The treatment with total contact cast in diabetic ulcers and the factors affecting this treatment (The success of total contact cast treatment in diabetic foot ulcers)

Our purpose is to assess the success of total contact cast (TCC) treatment, and the factors affecting treatment period and number of casts.16 feet of 15 patients, applied for diabetic foot ulcer admitted to our clinic between the dates June 2006 - January 2008, and treated with TCC, had been included in the study. However one of the patients had been excluded from the study, due to infection during the first cast application.Patients' sex, age, level of education, height, weight, initial HgA1C levels and blood glucose levels, Doppler USG-current pattern, inspection of pulse via palpation, sedimentation rate, diabetes age, diabetes ulcer period, ankle - brachial index (ABI), Wagner ranking scale, Semmes- Weinstein monofilament test and inspection of sense, the first antibiogram culture, current foot deformities, localization and diameter of diabetic lesion had been recorded. Besides, the X-Rays are taken in terms of deformity and osteomyelitis. With the Short Form 36's Turkish version, general pre-treatment and later living quality had been evaluated.We observed pre and post treatment and we found that the treatment duration and the number of casts had no relation with patient's age, Body Mass Index, diabetes age, HgA1c level, Ankle Brachial Index and lesion diameter (Spearman's Correlation test has been used). From the eight parameters (physical function, social function, role limits due to physical problems, role limits due to emotional problems, mental health, energy/vitality, pain and general health conception) assessed in SF 36 (Wilcoxon signed-rank test has been used) only in the physical function no significant increase was identified.The effect of sex on therapy duration and number of casts had been evaluated with Mann-Whitney U test. In statistical studies performed, significant relation (p=0.041) has been identified between number of casts and sex, and it's been observed that the number of casts is lesser in women. However no significant relation (p=0.125) has been identified between total therapy durations.The relation between Wagner grade and duration of therapy and the relation between Wagner grade and number of casts has been evaluated with Mann-Whitney U test. However since the number of patients is insufficient, Wagner grade1 and 2 lesions grouped as one group, and compared to Wagner grade 3 lesions, and no significant difference has been observed between them. Before beginning the treatment to the patients assessed as Wagner grade 3, we applied debridement to remove infection and later we applied antibiotherapy according to the outcome of the culture antibiogram. We started cast treatment after the infection findings has been regressed. In other words the cast treatment of patients, diagnosed with Wagner grade 3, has been started after the lesion has been turned into Wagner grade 2. For this reason we think that there is no significant relation between Wagner grade and number of casts and therapy duration.TCC is an effective treatment method when applied in selected patients. The limitations of this treatment are: it is a difficult method for surgeon and patients have low compliance with the treatment. However, patients having long period of diabetic ulcer, orientates themselves to the treatment in time, when they see healing in every cast change.Patients having no certain healings during cast application, should be assessed, for bone prominents causing compression, with both X-Rays and lesion location palpation, and bone prominents should be excised or surgical corrections should be planned to fix the related deformity.The other important two factors, which the surgeon should consider before treatment, are the infection and blood supply of the extremity. Patients having peripheric artery disease, should be assessed by a vasculary surgeon for revascularization initially. Before applying cast to an infected extremity,the culture material should be taken and debridement should be applied. Cast should be applied after the infection resolves, and first cast should be changed after a short period. The extremity should be assessed in terms of injuries that can be occurred during cast change.In our study 15 patients that had been treated with TCC successfully.As found in our study that the average period of diabetic lesions is 8.625 month (range, 15 days-36 months) and the average number of casts is 6.00 (minimum 4, maximum 9) and the duration of the treatment is 57.66 days (range 27.00- 114.00 days), TCC is a successfull treatment method in selected patients.