Is Total Contact Casting Time Effective?

By Brian McCurdy, Associate Editor

Is total contact casting (TCC) too time-consuming a modality to be used in treating plantar foot ulcerations? It’s a prevailing question that has thwarted wider use of the modality. However, a new study recently presented at the Symposium on Advanced Wound Care (SAWC) attempts to shed new light on the “time-effectiveness” of TCC. Study researchers concede there is a “relatively low use rate” of total contact casts for diabetic foot ulcers. Why? They say many do not use TCC because of the time involved in the process and frequent office visits. However, previous studies have shown that employing TCC has resulted in healing times of 38 to 60 days. Study co-author Jeffrey Jensen, DPM, calls TCC the “gold standard.” “(TCC) provides the patient and the clinician with a method of healing wounds quickly,” says Dr. Jensen, a Diplomate of the American Board of Podiatric Surgery and Associate Professor at the University of Colorado Health Sciences Center. “This increases the clinician’s credibility in the community and they will receive more referrals because they are getting desirable outcomes.” Addressing The Issue Of Time-Consuming Application Dr. Jensen and his co-authors tracked 50 patients for the study and timed the applications of casting. The total average time a patient spent in the office for cast application following wound debridement was 29 minutes, according to the study. For the average patient, set-up and drying time totaled 21 minutes and 29 seconds. Application time, or actual physician time with the patient, was seven minutes and 32 seconds. When using total contact casting, you can save time “by effectively utilizing and minimizing physician involvement, understanding the importance of appropriate application of the TCC and minimizing the number of visits to heal the wound,” the study concludes. Dr. Jensen says he and his colleagues at the University of Colorado Health Sciences Center and Diabetic Foot and Wound Center use about 750 casts a year, employing them in case rate scenarios for insurers like Pacificare. Weighing The Results “Patients like the (casts) because they heal quickly,” says Dr. Jensen. “In the absence of infection and with intact vascular status, there is no equivalent treatment.” Between 1993 and 1999, Dr. Jensen tracked 305 patients, whose average wound duration was 304 days before presenting to his clinic. He discovered the average healing time was 79 days for compliant patients and 135 days for non-compliant patients, based upon patients wearing their offloading device and presenting to the clinic on a weekly basis. According to Dr. Jensen, the overall average healing time was 89 days. While Dr. Jensen notes not all patients were healed utilizing total contact casts, the TCCs “contributed significantly” to healing and decreased healing times. Offloading is a key consideration to keep in mind and healing while ambulating is crucial, according to Dr. Jensen. “Patients cannot utilize crutches effectively and asking them to use crutches or wheelchairs is really setting them up to fail,” he says. “I have not had a great deal of success with the removable walking devices because, in my experience, they do not control shearing forces and often do not reduce plantar forces if the foot is moving within the device.” He also notes compliance issues. Will More DPMs Use Total Contact Casting? Dr. Jensen believes podiatrists will start using TCC more for several reasons. Patients using the casts heal and Dr. Jensen adds that managed care and Medicare “will gladly pay for” casting and its results. “Everybody wins,” he says. “That cannot be said for most wound care modalities or treatments.” Study co-author Eric Jaakola, DPM, has been working with TCCs for two years in his residency at the North Colorado Podiatric Surgical Residency. He hopes the study will encourage more DPMs to use the casts and advises his fellow residents about the casts. “It’s a choice I would make,” Dr. Jaakola says of using TCC. “I’ve seen quite a great deal of success with it.” While some patients are reluctant to accept the therapy due to the thought of wearing the cast, Dr. Jaakola says most accept it once they realize it is working. He says a selling point of the cast therapy is the lack of crutches and the patient’s ability to ambulate. Starting this summer, Dr. Jensen will be offering TCC workshops for clinicians. He says the aim is to standardize physicians’ use of TCC, cast components, application and removal in order “to get desirable outcomes while mitigating potential complications.” Becaplermin: Can It Facilitate Faster Results In Split Thickness Skin Grafts? By Brian McCurdy, Associate Editor For patients with large or complex wounds, you may find yourself frequently performing split thickness skin grafts (STSGs). Unfortunately, wound bed preparation and graft healing can last several weeks, and this can lead to longer hospital stays. However, there may be an alternative. One new study assesses the efficacy of becaplermin 100 mcg gel, a platelet-derived growth factor, in preparing wound beds for STSGs as compared to standard wound care dressings. The randomized pilot trial, which was recently presented at the SAWC conference, involved 19 patients who were treated with becaplermin gel, placebo becaplermin dressings or wet to dry dressings. While he notes that all wounds react differently depending upon the host and his or her underlying medical conditions, study co-author Peter A. Blume, DPM, says becaplermin gel (Regranex, Ortho-McNeil) may “enhance” the healing of wounds that receive STSGs. “(Becaplermin gel) creates a pre-wounding situation for the enhancement of cellular interactivity between the host and a split thickness skin graft in many patients who are either immunocompromised or have multiple comorbidities,” explains Dr. Blume, a Fellow of the American College of Foot and Ankle Surgeons and the Director of Limb Preservation at the Yale New Haven Hospital in New Haven, Ct. What One Pilot Study Revealed Of the seven patients in the becaplermin gel population, five completed the protocol and two are actively being treated. These patients had a mean of 23.6 days to graft, a 97 percent mean “graft take,” and achieved complete epithelialization in a mean of 19.6 days. Of the six patients in the placebo becaplermin dressing group, three patients completed protocol and one is being actively treated. There were 42 mean days to graft, a 91.5 percent mean graft take and a mean of 23 days to complete epithelialization. Of the six patients in the wet to dry dressings population, five completed protocol and none are being actively treated. There were 44.4 mean days to graft, an 86 percent mean graft take and a mean of 32.4 days to complete epithelialization. For the study, researchers included noninfected wounds below the knee that were less than a year old and had a surface area of more than 2 square cm. All of the wounds had adequate arterial perfusion and no underlying osteomyelitis. Dr. Blume cautions that more studies with larger patient populations are necessary to reinforce the findings of this pilot study. However, he does believe the study is “extremely important for podiatric practices” and that it may expand the spectrum of use and utilization of the Regranex gel. “With the ever increasing population of aged individuals and diabetic patients within the United States and abroad, closure of wounds is paramount towards keeping patients ambulatory and decreasing the risk for amputation,” emphasizes Dr. Blume. In Brief Brown Medical Industries, which manufactures a variety of medical devices, recently achieved ISO 9001 certification. Meeting the quality management standards set forth by the International Standardization Organization is a nice feather in the company’s cap, according to Donn Martens, the Manager of Quality and Regulatory Affairs at Brown Medical. “By conforming to these standards, customers and organizations around the world will know that (Brown Medical) has a quality management system in place that will allow us to produce a quality product and provide our customers with the quality service they deserve,” notes Martens.

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