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dear all,
recently i have started applying total contact cast for plantar ulcers.initial results were satisfactory. but after 3 months they came with the recurrent ulcers. please guide me how to prevent this? about foot wear modifications.

suresh

Hi
The majority of patients I see with ulcers, especially those on the plantar surface, are treated with orthoses, some custom, some pre-fab. I usually start this process as soon as possible. But sometimes it can be something really simple as a change in footwear.
But education is the most important thing I give to the patient, advice on what to look for i.e. check feet everyday etc etc and what to do i.e. come back as soon as possible. I think my patients might say I nag, but it must sink in, as we seem to be keeping recurring probs to a minimum.

Suresh

One needs to think about the reason why the ulceration happened in the first place, and why ground reaction forces have reached a point where there is skin breakdown. Although neuropathy is the driving issue, neuropathic ulcers (typically) will only occur over weight-bearing bony prominences (ie MT heads, IP joints, subluxed Charcot midfoot joints).

Hence a total contact cast will work to "heal" an active lesion, it does nothing to influence the long term biomechanical issues at play. This is where custom foot orthoses, footwear modifications etc are crucial for preventing recurrence.

Search the literature on custom, total contact diabetic foot orthoses and footwear modification (eg rocker soles) - these are the most effecting modalities I know of (short of surgery such as tendo Achilles lengthening and bony resections etc), to break the cycle of recurrent ulceration.

LL

Related threads:
Unloading mechanism in the total contact cast.
Offloading and total contact insoles
Total contact casting in minor amputations
Moderately ischemic diabetic foot ulcers do respond to TCC
Removable and irremovable cast walkers
Instant total contact cast

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I agree with the above,

Total contact casts can be effective (if used correctly!!) in the management of ulcerated feet etc. I would imagine that this individual would need to go into a pair of orthopaedic boots and total contact insoles when the cast is removed. A careful examination of his foot position at night time should also be looked at.

Declan

I also agree,

I the right client Total Contact Casting can be highly effective. it is then very disapointing to see the ucler reoccur.
What we tend to do is before the casting is to be stopped we will take a cast for a total contact insole to be fabricated so that when the client comes out of the Total contact cast they have appropiate off loading as well as suitable footwear that is adequate.
In some instances we will put then in a Diabetic walker with a custon insole initally and gradually introduce their footwear with a custom insole.
I know chronic foot ulcers can be very difficult and fustrating for all concerned.

Chris

Firstly l too agree with the above.

If initially everything is okay and then it fails it may be the material that you are using to make your TCO's ? they may well be breaking down/ compressing very quickly?

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David Sutton
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My location
www.bilbyshoes.com

Hi every one on this subject I would be really interested to get your opinions on the use of Aircast boots as an alternative to a TCC.

Hi Richie,
with regard to your question on the use of Air cast boots as an alternative to TCC.
I think this is a valid option from my readings and understanding a good fitting Air Cast walker combined with prehaps a suitable cusstom insert can be almost as effective as TCC.
The only problem with Air cast Walkers or similar Walkers is that they are removable. this does allow the client to wash or shower and to leave the walker off over night, which is convient.
However there can be a problem with compliance and frequency of use of the Air Walker.
I do use them for clients but they do need to be educated on the reasons you are giving them this device and that it needs to be worn during the day and at in particular at home.
There is an article produced by Dr Armstrong DPM on an instant TCC where they fasten the Diabetic Walker using casting tape so it is worn all the time. (a good article to look up)
The only problem with this is that clients feel that you dont trust them.
Hope This is useful

Chris

Many thanks for that it was very helpful.