MABAL shoe is as effective
as the total contact cast which is considered the gold standard offloading treatment for
plantar neuropathic foot ulcers. The healing percentages of 64% at 12 weeks and 85% at 20
weeks are comparable to published data of other removable modalities. However, most
studies reported on grade 1 and 2 ulcers whereas this study shows that larger grade 3 ulcers
can also be effectively treated with the MABAL cast shoe.
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P26.04
Introduction of an “Off the Shelf” Total Contact Casting (TCC) system in large
outpatient Diabetic Foot Ulcer (DFU) clinic
Jorge Puerta, Caja del Seguro Social Unit, Partilla, Panama
Jennifer Ramos, Caja del Seguro Social Unit, Partilla, Panama
Horacio Moreno, Caja del Seguro Social Unit, Partilla, Panama
Background/purpose: Foot ulcers are the leading cause of non-traumatic lower extremity
amputations in diabetic patient populations.1 In Panama, there is a 9.5% prevalence of
Diabetes Mellitus (DM) and mortality rate of 5.5% ; 5th leading cause of death.2 Evidence
has shown Total Contact Casts (TCC) as the gold standard of treatment for relieving
pressure and healing diabetic foot ulcers.3 The largest Diabetic Foot Ulcer (DFU) clinic in
Panama trialed an off the shelf TCC system from October 2013 to February 2014. Plans to
increase use of TCC as the gold standard in off-loading and healing diabetic foot ulcers will
require clinical confidence with a user friendly product.
Methods: 9 patients, ages 51-67 years; 3 females and 6 males; were included in this trial.
All had multiple co-morbidities with wound chronicity of 2 months to > 3 years. Education
and hands-on training was provided to wound center staff regarding purpose and use of this
unique pre-packaged system. Wounds were debrided and dressed according to advanced
wound care evidence based practice using moist wound healing principles. All patients were
placed in this TCC system to off-load pressure. Casts and dressings were changed 2-3 days
after the initial application and weekly thereafter.
Results/conclusion: All patients achieved approximately 50% reduction in surface area at 4
weeks. Average time to closure with this TCC-EZ® system was 8 weeks for 6 patients. The
remaining 3 patients achieved greater than 50% reduction of surface area in the 8 week time
frame.
Use of this off-the-shelf TCC system positively impacted healing rates of these 9 patients.
This less complicated TCC system gave clinicians new to TCC application more confidence
in using TCC. As a result, more patients will receive the gold standard of DFU care in
Panama at this busy DFU clinic.
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P26.06
Casting dramas: When establishing a Total Contact Cast (TTC) clinic there is need for
extensive pre -cast education to ensure safe patient compliance and concordance
Kim Martin, Royal Victoria Hospital, Belfast Health and Social Care Trust Northern Ireland,
Belfast, United Kingdom
John McCarry, Podiatry Service Royal Victoria Hospital, Belfast Health and Social Care
Trust Northern Ireland, Belfast, United Kingdom
Julia Shaw, Podiatry South and East Community, Belfast Health and Social Care Trust
Northern, Belfast, United Kingdom
Clinical effectiveness and efficiency are essential objectives in the management of Diabetic
foot conditions. Restricting weight bearing can be difficult for many patients due to the major
impact on work and lifestyle. Total Contact Casting has been widely advocated as the gold
standard for off-loading chronic, complex Diabetic Foot Ulcers (DFU)and minimising damage
associated with active Diabetic Charcot Arthropathy. It is well documented that a TCC
facilitates non weight bearing and promotes healing in DFUs by fully offloading the foot1-4.
Aims: The aim of the study was to identify challenges associated with concordance in
patients wearing a TCC.
Methods: In July 2014 a new TCC Clinic was established in secondary care to improve the
management of complex patients with DFUs and Charcot Arthropathy.Osteomyelitis was
excluded by x-ray and absence of probing to bone prior to TCC application. A Podiatry
training programme, a patient education programme and a referral process for the clinic
were established. Data was collected prospectively and any incidents and concordance
issues described.
Results: During the 4 month period in 2014 a total of 12 patients (1 female: 11 male) were
managed in the Out-Patient Department by the multidisciplinary team and had TCCs applied
(5 with Charcot neuroarthropathy, 7 with non-healing wounds). Results showed that 4 DFUs
healed, 1 deteriorated, 1 patient had a road traffic accident despite being advised not to
drive, 2 patients experienced “rubs” from the TCCs and 1 patient was referred to
Dermatology for further investigation. Five patients continued to be managed using TCCs. In
the patient group there were issues associated with falls and hygiene with the TCCs.
Conclusion: Patient assessment is crucial in the development of a TCC Patient Education
Programme. Concordance issues may be addressed by including advice against driving and
on how to manage personal and TCC hygiene when being managed in this way. It is
important that patients are supported and monitored during their treatment phase to reach a
successful conclusion.
References
1. Hygiene Mueller MJ : Total Diabetes Care 12:384–388, 1989
2. Lewis J . Cochrane Database of Systematic Reviews 2013, Issue 1
3. Armstrong DG . Diabetes Care 24:1019–1022, 2001..
4. Lee C. Rogers, DPM, Diabetes Care September 2011 vol. 34 no. 9 2123-2129
www.diabeticfoot.nl
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P26.07
Developing a nationally recognised strategy to improve outcomes of diabetic foot
complications through improving access to casting
Catherine Gooday, Foot Clinic, Norwich, United Kingdom
Rachel Berrington, Diabetes Outpatients, Leicester, United Kingdom
Aims: The aim was to define the parameters for safe and effective casting of diabetic foot
complications, introduce nationally agreed treatment algorithms and reduce the barriers to
the widespread introduction of casting through provision of a training program
Methods: The application of a total contact cast (TCC) is described as the ‘gold standard’
treatment to off-load neuropathic diabetic foot ulceration (DFU) and Charcot (CN). Despite
this it is not widely used. In USA <2% of clinicians reporting using the TCC for the treatment
of DFU1. In Europe only 35% of DFU received casting and only half of this was with a TCC2.
The CDUK study identified that only 40.1% of people with CN were initially treated with a
TCC3. A literature review showed little practical guidance for clinicians on cast type, material
and methods. There is limited availability of training programmes and the ones that exist are
not currently competency based or accredited. These factors have led to reluctance among
some centres to undertake casting.
Results: In 2011 a multidisciplinary meeting was organised, bringing together experts in
treatment of DFU and TCC. The group have standardised the terminology associated with
different cast types and treatment algorithms for the management of diabetic foot
complications have been developed. A step-by-step guide to the application of different cast
types has been devised. These initiatives will be implemented and supported through a
nationally accredited training programme supported by a mentorship.
Conclusion: The programme will be launched in 2015 through publication in relevant
journals and with the first courses already open for registration. Improved access to casting
will hopefully contribute to reduced variation in care and improve treatment outcomes for
patients. The ongoing National Diabetic Foot Audit will provide the outcome data to validate
the success of this programme. This use of consistent methodology to casting will also help
improve the validity of future research.
This work is present by the authors on behalf of the ‘Multidisciplinary Casting Consensus
Group’
1. Wu SC, Diabetes Care. 2008 Nov;31(11):2118-9
2. Prompers L, Diabetic Med. 2008 Jun;25(6):700-7
3. Game FL, Diabetologia. 2012 Jan;55(1):32-5
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P26.08
A silicone orthosis might be more effective than orthopaedic shoes alone to off-load
and heal neuropathic ulcers on clawed toes
Gustav Jarl, Örebro University, Örebro, Sweden
Carlos Martin de los Santos Diaz, Örebro University, Örebro, Sweden
Aim: To evaluate whether a silicone orthosis is an effective way to off-load and promote
healing of neuropathic ulcers on the apex of clawed toes.
Methods: 2 subjects with diabetes type 2 and a neuropathic ulcer on the apex of a toe with
claw-toe deformity were included (Table 1). They had had repeated ulcers on the same
location since ≥2 years and been using orthopaedic shoes for several years (subject 1: 10
years, subject 2: 3 years). A silicone orthosis (hardness 30 Shore A) was fabricated to offload the ulcer by redistributing pressure from the apex of the toe to the toe sulcus.
Result: Both ulcers demonstrated substantial improvement after delivering of the orthosis.
The long-lasting ulcer of subject 1 had almost healed after 2 months and the ulcer of subject
2 was completely healed after 2 weeks (Table 1).
Discussion/Conclusions: Previous research has reported that silicone orthoses are
effective to off-load the toe apex, reduce skin hardness and prevent new lesions (1-4). In
addition to this, the results of this study suggest that a silicone orthosis in addition to
orthopaedic shoes might be more effective to promote healing of neuropathic ulcers on
clawed toes compared to orthopaedic shoes alone. This could be due to superior off-loading
with the orthosis compared to shoes, and/or higher compliance with using it. There is a need
of controlled trials comparing the off-loading capability, compliance with using and healing
rates of silicone orthoses and other off-loading devices, such as shoes, walkers and casts.
References
1. Claisse PJ, et al. J Am Podiatr Med Assoc 2004;94(3):246-54.
2. Johnson S, et al. J Foot Ankle Res 2012;5(1):22.
3. Scire V, et al. J Am Podiatr Med Assoc 2009;99(1):28-34.
4. Slater RA, et al. Diabetes Res Clin Pract 2006;74(3):263-6.
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