Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study

Background Charcot neuroarthropathy (Charcot foot) is a highly destructive joint disease of the foot and ankle. If there is delayed diagnosis and treatment, it can lead to gross deformity, instability, recurrent ulceration and/or amputation. Total contact casting (TCC) is a treatment commonly used to immobilise the foot and ankle to prevent trauma, further destruction and preserve the foot structure during the inflammatory phase. At present, there is limited Australian data regarding the duration of TCC treatment for resolution of acute Charcot foot, and whether there are any patient and clinical factors affecting its duration. Therefore, this study aimed to address these deficiencies. Methods This study presents a retrospective analysis of 27 patients with acute Charcot foot attending for TCC treatment at a high-risk foot service (HRFS) in a large metropolitan health network in Melbourne, Australia. Over a three-year period, data were retrospectively collected by reviewing hospital medical records for clinical, demographic, medical imaging and foot examination information. To explore between-group differences, independent samples t-tests, Mann-Whitney U tests, Chi-square tests, and/or Fisher’s exact tests were calculated depending on data type. To evaluate associations between recorded variables and duration of TCC treatment, mean differences, odds ratios (OR) and 95% confidence intervals were calculated. Results Mean age was 57.9 (SD, 12.6) years, 66.7% were male, 88.9% had diabetes, 96.3% had peripheral neuropathy, and 33.3% had peripheral arterial disease. Charcot misdiagnosis occurred in 63.0% of participants, and signs and symptoms consistent with acute Charcot foot were present for a median of 2.0 (IQR, 1.0 to 6.0) months prior to presenting or being referred to the HRFS. All participants had stage 1 Charcot foot. Of these, the majority were located in the tarsometatarsal joints (44.4%) or midfoot (40.7%) and were triggered by an ulcer or traumatic injury (85.2%). The median TCC duration for resolution of acute Charcot foot was 4.3 (IQR, 2.7 to 7.8) months, with an overall complication rate of 5% per cast. Skin rubbing/irritation (40.7%) and asymmetry pain (22.2%) were the most common TCC complications. Osteoarthritis was significantly associated with a TCC duration of more than 4 months (OR, 6.00). Post TCC treatment, 48.1% returned to footwear with custom foot orthoses, 25.9% used a life-long Charcot Restraint Orthotic Walker, and 22.2% had soft tissue or bone reconstructive surgery. There were no Charcot recurrences, however, contralateral Charcot occurred in 3 (11.1%) participants. Conclusions The median TCC duration for resolution of acute Charcot foot was 4 months, which is shorter or comparable to data reported in the United Kingdom, United States, Europe, and other Asia Pacific countries. Osteoarthritis was significantly associated with a longer TCC duration. The findings from this study may assist clinicians in providing patient education, managing expectations and improving adherence to TCC treatment for acute Charcot neuroarthropathy cases in Australia.

EFFECTIVENESS OF TOTAL CONTACT CASTING IN LEPROTIC Vs DIABETIC PLANTER FOOT ULCER: A COMPARATIVE STUDY

Total Contact Casting (TCC) has been identied as 'Gold Standard' treatment approach by ofoading in neuropathic foot ulceration, a very common but notorious complication of Leprosy & Diabetes. Here we tried to compare its efcacy in diabetic & leprotic foot ulcer. AIMS & OBJECTIVES: 1. To observe the outcomes of TCC in Leprotic & Diabetic planter ulcer. 2. To compare the effectiveness of TCC in these two conditions. STUDY DESIGN: Prospective analytical study SAMPLE SIZE: n= 24 (12 diabetic & 12 Hansen's) STUDY DURATION: 12 months. STUDY PLACE: Dept of PMR; IPGMER & SSKMH, Kolkata INCLUSION CRITERA: 1. Unilateral solitary Grade 1 & 2 planter ulcerations (Wagner classication). 2. Age: 20-60 years. 3. Ambulatory patients. EXCLUSION CRITERIA: 1. Grade-3/4/5 planter ulcerations 2. Excessive leg or foot swelling. METHODS & MATERIALS:At rst, ulcers were debrided of all necrotic-tissue to create a smooth surface. Then after proper positioning, over a small amount of cotton padding, the cast was applied covering the toes up to 2 cm distal to bular head with a rocker sole for ofoading. ASSESSMENT: st rd th Assessment was done in consecutive 3 visits at the end of 1 /3 /6 week comparing the size, depth, downgrading of Wagner classication & time taken for complete ulcer healing. CONCLUSION: Overall healing in both groups was very good with TCC with no statistically signicant improvement difference

Efficacy of Intra-Lesional Platelet Rich Plasma in Diabetic Foot Ulcer

Background: Diabetic foot ulcer (DFU) is well managed by infection control, euglycemic state, debridement of ulcer followed by appropriate dressing and off-loading of the foot. Studies have reported that when DFU is properly off-loaded, about 90% of these would heal in nearly six weeks. Platelet rich plasma (PRP) serves as a growth factor agonist and has mitogenic and chemotactic properties which help in DFU healing. To evaluate the efficacy of local application of PRP with respect to healing rate and ulcer area reduction in treating diabetic foot ulcer. Materials and Methods: Sixty non-infected DFU patients with plantar ulcer of size less than 20cm2 and Wagner's Grade 1 & 2 were randomized to receive normal saline dressing (Control group - CG) or PRP dressing (Study group - SG) in conjunction with total contact casting for 6 weeks (or till complete ulcer healing), whichever was earlier. Evaluation was done at weekly interval for healing rate and change in ulcer area.Results: Mean ulcer area of study participants at baseline was 4.96 {plus minus} 2.89cm2 (CG) and 5.22 {plus minus} 3.82cm2 (SG) (p=0.77) which decreased to 1.15{plus minus}1.35cm2 (CG) and 0.96{plus minus}1.53cm2 (SG) (p=0.432) at 6wks. Percent reduction in mean healing area at 6wks was 81.72{plus minus}17.2% and 85.98{plus minus}13.42% in control group and study group respectively (p=0.29). Average rate of healing achieved at 6 weeks was 0.64{plus minus}0.36cm2 and 0.71{plus minus}0.46cm2 in control group and study group respectively (p=0.734). Conclusions: PRP dressing is no more efficacious than normal saline dressing in management of DFU in conjunction with total contact casting.

What to put on (and what to take off) a wound: treating a chronic neuropathic ulcer with an autologous homologous skin construct, offloading and common sense

ABSTRACT Closure of chronic lower extremity wounds is important for minimizing the risk of infection and amputation in a very high-risk population. Developments in tissue cultures and matrix therapies have shown promise in enhancing healing. The use of autologous homologous skin constructs in wound treatment may enable the regeneration of functional dermal structures. We present the case of a chronic medial heel ulcer that dehisced following intraoperative debridement, which was subsequently treated using a combination of an autologous homologous skin construct and total contact casting. This case emphasizes the importance of proper offloading for healing and preventing recurrence of lower extremity wounds.

PO 18251 - Functional clinical outcome of the conservative treatment of calcaneal fractures in patients with diabetic neuropathy

Introduction: Calcaneal fractures are potentially serious in diabetic patients with foot insensitivity. The consensus is that surgical treatment involves a high risk of complications in these cases, and conservative treatment is the option of choice because it allows monitoring of the onset of pressure ulcers and the degree of hindfoot collapse, which usually occurs as Charcot arthropathy progresses. Objective: To retrospectively evaluate the mid-term functional clinical outcome of conservative treatment of calcaneal fractures in diabetic patients with advanced peripheral neuropathy associated with loss of protective foot sensitivity. Methods: Fifteen patients (16 feet), 12 men and 3 women, whose mean age at the time of the calcaneal fracture was 53 years (ranging from 34 to 70 years) were retrospectively evaluated after conservative treatment with total contact casting. We considered a functional clinical outcome good when the foot was plantigrade and ulcer-free and the patient could wear deep footwear with custom-made insoles for insensitive feet. The outcome was considered acceptable when the patient had residual deformity requiring custom-made polypropylene ankle-foot orthosis (AFO) braces. The outcome was considered poor when extremity amputation was required, when the patient was unable to bear weight on the foot during gait due to hindfoot instability as a result of the fracture, or when the patient showed recurrent ulcer due to bone prominence resulting from fracture malunion. Results: After a mean follow-up time of 40 months (ranging from 12 to 168 months), we assessed a good outcome in 10 feet, an acceptable outcome in 2 feet with braceable residual deformity, and a poor outcome in 4 feet, 3 of which had recurrent ulcers in the foot support area and another that required amputation due to severe infection. Conclusion: Conservative treatment with total contact casting efficiently produced plantigrade, shoeable or braceable feet without pressure ulcers in approximately two-thirds of our small series of patients with diabetic foot insensitivity who suffered calcaneal fracture.

Vacuum assisted closure versus total contact casting in the healing of plantar foot ulcers: a comparative prospective study

Background: The objective of the study was to compare the effectiveness of vacuum assisted closure (VAC) and total contact casting (TCC) in the healing of plantar foot ulcers. Chronic leg ulcers are a significant cause of morbidity in developing countries like India, leading to excessive health care expenses and loss of effective work hours, inspite of availability of various novel modalities of management. This study aims to compare the effectiveness of vacuum assisted closure and total contact casting in the healing in plantar foot ulcers, in order to standardise a procedure with maximum benefits.Methods: This comparative prospective study was conducted on 150 individuals admitted to SVRRGG Hospital, Tirupati, with the diagnosis of plantar foot ulcers from august 2017 to march 2019. They were divided into 2 groups, Group A (75 patients treated with VAC) and Group B (75 patients treated with TCC). In this study, the outcomes assessed were reduction of wound size and length of hospital stay.Results: In this study, mean reduction of wound surface area with VAC and TCC was 21.09 and 12.83 respectively, mean percentage of reduction of wound size with VAC is 90.43 and in TCC was 52.36. Mean hospital stay with VAC and TCC was 24.90 days and 51.29 days respectively.Conclusions: VAC is more effective than TCC in the treatment of foot ulcers, with less duration of hospital stay and earlier returns to work.