TOTAL CONTACT CASTING –

A SOUTH AFRICAN APPROACH TOWARDS

OFFLOADING THE DIABETIC FOOT

LIEZL NAUDE

WOUND MANAGEMENT SPECIALIST AT ADVANCED LOWER LIMB & WOUND MANAGEMENT CENTRE, PRETORIA, SOUTH AFRICA

HOWARD ALEXANDER

PODIATRIST AT ALEXANDER & FARREL PODIATRY EDENVALE, SOUTH AFRICA

INTRODUCTION

• Foot ulcerations are the most common complications associated with the patient living with diabetes worldwide and South Africa is no different.

• Several Total Contact Casting (TCC) methods are available worldwide, most well-known the description of application of a TCC with plaster bandage as described in Levin and O’Neal’s The Diabetic Foot 7th edition.

• TCC undisputedly regarded as gold standard off-loading method to most rapidly heal neuropathic plantar foot ulcers.

• Most common reason for not using TCC: “fear of failure” by health professionals feeling uncertain about application.

• The introduction of a fibreglass cast system allows for a much lighter and sturdier cast as well as better patient compliance.

STUDY AIM & METHOD

To adapt the current existing TCC systems available to fit the

South African Environment.

Total of fifty (n = 50) TCC’s were applied at the two (2)

centres.

Patient Inclusion criteria:

Neuropathic ulcers in need of off-loading by reduction of plantar pressures

whilst walking.

Charcot foot in order to stabilize the structural deformity with or without

plantar ulceration.

Several existing TCC methods were evaluated such as:

• Removable Cast Walker

• Plaster Bandage

• Fibre glass cast

Two fibreglass systems were evaluated and described for the

purpose of this study

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System A

o Fibreglass hard cast x 1

o Fibreglass soft cast x2

o Stockinet x 2

o Microfoam

o Woolpadding

o Cast Shoe

System B

o Fibreglass hard cast x 1

o Fibreglass soft cast x2

o Stockinette x 1

o Water resistant Stockinette x 1

o Felt padding

o Woolpadding

o Cast Shoe

ATTRIBUTES EVALUATED IN ORDER TO ENHANCE PATIENT COMPLIANCE:

Cast weight (light weight fibreglass material)

Durability (Strong and re-usable)

Removability (easy re-application)

Aeration (good evaporation due to materials used)

Wash-ability & Hygiene

Total Plantar surface contact

Protection and prevention of skin abrasions and additional pressure points

Open toe box (for easy inspection of toes also allowing aeration)

CASE EXAMPLES

Neuropathic Diabetic Foot Ulcer (DFU) 2nd & 3rd Metatarsal Head

Day 0 Day 12

Patient with a history of trauma due to shear ad friction. Patient has severe peripheral neuropathy and had to drive a delivery truck overnight for 12 hours continuously resulting in blistering with subsequent bleeding and tissue breakdown. Photographs shows results after 12 days in a TCC removable fiberglass cast.

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Charcot Foot with Mid foot DFU

Day 0 Day 0 Charcot foot

Day 5 Day 8 Structural stabilisation of Charcot foot

Charcot foot with mid foot

DFU Patient with a history of Charcot with subsequent foot deformity and pressure points resulting in ulceration. Problem started 2 years ago, patient developed blood blister after he was supplied with faulty innersoles in August 2012 and was referred to Orthopaedic surgeon. On the 14th of November 2012 the Orthopaedic surgeon stabilized the Charcot foot in theatre with instrumentation. In May 2013 patient developed new blood blister which was again debrided in theatre 25 June 2013. Current ulceration not healing and still draining with subsequent incidences of bleeding due to pressure. Wound care was started together with BSN Fiberglass TCC on the 3rd of October 2013. Complete closure as well as stabilization of the Charcot midfoot defect was achieved within 8 days.

RESULTS System A & B both were effective in reducing plantar pressures while walking by 84% to 92%.

Both systems demonstrate efficacy in stabilising Charcot foot.

Both systems demonstrate a cohort mean wound closure time of 36 days during this study.

Both systems reduced lower limb oedema due to the soft fibre glass cast.

Both systems improved patient mobility.

Both systems improved patient quality of life.

Both systems reduced overall wound care costs.

Both systems prevented further amputation.

System B provides better aeration than System A, the Removable Cast Walker and Plaster cast.

System B enables better hygiene as a removable, washable cast.

Improved patient’s adherence were seen with System B due to the aeration and hygiene associated with the cast.

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COMPARISON BETWEEN SYSTEM A AND SYSTEM B

Attribute System A System B

Cast Weight (light weight fibre glass) Yes Yes

Durability (strong and re-usable) Yes Yes

Removability (easy re-application Yes Yes

Aeration (good vaporation) Better than plaster cast or

removable walker

Improved aeration due to water

resistant inner lining

Wash-ability & Hygiene Cast not washable due to inner

lining with stockinet, if washed it

takes a very long time to dry

Washable water resistant inner

lining which allows for quick

drying whilst doing wound care

Total plantar surface contact Yes Yes

Protection & prevention of skin abrasions and

additional pressure points

Yes Yes

Open toe box (for easy inspection of toes and

also allowing aeration)

Yes Yes

COMPARISON

*System A – 3M casting material System B – BSN casting material

CONCLUSION

The study showed that through small adjustments better patient adherence can be achieved especially in the warm South African climate.

System B demonstrated an improved patient adherence due to the wash ability and aeration of the cast material

It is recommended that more skills training workshops are needed in order to guide health professionals and change perceptions in incorporating TCC as the gold standard in all practices working with patients with diabetic foot ulcers.

Howard Alexander

www.fixmyfeet.biz

howardal@mweb.co.za

Liezl Naude

www.eloquent.co.za

Liezl@eloquent.co.za

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