Total Contact Casts

Neuropathic wounds are caused by excessive pressure and / or shear

applied to an foot that cannot adequately feel pain.

It makes sense, then, that addressing that deforming pressure or shear

force would be vital in allowing the wound to heal. In other words, if
there is a mechanical cause to a complaint, the solution requires
addressing that mechanical cause.

Removing the forces causing a wound is called offloading. We discuss
the various ways a wound can be offloaded here, but the total contact
cast is the gold standard of offloading a wound. Simply put, TCCs show
the highest success rates in getting a wound to close (1,2,3,4,5,6,7,8).
Success ates are commonly reported in the 75% to 90% range. You can

read more about their effectiveness here.

And they work quickly--usually about seven weeks.

Why do they work?

TCCs redistribute body weight over the entire surface of the foot. They

keep the ankle at 90 degrees, diminishing the deforming forces when

the foot pushes off. They shorten the patient's stride and diminish the

number of steps taken. Most importantly, they are not removable, so

they enforce compliance.

The History of the Total Contact Cast

The idea of the total contact cast can be traced back to Ceylon, India,
now Sri Lanka. It was then that Dr. Milroy Paul, right, a Ceylonese
physician first used casting to treat a neuropathic ulcer from Hansen's
Disease (leprosy).

Dr. Joseph Khan, also working with leprosy patients in India, published
the technique in 1939 (9).

Dr. Paul Brand learned and practiced the technique in India in the
1940s and 1950s, modifying it with less padding to better conform
to the leg, and applying the technique for diabetic patients. Brand
brought the technique to the US in the 1960s.

How Do Total Contact Casts Work?

Total Contact Casts are thought to work through several mechanisms.

1) They redistribute weight over the entire surface area of the bottom of
the foot.

2) They recruit the leg to bear some of the load.

3) They alter the mechanics of the foot. Specifically, they shorten the stride
of gait, significantly limit the motion of the joints of the foot, and they
tend to limit the number of steps a patient takes during the day.
4) Finally, they enforce compliance, as they cannot be removed by the
patient.

How Well Do they work?

There are multiple studies in the literature showing that total contact casts can achieve 90% closure rates in under two months. For a more in-depth look at the statistics of TCCs compared with other forms of offloading, click here.

Contraindications

While total contact casts are frequently successful in
treating neuropathic wounds, there are some reasons
they may not be chosen as a treatment.

First, they are not used in the presence of infection.

An infected wound would be difficult to monitor

inside a cast, and one doesn't wish to seal bacteria

inside a wound.

Second, they are difficult to use in the elderly or

fragile patient, making these patients more prone

to falls.

Bathing is difficult with a TCC. It can be difficult to

sleep with a TCC. It's very difficult to drive with a

TCC. And they can be claustrophobic for some.

They're also more expensive than other forms of

offloading. It takes time to remove the old cast,

and time to apply a new one. And it requires a

certain skill set for the caregiver to learn.

The Application of a Total Contact Cast

There are several commercial Total Contact Cast kits available on the market designed to make the process eassier. We'll show you an example of one. With this kit, there are ten steps, and they come numbered in the kit.

The patient may be positioned either in a seated position or on his or her stomach, where practical.

We begin by covering the wound with a light dressing.

1. First, a stockinette (a stretchy sock) is pulled over the leg (below left).

2. This is followed by the application of some adherent felt (below right). This protects the bony prominences of
the leg and ankle from the cast, and it protects the leg from the cast cutter when the cast is eventually removed.

3. Next, a foam toe guard is foamed over the toes (below left).

4. Two layers of a roll-on cotton cushion are then wrapped around the foot (below right)

5. Now that several layers of cushioning are in place, it's time to apply the hard layers. First, a roll of fiberglass casting
material is applied over the layer of roll-on cotton.

6. This is followed by a plaster sheet running down the back of the leg and plantar foot (below right).

7. That plaster layer is held in place by a roll of fiberglass casting material, which is wrapped around the leg
(below left).

8. Another layer of material, this time fiberglass, is applied down the back of the leg, across the plantar surface
(bottom of the foot), with the remainder either folded back on the plantar surface or on the anterior portion
of the leg (below right).

9. To hold the fiberglass sheet (above right) in place, a layer of fiberglass casting material is wrapped around the
leg (below left).

10. The stockinette edge below the knee is now folded down over the cast, (below left). to give a smooth edge,
and a final layer of fiberglass is wrapped around the leg (below right). The cast is left to cure at 90 degrees to
the ground and the patient ambulates in a boot or shoe.

Total contact casts are typically changed weekly. This
allows the wound to be inspected for healing, infection,
or other complications.

Debridement of the wound may performed at that time.

When it's time to remove this cast, a cast cutter is used to cut
down the medial side of the leg and foot, across the toes, and
along the lateral side of the leg and foot (right).

Other casts may be designed for the cut to be performed in a
different manner.

A cast splitter (below) is used to separate the two components of the cast.

The soft materials remaining on the foot are then removed.

The wound is assessed, cleaned, debrided, and redressed,
followed by application of another total contact cast.

This process is repeated until the wound is resolved.

Case Examples

This first example is a patient with a difficult, uncooperative mid-foot ulcer caused by Charcot neuroarthropathy.

The patient, a war veteran, had significant coronary artery disease and was on dialysis. His ulcer had been present for over a year at the time of his first presentation. It took 9 weeks to close the ulcer with a total contact cast. The foot was maintained successfully without re-ulceration for the following two and a half years with an orthotic in a standard shoe, at which time the patient passed away from a coronary event.

The ulcer below was also created by a deformity caused by Charcot neuroarthropathy. This ulcer had been open for three years, non-responsive to standard ulcer care. It was complicated by the patient's 425 pounds.

This ulcer took just 7 weeks to close with a total contact cast. The patient has been maintained closed with a custom-made shoe with a deep accommodation. The patient was ulcer-free for over a year and a half, but suffered a recurrence when he was hospitalized for a hip replacement. As part of his rehab for that surgery, he was instructed to get up and walk in the hospital, but he didn't have his custom shoes there, so the wound recurred.

We got the wound closed once more after his discharge, and he has again been stable in his custom shoes.

Below is another ulcer caused from Charcot neuroarthropathy. This ulcer had been present for 2 1/2 years. It took 8 weeks to close with total contact casting. The patient has been maintained with a custom shoe. Photo below right was taken 18 months after wound closure.

The patient below had a trans-metatarsal amputation that never healed following surgery. New ulcer sites formed on the bottom and side of the foot from the use of an inappropriate shoe.

Despite standard wound care visits, the wounds would not heal, and the patient was eventually referred to a surgeon who told him a leg amputation was his only option.

A colourful individual, the patient cursed at the doctor who suggested the amputation, and he never returned to the wound clinic. Instead, he decided to ignore the wounds, walking on the foot in regular shoes, and showing up to the hospital every so often, whenever the wounds became infected.

When we first saw this patient in the dialysis clinic, he had been living with these ulcers in this way for nine years (!)

When we first saw this patient, a chronic, stubborn, and antibiotic-resistant MRSA (methicillin-resistant staphylococcus aureus) and VRE (Vancomycin-resistant enterococcus) infection precluded the use of a total contact cast early. We tried other forms of offloading during this time, but they did not work.

It took months to fully resolve the chronic infection, but when the infection was finally gone, we were able to start applying the total contact casts and achieve wound healing.

The wound was finally healed a week before our funding in the dialysis program was exhausted. Despite results like these, the provincial health service, the health district, and the hospital each declined to take over funding, and the program ended.

A few months later, we were informed that the patient eventually passed away from a heart attack. But he died with both of his legs attached.

References:

Armstrong, D.G., et al., Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care, 2001. 24(6): p. 1019-22.
Bloomgarden, Z.T., American Diabetes Association 60th Scientific Sessions, 2000: the diabetic foot. Diabetes Care, 2001. 24(5): p. 946-51.
Morona, J.K., et al., Comparison of the clinical effectiveness of different off-loading devices for the treatment of neuropathic foot ulcers in patients with diabetes: a systematic review and meta-analysis. Diabetes Metab Res Rev, 2013. 29(3): p. 183-93.
Mueller, M.J., et al., Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am, 2003. 85-a(8): p. 1436-45
Piaggesi, A., et al., An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast. Diabetes Care, 2007. 30(3): p. 586-90.
Van De Weg, F.B., D.A. Van Der Windt, and A.C. Vahl, Wound healing: total contact cast vs. custom-made temporary footwear for patients with diabetic foot ulceration. Prosthet Orthot Int, 2008. 32(1): p. 3-11.
Mueller, M.J., et al., Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care, 1989. 12(6): p. 384-8.
Caravaggi, C., et al., Effectiveness and safety of a nonremovable fiberglass off-bearing cast versus a therapeutic shoe in the treatment of neuropathic foot ulcers: a randomized study. Diabetes Care, 2000. 23(12): p. 1746-51.
Khan, J.S., Treatment of Leprous Trophic Ulcers. Lepr India, 1939. 11: p. 19-25.

Evidence of an infection, such as this ascending red streak, is a contraindication to the application of a Total Contact Cast.

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Above: Dr. Milroy Paul (1900-1989), a graduate of the Royal College, Colombo, the Ceylon Medical College, and King's College, London

Below: Dr. Paul Brand (1914-2003), a graduate of University College Hospital, London

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"Try imagining a place where it's always safe and warm 'Come in,' she said, 'I'll give you shelter from the storm.'" -- "Shelter From the Storm" Bob Dylan

"Try imagining a place where
it's always safe and warm
'Come in,' she said, 'I'll give you
shelter from the storm.'"

-- "Shelter From the Storm"
Bob Dylan