What Causes A Foot Ulcer
Patients with diabetes are prone tomajor foot problems. This is because the foot expresses many of the underlying effects of diabetes, including neuropathy, vascular disease, and diminished response to infection.
As a result of the neuropathy, the foot can develop an ulcer. This happens for two reasons. The first is that the neuropathy causes paralysis of small muscles in the foot, which results in clawing of the toes. Clawing of the toes causes prominence of the metatarsal heads on the bottom of the foot as well as the knuckles on the dorsum of the foot.
Neuropathy also causes diminished sensation. As the prominent metatarsal heads on the plantar of the foot are subjected to increased pressure, the skin will begin to enlarge and become callused. The callused skin can be subjected to shear forces that cause a separation between the layers of the skin. The layers can fill with fluid, which can then become contaminated and infected. The pressure also can cause primary breakdown of the skin in these areas, causing a foot ulcer. Once the initial breakdown and contamination occurs, the foot may develop more significant problems because of infection.
Study Design And Settings
This study was a multicenter, cross-sectional study design conducted in three large referral diabetic foot clinics in Jordan: the National Centre for Diabetes, Endocrinology, and Genetics Jordanian Royal Medical Services and Prince Hamza Hospital . Ethical approval was granted for this study by the Office of Research Ethics and Integrity at the Queensland University of Technology , Australia and each of the Institutional Review Board Committees at the NCDEG , JRMS , and PHH .
Experimental Protocol And Data Analysis
The participants walked at a comfortable self-selected walking speed along a 9m walkway. Trials, whereby the participants walked at a velocity outside a 10 % individual tolerance, were excluded from the study. Both pedar® and pliance® collected data simultaneously at a sampling rate of 50Hz synchronised to the temporal event of heel strike. Each trial started with the participant standing with two feet together. Each participant was instructed to commence walking after the various data collection systems had commenced recording. In this way, the heel strike of the first step of each trial could be used for synchronisation purposes. This synchronisation was completed manually by combining video, plantar and TCC wall data. Each participant walked a minimum of two successful trials.
Descriptive statistics and normality of data distribution were computed in SPSS v22.0 . The magnitude of TCC wall load as a proportion of plantar load was calculated. Following removal of the cast walls, the difference in plantar loading between the TCC and the shoe-cast for the whole foot and three clinically relevant regions of the foot, including rearfoot, midfoot and forefoot , were calculated using the Novel software . Paired sample t-tests were undertaken to assess significance between TCC and shoe-cast conditions. The alpha value was set at 0.05.
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Advantages Over Other Treatments
Medical or surgical treatment may not be adequate for diabetic foot ulcers. Even if the best care is given, healing may be delayed if the ulcer is subjected to constant pressure while walking. Total contact casting provides optimal wound healing conditions by ensuring that the ulcer is not further traumatized and also prevents the development of new ulcers in the bony prominences of the foot.
Precautions
A patient scheduled to receive a total contact cast should be properly informed of the procedure, since this treatment will impose limitations on freedom of movement. Walking should be done with the aid of a cane or crutch in order to avoid exerting any pressure on the affected foot and to prevent any fall-related injuries. Any development of hip or back pain should be reported to a doctor, as this may signal musculoskeletal strain due to the cast. The cast should remain dry, so the patient is advised to take sponge baths instead of showers.
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Clinical Evidence For Total Contact Casting
The use of TCC as the most effective off-loading method is strongly supported by clinical evidence. Randomized clinical trials provide strong evidence of reduced healing time and greater numbers of healed DFUs for TCC when compared to other methods.
Lavery et al. showed that TCC had a wound closure rate of 88.9%, compared to 50% for healing sandal and 40% for shear-reducing walking boot. They also showed that median time to healing for TCC was 5.4 weeks, compared to 8.9 weeks for a healing sandal and 6.7 weeks for sheer reducing walking boot.
Armstrong et al. determined that TCC had a healing rate of 88.9%, compared to 65% for a removable cast walker and 58.3% for a half-shoe, and time to healing was least for TCC at 4.8 weeks, compared to 7.2 weeks for the removable cast walker and 8.7 weeks for the half-shoe. This data was reiterated by Lavery almost 14 years later in a newer study .
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Important Total Contact Cast Facts
The total contact cast is the gold standard of treatment and the standard of care for diabetic foot ulcers that are neuropathic, Wollheim said.
However, there are some alternatives to the total contact cast for off-loading .
One is the use of a product called TCCEZ, which some clinicians feel more comfortable using because it is easier to apply.
The healing rates of the TCC-EZ is about the same as with the use of a traditional total contact cast, Wollheim said.
Another option is the use of a removable cast walker that is a clamshell type of structure with Velcro.
With a removable cast walker, we typically see a 65% healing rate not as good as a total contact cast, Wollheim said. However, some clinicians are more comfortable using it.
A clinician can create an instant total contact cast, according to Wollheim, by using a removable cast walker and securing it with duct tape or rolled plaster.
This can force compliance as the patient will not be able to take it off, he said. We call this an instant total contact cast and the healing rates are the same as with a total contact cast 75% to 100%.
The topical antimicrobial products used in wound care and the use of systemic antibiotics will vary, Wollheim said.
How Is The Tcc Applied
The following depicts the usual steps when applying a total contact cast:
- Have the patient lie on his/her stomach with the affected leg pointing straight up
- Ensure that the ankle is bent in a neutral position
- Apply a thin dressing over the ulcer
- Apply a thin layer of stockinette
- Apply protective cast padding between the toes
- Apply cast padding in a thin layer up the limb
- Apply secondary foam padding over vulnerable areas
- Apply the plaster undercoat smoothly to the foot and leg, covering the toes and going up the leg
- The sole of the cast is applied so that it very closely molds the contours of the sole of the foot any valleys in the sole are filled in with plaster of Paris so that the sole is flat
- The cast may be reinforced with fiberglass and a rocker bottom sole or specially curved sole is applied for patients that are to be permitted to weight bear
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Diabetes: Options For Offloading
Total contact casting may be the gold standard, but few practitioners use it. Evidence supports the removable cast walker as a less-complicated alternative that can also be rendered irremovable for improved compliance.
Figure 1: Removable Cast Walker
Although the total contact cast has long been considered the gold standard for offloading the diabetic foot, few practitioners use this modality on a daily basis.1,2,3 The majority of studies of the TCC have demonstrated healing rates as high as 90% at 12 weeks.4,5 In spite of these data, the majority of practitioners treating diabetic wounds use one of several alternative devices to try and accomplish the same results.6 These include the removable cast walker , the non-removable cast walker or instant total contact cast , the modified Carville healing sandal, the felted foam technique, the football dressing, commercial offloading shoes, and depth footwear. Practitioners choose between these devices using a variety of sources of information. Decisions are most often dictated by individual experience with a particular modality, clinical availability, patient preference, or insurance reimbursement.
Figure 2: Instant Total Contact Cast with a Cable Tie
Figure 3a: Hex Insole with Plugs Removed
wounds within the 12 week standard window.1,2 .
Figure 3b: Removing Diamond Segments from a RCW Insole
Figure 4a: Football Dressing Cast Padding
Instant reaction
Figure 4c: Football Dressing Coban Wrap
References
Removable Walker Cast For Diabetic Foot Ulcers
Diabetic plantar ulcers heal just as well with removable walker casts as with nonremovable fiberglass total-contact casts, a new study reveals.
The researchers say the removable cast could be a good option when patients cannot have a nonremovable total-contact cast and they present a long list of such patients: those with infection or critical ischemia, those who are very elderly or have problems with vision or equilibrium, and those with a contralateral foot ulcer or varicose veins.
Dr. Giacomo Clerici of IRCCS Multimedica in Sesto San Giovanni, Milan, Italy, and colleagues describe a study in which they randomized 48 patients with nonischemic, noninfected neuropathic plantar ulcer to either a removable walker cast or a nonremovable total contact cast .
Among the 23 patients in the control group, average ulcer surface area shrank from 1.41 sq. cm at baseline to 0.2 sq. cm after treatment. In the 22 Stabil-D group patients, mean ulcer area shrank from 2.18 to 0.45 sq. cm. There was no difference between the two groups in ulcer surface area change.
Seventeen controls and 16 Stabil-D subjects achieved healing of the ulcer. Average healing times were similar: 35.3 days in the control group and 39.7 days in the Stabil-D group.
Because this study is a noninferiority trial, we cannot say that the use of a removable walker should be the treatment of choice for patients with neuropathic ulcers, Dr. Clerici said.
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Impact Of Removable Cast Walker Design On Usability For Patients With Diabetic Foot Ulcers
| The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government.Know the risks and potential benefits of clinical studies and talk to your health care provider before participating. Read our disclaimer for details. |
| Recruitment Status : Not yet recruitingFirst Posted : June 13, 2022Last Update Posted : June 13, 2022 |
- Study Details
| Study Type : | |
| Treatment | |
| Official Title: | Improving Diabetic Foot Ulcer Offloading: A Pilot Study on the Impact of Removable Cast Walker Design Factors on Usability |
| Estimated Study Start Date : |
| Device: RCW design form |
Tall RCW= a knee high removable cast walker with an offloading insole
Short RCW= an ankle high removable cast walker with an offloading insole, paired with an external shoe lift to be used with a diabetic shoe on the contralateral limb
Tall RCW= a knee high removable cast walker with an offloading insole
Short RCW= an ankle high removable cast walker with an offloading insole, paired with an external shoe lift to be used with a diabetic shoe on the contralateral limb
What Do I Need To Know About My Cast
Depending on the type of cast you have, the cast will take either 30 minutes or 24 hours to dry after it is first fitted. Your doctor will tell you what kind of cast you have. It is important that you dont put any weight on the cast while its drying.
You should do as little walking as possible after the cast dries, for these reasons:
- The ulcer will heal faster if you put less pressure on it.
- Your leg with the cast is longer than your other leg. This can cause pain in your hip or back if you walk too much.
- Youre less stable when youre wearing a cast. Your chances of falling and hurting yourself are increased. The less you walk, the less likely you are to fall. Be very careful on slippery or uneven ground. Use a cane for added stability, even if you usually dont use a cane. If you were already unsteady before wearing the cast, it is a good idea to use a walker.
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Who Needs A Total Contact Cast
Total contact casts are commonly used by people who have diabetes with foot ulcers that are not healing. Diabetes can cause problems with the feet. A complication called neuropathy can cause a loss of feeling in the feet. This can make it hard to tell if you have a blister or sore on your foot. Small sores can turn into big sores fast. If small sores arent taken care of, they can get worse and turn into ulcers.
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Evaluating A Removable Knee
- 27 Sep 2019
The incidence and cost of diabetic foot disease is recognised to be an increasing problem. Between 5% and 7% of people with diabetes will develop ulceration, at a cost of £935mn to the NHS . Therefore, it is essential that successful diagnosis and effective care is delivered, including optimising diabetes control, optimising vascular flow, debridement and dressing the wound, and offloading the foot .
Offloading of the foot for patients with diabetes has been identified as the most important intervention to heal a neuropathic plantar ulcer . NICE and IWGDF have published guidelines for which the most effective method of offloading to improve the outcomes for patients and to prevent the complications which can lead to amputation .
Appropriate offloading should be offered to any patient who clinically needs it as soon as possible with the device selected based on the clinical presentation and patient preference.
Non-removable knee-high devices with an appropriate footdevice interface are recommended as the most effective offloading method. This includes ulcers which are complicated with mild ischaemia or infection. Non-removable devices may not be acceptable to patients because they restrict daily activities such as bathing, driving and sleeping . The use of a total contact cast also requires frequent application by a fully trained, experienced practitioner, which adds additional costs .
Exclusion criteria:
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Removable Walker For Neuropathic Ulcers
| The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. |
| First Posted : October 30, 2009Last Update Posted : October 30, 2009 |
| Device: non-removable fiberglassDevice: Stabil-D® | Phase 3 |
Study design:
| Study Type : | |
| Treatment | |
| Official Title: | Effectiveness of Removable Walker Cast Versus Non-removable Fiberglass Off-bearing Cast in the Healing of Diabetic Plantar Foot Ulcer- a Randomized Controlled Trial |
| Study Start Date : |
Compliance With Removal Devices And The Instant Tcc
We have postulated that, although the RCW and TCC may off-load equally well , patients who have dense neuropathy might not strictly adhere to a standard off-loading regimen. In a recent study , we evaluated the activity of patients with diabetic foot ulcers and their adherence to an off-loading regimen. This study, which made use of accelerometers worn on the patients’ waists and hidden on the RCW, suggested that patients wore their off-loading device during < 30% of their total daily activity . This disappointing result has prompted us to search for simple solutions.
Understanding that most centers do not have the infrastructure, expertise, and/or personnel to apply TCCs, we have suggested that a potential alternative might be to make the RCW less easily removable. This simple concept, termed an instant TCC , involves simply wrapping the RCW with cohesive bandage, plaster, or fiberglass . This solution could have the benefit of adequate off-loading and adequate adherence to the prescribed course of pressure reduction.
Removable cast walker wrapped in a cohesive bandage to convert it to an instant total contact cast.
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