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Total Contact Casting Promotes Wound Healing in Peripheral Artery Disease and Diabetic Foot Ulcers
Jason Zhang, MD, Mikel Sadek, MD, Lou Iannuzzi, DPT, Caron Rockman, MD, Karan Garg, MD, Allison Taffet, BS, Amir Mullick, MD, Todd Berland, MD, Thomas Maldonado, MD, Glenn Jacobowitz, MD, Frank Ross, MD.
New York University, New York, NY, USA.

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.
We identified 152 patients who underwent TCC. Mean age was 58.812.1 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 8.279.9cm2, with mean depth 0.610.49cm. Forty-seven patients (30.9%) had chronic osteomyelitis. Average PEDIS (Perfusion-Extent-Depth-Infection-Sensation) score was 4.571.24. 112 patients had palpable pedal pulses on the affected extremity (73.7%). Average ABI was 1.120.22 (n=90).
Complete healing was observed in 122 (80.3%) patients, with average healing time of 81.557.1 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 (5.041.30 vs 4.491.21, 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 (11.2812.27 vs 7.729.38 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 (4.971.31 vs 4.461.20, p=0.036), with lower ABIs (0.940.25 vs 1.170.18, p=0.0008) compared to patients without intervention.
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.

Table 1. Pre and Post-TCC Characteristics for Patients with and without Intervention
CharacteristicIntervention, Number of Patients (%)No Intervention, Number of Patients (%)p-value
Total PatientsN=33N=119
Age, years61.6 9.858.0 12.60.13
Male24 (72.7%)22 (18.5%)<0.00001
Current smoking3 (9.1%)18 (15.1%)0.37
A1C, mean8.1 +/- 1.98.2 +/- 2.50.80
Ulcer characteristics
Previous vascular intervention19 (57.6%)16 (13.4%)<0.00001
Prior minor amputation16 (48.5%)47 (39.5%)0.35
Palpable pulse10 (30.3%)104 (87.4%)<0.00001
ABI0.94 +/- 0.25 (n=21)1.17 +/- 0.18 (n=69)0.0008
Incompressible vessels12 (36.4%)9 (7.6%)<0.00001
Ulcer area, cm27.8 +/- 11.08.4 +/- 9.60.79
Ulcer depth, cm0.6 +/- 0.480.6 +/- 0.490.92
PEDIS score4.97 +/- 1.314.46 +/- 1.200.036
Healed ulcer22 (66.7%)100 (84.0%)0.027
Ulcer in process of healing1 (3.0%)6 (5.0%)0.63
Average time to healing, days88.6 +/- 56.479.9 +/- 57.40.51
Required minor amputation4 (12.1%)9 (7.6%)0.41
Recurrent ulcer after healing15 (45.5%)57 (47.9%)0.80
Compliance issue8 (24.2%)27 (22.7%)0.85
Type of intervention
Diagnostic1 (3.0%)
Angioplasty27 (81.8%)
Atherectomy21 (63.6%)
Stent5 (15.2%)
Bypass3 (9.1%)
Location of intervention
Aortoiliac1 (3.0%)
Femoropopliteal15 (45.5%)
Tibial24 (72.7%)

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