Total Contact Cast Research Articles

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.

Ease of Application and Removal of Common Total-Contact Cast Systems Used in the Podiatric Medical Community.

Although total-contact cast (TCC) systems are considered the gold standard for off-loading plantar ulcers, less than 6% of patients with diabetic foot ulcers receive them due to negative perceptions of special technique requirements and time investment in their application and removal. We compared the ease of use and casting time of four TCC systems. Four novice casters applied each of the four TCC systems three times using the manufacturer's written instructions for cast application and removal of each cast type. For each TCC system, casters also provided ratings of quality and effectiveness, their level of confidence in applying each system, and overall ease of use. The time to complete the first application of each cast type was not different among TCC systems. However, by the third application, TCC-EZ had a significantly faster application time than the other three TCC systems. In addition, TCC-EZ was considered better overall in packaging and instructions, quality of cast components, and casting method than the other TCC systems. Half of the casters rated TCC-EZ and MedE-Kast as the easiest to apply after the third and final trial, and TCC-EZ and MedE-Kast were rated as being the cast chosen to use in the casters' clinical practices. One of the obstacles to use of TCC systems, despite being recognized as the gold standard of off-loading, is the perception of a prolonged learning curve on application. This study demonstrated that TCC-EZ can be applied by novice casters in less than 14 minutes after their third application experience.

A 10-year Retrospective Case-Series of Venous Thrombo-Embolism frequency in Patients Treated with Total Contact Casts

Category:DiabetesIntroduction/Purpose:Venous Thrombo-Embolism (VTE) is a recognized complication of lower limb immobilization. In the neuropathic patient total contact casting (TCC) is used in the management of acute charcot neuroathropathy and/or to off-load neuropathic ulcers. To our knowledge, there is currently no literature stating the prevalence of VTE in patients, despite the possibility of prolonged lower limb immobilization. There are also no recommendations regarding VTE prophylaxis in the setting of TCCs. We report a retrospective case series assessing the frequency of symptomatic VTE in the patients treated with TCCs. Given that diabetic foot disease manifests as one of many co-morbidities in this medically complex group of patients we hypothesize that the rate of occurrence of VTE should be higher than that of the general population.Methods:Patients undergoing TCC between 2006 and 2018 were identified using plaster room records. These patients subsequently had electronic clinical letters and radiological reports assessed for details around the TCC episode, past medical history and any VTE events.Results:There were 143 TCC episodes in 105 patients. Average age at cast application was 55 years. The mean time in a cast was 45 days (range from 5 days to 8 months). 3 out of 4 patients had neuropathy as a consequence of diabetes. One TCC related VTE (0.7% of casting episodes) was documented. This was a proximal DVT confirmed on USS 9 days following cast removal. Only 3 patients received VTE prophylaxis while in TCC.Conclusion:Despite these complex patients having a multitude of co-morbidities the frequency of VTE in the TCC setting remains similar to that of the general population. This may be due to the fact that TCCs permit weight bearing or that Charcot arthropathy leads to a high outflow state, potentially turning Virchow’s triad in the patient’s favour. This case series suggests that, while all patients should be individually VTE risk assessed as for any lower limb immobilization, chemical thromboprophylaxis is not routinely indicated in the context of TCCs.

Risk of Complications with the Total Contact Cast in Diabetic Foot Disorders

Category:DiabetesIntroduction/Purpose:The total contact cast is an important component of the clinical treatment algorithm for diabetic foot ulcers and Charcot Foot Arthropathy. Few studies have reported on the complications associated with this treatment modality.Methods:Over a ten year period, 2265 total contact casts were placed on 384 patients during their treatment for diabetic foot disorders. All of the casts were applied by a Certified Orthopaedic Technologist under the supervision of a University Faculty member. Complications were grouped as: (1) development of a new ulcer or wound, (2) new or increasing odor or drainage, (3) wound infection, (4) gangrene, (5) newly identified osteomyelitis, and (6) pain or discomfort necessitating cast change / removal. Complications were then associated with Hemoglobin A1C levels at the time of treatment.Results:Using this very stringent definition of a complication, ten percent of patients had some form of a complication. Most complications resolved following cast change or cast removal.Conclusion:The total contact cast has been demonstrated to be a valuable tool in the treatment of diabetic foot disorders. This retrospective chart review should serve as a valuable reference to assist clinicians when counseling patients during treatment for diabetic foot disorders.

PodCast: A rural and regional service model for podiatrist-led total contact casting.

Diabetes-related foot disease causes significant health system costs and is a leading cause of morbidity and disproportionately affects rural populations. Total contact casts or instant total contact casts are gold standard for management of foot ulcerations resulting from diabetes-related foot disease. The aim of this study was to evaluate the impact of a podiatrist-led casting service model within a rural and regional setting. The implementation of the service model was evaluated over a 12-month period using a quality improvement approach, informed by multiple methods. Quantitative and qualitative methods were used. An outpatient high-risk foot clinic and community-based podiatry services within a large regional health service. The location was central Victoria, servicing rural communities within the Loddon Mallee region. Patient-related data included information relating to demographics, diabetes and foot pathologies. Service-related data included occasions of service, locations and the number and type of casts applied. Upskilling podiatrists to provide the service in a safe, supportive and sustainable manner and ensuring the podiatrist-led casting service model was sufficiently adaptable for patients to access at the rural sites. Increased access to total contact casts and instant total contact casts, comparable wound healing times to other studies and the model was able to be sustained. Podiatrist-led casting resulted in increased utilisation of total contact casts and instant total contact casts. The increased use of instant total contact casts in particular may help address the lack of uptake of this treatment for people with diabetes-related foot disease, thereby improving rural health outcomes.

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.

Management of Diabetic Foot Ulcer in a Tertiary Level Hospital-Faridpur

A descriptive type of cross sectional study among 210 diabetic patients with foot ulcer was carried out in Diabetic Association Medical College during the period of May 2016 to April 2017 and were categorized based on Meggitt-Wagner system to find out the complications, management, below knee amputation rate and mortality rate. The aim of this study was to practise a profile of diabetic foot ulcer (DFU), complications and its management to assess the outcome of the surgical interventions. Majority of the patients were male 112(53%), and most of them 116 patients (55.23%) presented within Wegner grade - 2 and grade-3 diabetic foot ulcers. The duration of diabetes more than 10 years was 116 (55%). 99 (47%) patients out of 210 patients developed diabetic neuropathy. 76 (36%) patients presented with CKD. Lack of awareness about diabetes mellitus and its lower limb complications, poor compliance to the treatment, poorly controlled blood sugar levels, delay in diagnosis, and late presentation to the tertiary care center, associated habit of smoking are all factors which lead to incidence of DFU at an earlier age than that seen in other studies. After admission of diabetic foot ulcer patients, diabetic foot ulcer is classified according to Wagner grading and treated the diabetic foot ulcer patients as the using protocol ’!1.Assesment whether it was conservative or surgical. 2. Optimal blood sugar control. 3. Systemic antibiotic. 4. Moist wound environment. 5. Offloading such as total contact casting. 6. Improves peripheral arterial circulation due to lack of vascularity. 7. Surgical debridement or minor amputation or major amputation. In case of G-4 or G-5 patients, ischemia was treated before debridement or amputation so that vascular circulation improved in the ulcer area and then healing potential was fastened.
 Bangladesh Heart Journal 2019; 34(1) : 52-57

Comparing Human Amniotic Allograft and Standard Wound Care When Using Total Contact Casting in the Treatment of Patients with Diabetic Foot Ulcers.

This prospective, randomized study compared two treatments for diabetic foot ulcers: total contact cast and a skin substitute versus total contact cast and standard wound care. Researchers screened 270 adult outpatients in a Midwestern wound care clinic for inclusion. Adults 18 years or older with type 1 or 2 diabetes and a diabetic foot ulcer located on the plantar surface larger than 0.5 cm in area were invited to participate if they had not demonstrated a 50% reduction in wound area following 4 weeks of standard treatment. Thirteen patients were randomized into two intervention groups. The majority of the participants had type 2 diabetes. Group A treatment: total contact cast and a skin substitute (human amniotic allograft); group B treatment: total contact cast and standard wound care. Mean ulcer surface area, time to closure, recurrence rates, satisfaction with total contact casting, infection, and hemoglobin A1c were measured. The majority of participants experienced wound closure during the course of the study (92.3%). Two participants did not achieve closure, both of whom had Charcot foot. Group A, which had a higher mean hemoglobin A1c at study outset, experienced a longer mean time to closure (29.50 days) compared with group B (26.20 days). The 90-day recurrence rates were different for the two groups, with only one recurrence for group A (14.29%) but five recurring ulcers in group B (83.33%). Although significance was not established because of sample size, there was a definite trend toward significance that merits further investigation with human amniotic allograft.

Diyabetik Ayak Yaralarında İnfeksiyon Durumu Pencere Açılarak Uygulanan Total Temas Alçılama İçin Hala Bir Kontrendikasyon mudur?

Diyabetik Ayak Yaralarında İnfeksiyon Durumu Pencere Açılarak Uygulanan Total Temas Alçılama İçin Hala Bir Kontrendikasyon mudur?

Clinical features, radiological characteristics and offloading modalities in stage 0 Acute Charcot's neuroarthropathy - A single centre experience from South India

AimsStage 0 Acute Charcot's Neuroarthropathy (ACN)in Type 2 Diabetes patients is a challenging diagnosis with subtle clinical features and normal appearing plain radiographs of the affected foot. Delay in diagnosis can lead to progression of disease and irreversible deformities. There is a paucity of data on Stage 0 ACN from India. The aim of this study was to assess clinical and radiological characteristics and treatment outcomes in Indian Type 2 Diabetes patients with Stage 0 ACN. Materials and methodsA comparative, case-control study was carried out amongst patients attending the Integrated Diabetes Foot Clinic at a tertiary care South Indian hospital. During the 3-year study period, a total of 1811 patients with Type 2 Diabetes Mellitus were screened. Of these, n = 10 patients with stage 0 ACN Charcot's arthropathy were identified based on clinical features and MRI imaging of the foot for confirmation of diagnosis. These were compared with an age and duration of diabetes-matched group of n = 50 patients without ACN as controls. ResultsOur study identified 10 patients (0.5%) with Stage 0 Acute charcot neuroarthropathy (ACN) in the study population. Those with ACN had higher BMI, poorer glycaemic control and greater degree of peripheral neuropathy (p < 0.05). Clinically relative lack of pain and infrared thermometric temperature difference >2 °C in the affected foot were the most significant findings, while MRI foot was useful in early detection of active and severe stage 0 disease. Total contact cast was the preferred initial offloading modality, with delay in initiating complete immobilization leading to worse outcomes. ConclusionsThis is the first study to highlight the characteristic features of Stage 0 ACN in Indian Type 2 Diabetes patients. Thorough clinical evaluation, infrared thermometry and radiological findigs on MRI foot leads to early disease detection. Complete offloading, preferably with total contact casts can prevent disease progression and chronic deformities.

Pressure distribution under the contralateral limb in Charcot arthropathy with different walking speeds

BackgroundThe total contact cast has been recognized as the “gold standard” for treatment of Charcot neuro-osteoarthropathy (CN). However, removable cast walkers (RCWs) became an alternative option especially after resolution of the acute stage. RCWs with an elevated sole construction often induce leg length discrepancy (LLD) that could significantly affects plantar pressure (PP) distribution in diabetic patients with neuropathy. AimTo study the additional effect of walking speed on PP abnormalities induced by LLD. MethodThe study included 16 patients with diabetes (59±8.8years; 8 men and 8 women), with unilateral CN offloaded by RCW. In-shoe PP distribution was measured using F-scan (Tekscan Inc.), whilst patients walked at their normal speed (53±4 steps/min), versus short slow steps (24±3/min) under the two walking conditions: (1) neglected LLD, and (2) corrected LLD. ResultsThe greatest reduction in PP was seen during reduction of walking speed, with corrected LLD, followed by corrected LLD with normal walking speed, followed by neglected LLD with slowing of walking speed. The highest PP was found when the patient remain on their normal walking speed and LLD was neglected. ConclusionThe contralateral foot of CN offloaded with RCW, is subjected to high pressure loads beneath the hallux, 1st, 2nd, 3rd, and 5th metatarsal heads. As such, care should be taken not only to avoid minor LLD, but to also advise the patient to practice short slow steps while walking, so that pressure overload on contralateral limb and its possible contribution to the development of bilateral Charcot, could be minimized.

Results of Simple Conservative Treatment of Midfoot Charcot Arthropathy.

BackgroundTraditionally, conservative management with an offloading orthosis, such as total contact cast (TCC), has been the standard of care for midfoot Charcot arthropathy. Considering complications of TCC and surgery, we treated midfoot Charcot arthropathy without TCC in our patients. The purpose of this study was to report clinical and radiological outcomes of conservative management of midfoot Charcot arthropathy.MethodsA total of 34 patients (38 feet) who were diagnosed as having midfoot Charcot arthropathy between 2006 and 2014 were included. Patients started full weight bearing ambulation in a hard-soled shoe immediately after diagnosis. Outcomes such as progression of arch collapse, bony prominence, ulcer occurrence, limb amputation, and changes in Charcot stage were evaluated.ResultsOf 38 feet, arch collapse was observed in four while progression of bottom bump of the midfoot was observed in five feet. Foot ulcers related to bony bumps were found in two feet.ConclusionsConservative treatment without restriction of ambulation is recommended for midfoot Charcot arthropathy because it is rarely progressive, unlike hindfoot-ankle arthropathy. In some cases, simple bumpectomy can be required to prevent catastrophic infection.

Tuberculosis of the foot mimicking Charcot arthropathy

Mycobacterium tuberculosis bone and joint infection accounts for 2% to 3% of all tuberculosis cases but is uncommon in the foot. A 32-year-old woman had foot pain and swelling, and radiographs showed midfoot bony destruction and fragmentation. She was diagnosed with Charcot arthropathy, but had no neuropathy or improvement despite total contact casting. Bone biopsy 16 months after initial presentation did not show acid-fast bacilli on smear, but M. tuberculosis was recovered on culture; concurrent chest radiographs showed patchy and nodular opacities in both upper lung zones, consistent with previous pulmonary tuberculosis. Sputum smear showed acid-fast bacilli and culture yielded M. tuberculosis. In retrospect, the patient was at increased risk for M. tuberculosis infection because of previous residence in Myanmar and India. Clinicians should consider M. tuberculosis infection in the differential diagnosis of Charcot arthropathy for patients who have exposure history and absence of risk factors for Charcot arthropathy.

Diabetic Foot Ulcer: Prevention, Management, and Controversies

The purpose of this review is to update the reader on current practices and new developments in caring for the patient with a diabetic foot ulcer. Surgical offloading may be superior to total contact casting but additional data is needed. Multidisciplinary care of the diabetic foot is effective at reducing amputations and reducing overall cost of care. Prevention of diabetic foot ulcers is most effective when diabetes and comorbidities are adequately managed and frequent foot care is performed by the patient daily and the clinician annually. Offloading is central to healing diabetic foot ulcers. Diabetic foot care is complex and requires a broad spectrum of medical, surgical, and orthotic specialists. When care occurs within a coordinated, multidisciplinary team, cost and outcomes improve.

New progress in the treatment of chronic wound of diabetic foot

Diabetic foot is one of the serious complications of diabetic patients. It is caused by diabetes combined with different degrees of lower extremity vascular lesions and neuropathy, and the wound can not heal for a long time. The serious results can cause bone marrow infection, bone destruction, and have high disability and death rate. At present, there are various treatment methods for diabetic foot chronic wound. On the basis of internal medicine controlling blood sugar, anti infection, lowering blood lipid, improving microcirculation and nourishment nerve, the surgical method is adopted, including the debridement of the necrosis in a short time to prevent the infection from spreading; maggot biological debridement and ozone chemical debridement will promote the growth of granulation tissue while controlling infection. Skin grafting, skin flap transplantation, skin distraction closure can be used to repair soft tissue defects, or fat transplantation, platelet-rich plasma, and rich blood are used for the refractory wound after infection control. In patients with diabetic foot, the reconstruction of lower limb blood supply is beneficial to the recovery of chronic ischemic wounds. It is feasible to improve the blood supply of the lower extremities, improve the blood supply of the lower extremity artery bypass grafting, and improve the microcirculation of the peripheral vessels around the lower extremities. Lower extremity vascular bypass pressure perfusion therapy for vascular network expansion, tibia lateral moving technique for lower limb microcirculation reconstruction. For diabetic foot ulcer caused by peripheral neuropathy, such as Charcot foot, while the application of external fixator, total contact cast technology of affected foot for reducing treatment to promote wound healing; the preparation of orthopedic shoes can play a maximum protective effect on the healing of diabetic foot wound healing.

NEMISIS for diabetic forefoot pathology

Category: Diabetes Introduction/Purpose: The most common cause of Charcot Neuroarthropathy is diabetes. The incidence of diabetes continues to rise globally, with a significant socio-economic burden to both patient and society. Despite good total contact casting techniques, deformity and subsequent ulceration still occurs in this patient group. This make shoe-fitting challenging and the risk of subsequent ulceration increases. This in-turn increases the patients risk of amputation and mortality at five years. Conservative treatment is often protracted, with multiple clinic visits. The has a significant impact on the patients ability to work and quality of life. Open surgery carries a significant risk of poor wound healing and infection again with risk of ulceration. NEMISIS for mid-foot Charcot provides surgeons with a surgical technique for osteotomy, that protects the soft tissues. Methods: 15 patients had NEMISIS Minimally Invasive Surgery to their forefoot for management of diabetic foot ulceration. 8 patients (11 metatarsal heads)had debridement of a metatarsal head with Minimally Invasive Shannon and Wedge Burrs. 1 patient had 3 separate debridements, but of different metatarsal heads. 2 patients had surgery to the 1st metatarsal. 1 patient had minimally invasive debridement of sesamoids. All patients had their Achilles tendon assessed for increased tension. Percutaneous tenotomy was performed if the Achilles was found to be tight. Only the patients with surgery to the 1st Metatarsal required screw fixation. All cases were performed as day cases. Results: Patients were able to be discharged the same day, with weekly follow-up for dressings. Patients were allowed to fully weight bear as tolerated. Ulcers healed within six week on average. There were no recurrences of ulcer on the same metatarsal head within the time period. Patients had often had ulcers present, in excess of six months prior to being referred for surgery. All patients were delighted with the result. Conclusion: NEMISIS Minimally Invasive Surgery for diabetic forefoot pathologies provides rapid healing for patients with chronic ulceration. Their biomechanics should be assessed pre-operatively to check if there is significant forefoot overloading. If so, the Achilles tendon should also be addressed. Early intervention with NEMISIS Minimally Invasive Surgery, could reduce the number of visits the patient has to make to the clinic and also facilitate the firing of easier constructed shoes. This potentially will allow the patient to return to normal function as quickly as possible and thus potentially has significant cost benefit implications also.

NEMISIS Minimally Invasive Surgical Correction for Midfoot Charcot Arthropathy

Category: Diabetes Introduction/Purpose: The most common cause of Charcot Neuroarthropathy is diabetes. The incidence of diabetes continues to rise globally, with a significant socio-economic burden to both patient and society. Despite good total contact casting techniques, deformity and subsequent ulceration still occurs in this patient group. This make shoe-fitting challenging and the risk of subsequent ulceration increases. This in-turn increases the patients risk of amputation and mortality at five years. Conservative treatment is often protracted, with multiple clinic visits. The has a significant impact on the patients ability to work and quality of life. Open surgery carries a significant risk of poor wound healing and infection again with risk of ulceration. NEMISIS for mid-foot Charcot provides surgeons with a surgical technique for osteotomy, that protects the soft tissues. Methods: The surgical technique utilises Minimally Invasive Shanon and Wedge burrs to perform a biplanar closing wedge osteotomy to achieve a triplanar correction. This takes the tension off the soft tissues which ensures that there is still good tissue cover, without compromising the blood supply to the skin, therefore in theory reducing the risk of infection. Stabilisation is achieved with screws, beams and bolts, +/-medial column plating. Patients are immobilised in a Bholer walker for a period of 3 months post-op. The short to medium term results (3months to 3 years) are presented. Patients are followed up to asses for re-ulceration at the same site, different site, failure of metalwork, return to surgery. Results: 16 patients were followed-up. 14 were diabetics. 4 patients developed deep-seated infection, which required removal of the metal-work. 2 of these patients did not have recurrence of their deformity and progressed to orthotic foot-wear. 1 patient had recurrence of deformity with wound breakdown and is awaiting further surgery. 1 patient had removal of metalwork from midfoot and subsequently developed hind-foot deformity which was stabilised with a hind-foot fusion nail. 1 patient broke the medial beam and bolts and required revision surgery. 2 patients had recurrence of plantar exostosis which was managed with minimally invasive exostectomy. 1 patient had early stabilisation of mid-foot and had subsequent Charcot of the talus, managed conservatively. The remaining patients have not required revision surgery. There have been not amputations. Conclusion: NEMISIS Minimally Invasive Surgery for Mid-Foot Charcot is a promising surgical technique which may help to reduce infection rates and subsequent amputations. The technique is relatively straightforward to teach, but is currently limited by the size of the burrs. The technique however can be coupled with innovation in biologics to aid the surgeon further in trying to achieve a stable plantigrade foot that does not have recurrence of ulceration and deformity.

Effect of different casting design characteristics on offloading the diabetic foot

BackgroundNon-removable knee-high devices, such as a total contact cast (TCC), are recommended for offloading diabetic plantar forefoot ulcers. However, it is insufficiently known how each of the different design characteristics of these devices contribute to offloading the diabetic foot. Research questionWhat is the offloading effect of the different design characteristics that make up a non-removable knee-high cast for people with diabetes and active or previous plantar forefoot ulcers? MethodsSixteen persons with diabetes, peripheral neuropathy and a healed or active plantar forefoot ulcer had their plantar pressures measured during walking in a non-removable knee-high device (TCC), in that device made removable (BTCC), in that device made below-ankle (cast shoe), in that cast shoe worn with a different walking sole and in a newly made cast shoe without a custom-moulded foot-device interface. Peak pressures, force-time integral, and perceived walking comfort were assessed. ResultsCompared with the BTCC, peak pressures in the TCC were 47% (P = 0.028), 26% (P = 0.003) and 15% (P = 0.050) lower at the hallux, midfoot and (previous) ulcer location, respectively. Compared to the cast shoe, peak pressures in the BTCC were 39–43% and 47% (both P < 0.001) lower in the forefoot regions and (previous) ulcer location, respectively. The total force-time integral was 21% and 11% (P < 0.007) lower in the TCC and BTCC compared to the cast shoe. Perceived walking comfort was 5.6 in the TCC and 6.5 in the BTCC (P = 0.037). Effects of the other design characteristics (i.e. walking sole and plantar moulding) were non-significant. SignificanceThe TCC gives superior offloading, mostly because of being a knee-high and non-removable device, providing an optimal ‘shaft effect’. The TCC does, however, negatively affect walking comfort. These results aid decision-making in offloading diabetic plantar forefoot ulcers.

Foot Ulcers: A Different Technique to Total Contact Casting for Healing Chronic Foot Ulcers

Total Contact Cast (TCC) is considered the gold standard method for healing diabetic foot ulcers (DFU) [1]. Chronic foot ulcers are a growing concern worldwide. Evidence-based research suggests that TCC is the best method to offload the plantar foot by adequately redistributing plantar pressures related to body mass while still maintaining patient mobility.

Sexuality in Patient with Breast Cancer Hospitalized in Professional Nursing Vision

The study seeks to investigate aspects of sexuality of women with breast cancer interned. The emergence of the study took place at the time of my professional practice where I came across patient dialogues, and health professionals with the behavior of women in different times, having sexual practice and professional assistants, on the other hand the kind of suppressed such an attitude as well as the patients more “excited” In the context of health, the educational process consists much more than the simple act of teaching. The client, who is often mistakenly called a passive individual, is a key player in the care process, since we already know that the process of health care is dynamic and requires the participation of both parties, whether caregiver or individual who will receive the care.