This has always been an issue for me and there is no good data on it, but consider it this way:
1. Neuropathic ulcers DO heal with "offloading" pressure with an aperture.
2. Neuropathic ulcers DO heal with "downloading" pressure with a total contact cast (there is some pressure still on the wound, but its reduced due to the nature of the TCC)
Even though an aperture does have some theoretical disadvantages (eg increase in wound oedema; met head 'drops' down into aperature --> stress in wound; the 'edge effect', if it exists etc, etc), they do heal...
As for a TCC, it does reduce pressure on the plantar wound, but there is still some theoretically there (unless you also use an aperature) - the effect of this pressure on the wound would, theoretically, be to reduce wound oedema, prevent the metatarsal head from 'dropping' into wound, eliminate the 'edge effect', etc ---- TCC's are very effective as getting wounds healed.
The problem is testing the hypothesis, as TCC have a lot of other effects rather than just those potential theoretical local effects on the wound itself (eg eliminate propulsive phase; complinance; reduction of ankle oedema, leg of cast taking weight etc).
The premise I have always worked on is that some pressure on a wound may be good, but reduced pressure is needed for healing (I do not think it really matters if that presssure comes from a TCC or a cushioning plug in an aperture pad).
The only problem that remains, assuming this hypothesis is correct, is determining the "line in the sand" between good and bad levels of pressure .... and we just do not have the data.
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Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
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God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
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