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OBJECTIVE— A limited number of clinical trials have shown that the total contact cast (TCC) is an effective treatment in neuropathic, noninfected, and nonischemic foot ulcers. In this prospective data collection study, we assessed outcome and complications of TCC treatment in neuropathic patients with and without peripheral arterial disease (PAD) or (superficial) infection.
RESEARCH DESIGN AND METHODS— Ninety-eight consecutive patients selected for casting were followed until healing; all had polyneuropathy, 44% had PAD, and 29% had infection. Primary outcomes were percentage healed with a cast, time to heal, and number of complications.
RESULTS— Ninety percent of all nonischemic ulcers without infection and 87% with infection healed in the cast (NS). In patients with PAD but without critical limb ischemia, 69% of the ulcers without infection and 36% with infection healed (P < 0.01). In multivariate analyses, PAD, infection, and heel ulcers were associated with a lower percentage healed (all P < 0.05). Median duration of cast treatment was 34 days. New ulcers, all superfical, developed in 9% and preulcerative lesions in 28% of the patients; these skin lesions healed in the cast within a maximum of 13 days.
CONCLUSIONS— In comparison to pure neuropathic ulcers, ulcers with moderate ischemia or infection can be treated effectively with casting. However, when both PAD and infection are present or the patient has a heel ulcer, outcome is poor and alternative strategies should be sought. The high rate of preulcerative lesions stresses the importance of close monitoring during TCC treatment.
the question i would have,is whether the idea of casting a patient with an ischemic ulcer via total contact casting within the parameters of standard of care.ischemic ulcers by their nature tend to become infected and necrotic rather easily.how would one be able to monitor such changes within a contact cast?
My experience with casting is we change the casts every week to 10 days, debride the wound and redress with very absorbant dressings as appropriate.
Casting dramatically reduces the amount of exudate produced almost immediately, possibly due to the reduction of localised oedema.
This is turn helps control the development of infection: no bugs can get in there! Our only problem has been with obese patients who break the casts and need to be reviewed more often.
It really does work if the cast is applied appropriately, and the results are dramatic for wound healing.
We don't use casts on infected wounds and would swab to exclude this before applying the cast.