OBJECTIVES: Total contact casting (TCC) is used to promote wound closure in diabetic foot ulcers (DFUs); however, this technique is underused today. This study aims to further evaluate the efficacy of TCC in a large cohort, including patients with peripheral artery disease (PAD).
METHODS: This was a retrospective analysis of patients who underwent TCC from January 2017 to December 2021. PAD was defined as absence of pedal pulse or ABI<0.9. Demographic data, DFU characteristics, and arterial intervention were evaluated. Outcomes included complete healing of DFUs, healing time, and rate of major amputation.
RESULTS:
We identified 152 patients who underwent TCC. Mean age was 58.8±12.1 years, 79.6% were male, and 26.3% had PAD. A subset of patients had history of ipsilateral revascularization (23.0%) or previous amputation (41.4%). Mean DFU size was 8.27±9.9cm2, with mean depth 0.61±0.49cm. Forty-seven patients (30.9%) had chronic osteomyelitis. Average PEDIS (Perfusion-Extent-Depth-Infection-Sensation) score was 4.57±1.24. 112 patients had palpable pedal pulses on the affected extremity (73.7%). Average ABI was 1.12±0.22 (n=90).
Complete healing was observed in 122 (80.3%) patients, with average healing time of 81.5±57.1 days. Seven (4.6%) patients were in process of healing, while thirteen (8.6%) eventually required amputation (3 major). Compared to patients with healed DFUs, those without healing had higher PEDIS scores (5.04±1.30 vs 4.49±1.21, p=0.047), rates of amputation (39.1% vs 3.1%, p<0.001), intervention (43.4% vs 17.8%, p=0.006), noncompliance (39.1% vs 20.2%, p=0.046) and trend towards larger ulcer sizes (11.28±12.27 vs 7.72±9.38 cm2, p=0.11).
Thirty-three patients underwent revascularization, undergoing angioplasty (81.8%), atherectomy (63.6%), stent (15.2%), and/or bypass (9.1%). Interventions were performed in aortoiliac (3.0%), femoropopliteal (45.5%), and tibial (72.7%) segments. Twenty-two (66.7%) patients who underwent revascularization completely healed. Patients requiring revascularization were more likely to have previous intervention (57.6% vs 13.4%, p<0.0001), incompressible vessels (36.4% vs 7.6%, p<0.00001) and higher PEDIS scores (4.97±1.31 vs 4.46±1.20, p=0.036), with lower ABIs (0.94±0.25 vs 1.17±0.18, p=0.0008) compared to patients without intervention.
CONCLUSIONS:
TCC remains an effective option for treatment of DFUs, as most DFUs were completely healed or healing. Revascularization is a useful adjunct to TCC for patients with more significant PAD, as most DFUs closed with intervention.
| Characteristic | Intervention, Number of Patients (%) | No Intervention, Number of Patients (%) | p-value |
| Demographics | |||
| Total Patients | N=33 | N=119 | |
| Age, years | 61.6 ± 9.8 | 58.0 ± 12.6 | 0.13 |
| Male | 24 (72.7%) | 22 (18.5%) | <0.00001 |
| Current smoking | 3 (9.1%) | 18 (15.1%) | 0.37 |
| A1C, mean | 8.1 +/- 1.9 | 8.2 +/- 2.5 | 0.80 |
| Ulcer characteristics | |||
| Previous vascular intervention | 19 (57.6%) | 16 (13.4%) | <0.00001 |
| Prior minor amputation | 16 (48.5%) | 47 (39.5%) | 0.35 |
| Palpable pulse | 10 (30.3%) | 104 (87.4%) | <0.00001 |
| ABI | 0.94 +/- 0.25 (n=21) | 1.17 +/- 0.18 (n=69) | 0.0008 |
| Incompressible vessels | 12 (36.4%) | 9 (7.6%) | <0.00001 |
| Ulcer area, cm2 | 7.8 +/- 11.0 | 8.4 +/- 9.6 | 0.79 |
| Ulcer depth, cm | 0.6 +/- 0.48 | 0.6 +/- 0.49 | 0.92 |
| PEDIS score | 4.97 +/- 1.31 | 4.46 +/- 1.20 | 0.036 |
| Outcomes | |||
| Healed ulcer | 22 (66.7%) | 100 (84.0%) | 0.027 |
| Ulcer in process of healing | 1 (3.0%) | 6 (5.0%) | 0.63 |
| Average time to healing, days | 88.6 +/- 56.4 | 79.9 +/- 57.4 | 0.51 |
| Required minor amputation | 4 (12.1%) | 9 (7.6%) | 0.41 |
| Recurrent ulcer after healing | 15 (45.5%) | 57 (47.9%) | 0.80 |
| Compliance issue | 8 (24.2%) | 27 (22.7%) | 0.85 |
| Type of intervention | |||
| Diagnostic | 1 (3.0%) | ||
| Angioplasty | 27 (81.8%) | ||
| Atherectomy | 21 (63.6%) | ||
| Stent | 5 (15.2%) | ||
| Bypass | 3 (9.1%) | ||
| Location of intervention | |||
| Aortoiliac | 1 (3.0%) | ||
| Femoropopliteal | 15 (45.5%) | ||
| Tibial | 24 (72.7%) |
