Total Contact Cast Use in Patients With Peripheral Arterial Disease

A Case Series and Systematic Review

Anthony Tickner, DPM, DABPM, FACCWS, FAPWCA, FAPWH; Cheri Klinghard, RN, BSN, CWON, DWC; Jonathan F. Arnold, MD, ABPM-UHM, CWS-P; Valerie Marmolejo, DPM

Disclosures

Wounds. 2018;30(2):49-56. 

In This Article

Abstract and Introduction

Abstract

Introduction. As the majority of diabetic foot ulcerations (DFUs) occur on the plantar foot, excessive pressure is a major contributing factor to delayed healing. The gold standard for offloading is the total contact cast (TCC); yet, TCC use is contraindicated in patients with ischemia. Lower extremity ischemia typically presents in the more severe end stages of peripheral arterial disease (PAD). As PAD exists on a severity spectrum from mild to severe, designation of a clear cutoff where TCC use is an absolute contraindication would assist those who treat DFUs on a daily basis.

Objective. The aim of this study is to determine if a potential cutoff value for PAD where TCC use would be an absolute contraindication could be ascertained from a retrospective case series and a systematic literature review of patients with PAD in which treatment included TCC use.

Materials and Methods. A retrospective cases series and systematic review of patients with mild to moderate PAD treated with a TCC was performed. All reports of TCC use in patients with PAD and a neuropathic ulceration that included results of noninvasive vascular studies were included.

Results. Results suggested that TCC use is a viable treatment modality for pressure-related DFUs in patients with an ankle pressure ≥ 80 mm Hg, a toe pressure ≥ 74 mm Hg, an ankle-brachial index ≥ 0.55, or a toe-brachial index ≥ 0.55.

Conclusions. Vascular evaluation, individual risk/benefit analysis, close follow-up, and patient education are essential components of TCC use in these patients. Repeat vascular evaluation is recommended if the wound fails to progress towards resolution with TCC use.

Introduction

The prevalence of peripheral arterial disease (PAD) in the general population ranges from 10% to 40%.[1,2] In the clinical practice guidelines for management of the diabetic foot put forth by the Society for Vascular Surgery, the American Podiatric Medical Association, and the Society for Vascular Medicine, at least 65% of diabetic foot ulcerations (DFUs) are reported to be complicated by PAD.[1] The Eurodiale study, a 1-year retrospective review of all patients presenting with a DFU at 14 diabetic foot centers in Europe, found that 61% of patients had PAD.[2] Of these patients, 49% were defined as having moderate PAD, with an ankle-brachial index (ABI) < 0.9 or absent palpable pedal pulses, and 12% were defined as having severe PAD with an ABI < 0.5. In addition, 32% of patients had falsely elevated ABIs, making the diagnosis of PAD severity difficult. The prevalence of PAD was found to increase with age > 70 years and the presence of disabling comorbidities. Healing rates were worst when DFUs were complicated by both PAD and infection. However, these types of ulcerations occurred more often on the dorsal aspect of the foot where pressure is less likely to be a contributing factor to delayed healing.[2]

Offloading has been reported to be the single most important factor in the resolution of plantar neuropathic ulcerations.[3,4] Postoperative shoe and removable cast walker use are the most common offloading modalities employed.[5–8]

However, these offloading modalities rely heavily on patient compliance with use for success. Studies have shown that patients often only use these devices between 2% to 28% of waking/walking hours, making the associated prolonged healing times and greater incidence of infection and amputation not surprising.[9–11] Dr. Paul Brand brought the concept of the total contact cast (TCC) to the United States in the 1960s as a treatment for leprosy-related neuropathic ulcerations.[12] The TCC later became touted as the gold standard for offloading plantar DFUs as it forces patient compliance; provides the greatest reduction in peak plantar pressures, particularly to the forefoot; and has reported resolution rates ≥ 73%.[3,5,6,8,10,13–21]

However, its use remains limited due to a variety of clinician, organization, and patient-related barriers. One of these barriers is the contraindication of use when ischemia or severe PAD is present, although a clear definition or cutoff value has not been defined.[5,8,21–29]

As PAD exists on a spectrum of severity, with ischemia typically noted in the end stages, and the prevalence of neuroischemic neuropathic ulcerations on the rise, a clear cutoff value for PAD that would make TCC use an absolute contraindication would assist clinical decision-making for these patients. The aim of this study is to determine if a potential cutoff value for PAD where TCC use would be an absolute contraindication could be ascertained from a retrospective case series and a systematic literature review of patients with PAD in which treatment included TCC use.

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