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KERALA SURGICAL JOURNAL

Official Publicaiton of The Association of Surgeons of India, Kerala Chapter
CONTENT
Total Contact Casting (TCC) in Diabetic Plantar Ulcers

Original Article

Abstract

Total contact casting is the choice of treatment in neuropathic diabetic ulcers. We took 50 cases of diabetic ulcers to study the effect of total contact casting in healing of Neuropathic diabetic foot ulcers.A total of 50 patients with plantar diabetic ulcers with Wagner’s grade 1 and 2 were included in the inclusion criteria and patients with peripheral vascular disease and wagners grade 3 and 4 were excluded. The study was conducted based on the ulcer healing time and followed up for 8 weeks. Our results found out that 87.3% of foot ulcers healed in our study group. The mean ulcer healing time was 3 weeks.

Dr. K Chinthnidhi, Senior Resident, Department of Surgery, Government Medical College, Trivandrum 695011.
Dr. MS Sulfekar* Associate Professor of Surgery, Government Medical College, Trivandrum 695011.

INTRODUCTION

Diabetes mellitus is one of the most important metabolic disorders. Among the most common, complex, and costliest complications of diabetes mellitus are ulceration (2%-19%) and infection of the foot (about 15%); 7% to 20% of diabetic patients with foot ulcers and/or infections will require amputations for definitive treatment 1,2,3.

Diabetic Foot is defined as a group of syndromes in which tissue breakdown occurs because of neuropathy, ischemia and/or infection 4,5. The foot of a diabetic patient has the potential risk of pathological consequences including infection, ulceration and destruction of deep tissues associated with neurological abnormalities, various degrees of peripheral arterial vascular disorder and metabolic complications of diabetes in lower limb.

Diabetic neuropathy involves sensory, motor, and autonomic nerves. Sensory neuropathy leads to a loss of protective sensation 6.7,8,9. With the loss of protective sensation, foot trauma is unrecognized and leads to ulceration. Diabetic foot problems may lead to loss of mobility and limb amputation, with consequent adverse impact on patients’ quality of life. The aim of any diabetic foot is preservation of limb. If amputation becomes the only option, it indicates failure of other diabetic foot services.

Diabetic foot ulceration represents a major medical, social and economic problem all over the world. Foot ulceration results from the interaction of several contributory factors, the most important of which is neuropathy. Histological evidence suggests that pressure relief results in chronic foot
ulcers changing their morphological appearance by displaying some features of acute wound. Thus repetitive stress on the insensate foot appears to play a major role in maintaining ulcer chronicity 10.

Neuropathic ulcers account for significant number of diabetic foot. Risk factors for ulceration include insensitivity (secondary to somatic neuropathy), high foot pressure and callus formation (due to high foot pressure) 11.

In the management of neuropathic ulcers, pressure relief is of utmost importance and Total Contact Casting (TCC) remains the gold standard means of achieving such pressure redistribution 12.

Of all the amputations, 50% occur in diabetic patients mostly as a final outcome of foot ulcers13. A major biomechanical factor in the causation of foot ulcers in persons with diabetes mellitus is elevated peak plantar pressure. Offloading the ulcer area in the form of equalization of pressure across the plantar surface can accelerate the healing of the ulcer. TCC is one such method of offloading and this study attempts to investigate the advantages of TCC when compared to other conventional methods.

Offloading forms the cornerstone of diabetic foot ulcer management but unfortunately the significant modality is not properly used. The one area that is critical to achieving successful ulcer healing, yet often overlooked, is offloading of a neuropathic ulcer.

TCCis the gold standard offloading method in treating plantar ulcers 14. It is an effective, rapid, economical, ambulatory and outpatient based method for the treatment of diabetic foot ulcers. The mechanism is by reducing the peak plantar pressure by increasing the plantar pressure to 24 to 40 % by TCC of the entire plantar surface15. The additional advantage in ulcer healing is made possible by ambulation in addition to TCC.

It causes quick healing of neuropathic plantar ulcers. It is the optimal method to achieve maximal reduction of focal plantar stresses. It has become the cornerstone in the management of plantar ulcers worldwide.

Offloading the ulcer reduces both vertical pressure and horizontal shear on the plantar surface while maintaining ambulation. It reduces plantar pressures at the site of ulcer by 84-92%, while walking15 Pressure reduction is by spreading pedal pressure over an increased surface area by 15-24% 16.

This results in dramatic reduction of Peak Plantar Pressure. 30% of weight bearing load is transferred to the cast wall on the leg segment17. Reduction in peak plantar pressure is more in forefoot than midfoot or hindfoot18. Hence ulcers here take longer time to heal than forefoot. TCC reduces edema and enhances the healing of the ulcer19.

The earliest reports of ambulatory casting dates back to 1930’s. It was first used by Dr. Milroy Paul of Sri Lanka in Hansen’s disease. One of the earliest written accounts was by Dr. Joseph Kahn in India in treating neuropathic ulcers20. Paul Brandin 1950 popularized the technique21. Later in 1960, he adopted it for diabetic foot patients in W Long Hansen’s Disease Centre in Louisiana, USA.Recently TCC is being used effectively for acute Charcot’s osteoarthropathy of ankle or foot with or without ulcer also. Thus TCC has become the time tested and proven offloading method.

MATERIALS AND METHODS

The objectives of the study were to study the effect of TCC in healing of neuropathic diabetic foot ulcers and to analyse the effect of ulcer healing time. It was a prospective cohort study conducted at the Government Medical college, Trivandrum for one year. Sample size was calculated using the formula, sample size = 4PQ/D2, where P = percentage of ulcer healing time in the previous study, Q = 100 – P and D = (20/100 x P)2

The minimal sample size required was 30. 50 patients with diabetic plantar foot ulcers attending the Surgical OP with diabetic foot ulcers belonging to Wagner’ s scale grading 1 and 2, with size of ulcer 2 to 10 cm were randomly selected. Patients with major ischemia, those with Wagner scale grading scale 3, 4 or 5 and patients with clinically established peripheral arterial disease were excluded.

Patients enrolled in the study were evaluated according toproforma. Measurement of healing rates of foot ulcers after the TCC was done during follow up every week,2 weeks, 4 week, 8 weeks to evaluate safety and possible side effects. Outcome was measured in terms of healing rates and wound surface area reduction. Any complication was recorded.

TCC APPLYING TECHNIQUE

TCC was made of easily and locally available cheap raw materials (Fig. 1).The foot ulcer (Fig. 2)was cleaned and debrided and covered with saline moist dressing (Fig. 3). This was lightly covered with four-inch cotton cast padding, and the leg was covered with cotton stockinet (Fig. 4). The ulcer areas and toes were covered with 3/8th inch foam and the bony areas covered with 1/8th inch orthopedic felt (Fig 5). Additional cotton cast padding was applied around the proximal and anterior lower leg and over the heel and dorsum of the foot. The leg was carefully wrapped with fourinch plaster bandage and rubbed until hard. The stockinet was folded over at the proximal lower leg and additional plaster used to reinforce the cast and level and apply the rubber walking heel (Fig. 6). The patients were instructed in partial weight-bearing ambulation with a walker.

  • Day 0 – ulcer cleaned and TCC applied
  • Day 1 – discharged from hospital
  • Day 7 – First inspection, reapplication of TCC
  • Day 21 – Ulcer inspection, reapplication of TCC
  • Day 35 – Ulcer inspection and if healed TCC removal and followed by usage of therapeutic foot wear to prevent further
  • ulceration due to trauma.Outcomes are recorded in terms of
  • healing of the ulcer and complications.














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