The effect of removable total contact cast therapy on healing of patients with diabetic foot ulcers, acute Charcot osteoarthropathy and neuropathic fractures.

Authors: V. Fejfarová;  A. Jirkovská;  M. Křížová;  J. Skibová
Authors‘ workplace: Centrum diabetologie, IKEM, Praha přednosta prof. MUDr. Terezie Pelikánová, DrSc.
Published in: Vnitř Lék 2005; 51(9): 988-994
Category: Original Contributions


Removable total contact cast (TCC) is one of the appropriate methods used for lower limb off-loading in patients with the diabetic foot.

The aim of our study:
To assess the effect of TCC therapy on healing of patients with neuropathic foot ulcers, acute Charcot osteoarthropathy and neuropathic fractures.

Removable TCC were applied for different indications during the observed period of 20 month: for chronic neuropathic ulcers in 27 patients (group 1; mean age 53.5 ± 8 years, mean diabetes duration 14.8 ± 7 years, mean HbA1c 8.2 ± 2%), for acute Charcot osteoarthropathy in 35 patients (group 2; mean age 53.9 ± 8 years, mean diabetes duration 16.6 ± 10 years, mean HbA1c 8.4 ± 2%) and for neuropathic fractures in 12 patients (group 3; mean age 52.8 ± 10 years, mean diabetes duration 14.8 ± 12 years, mean HbA1c 8.9 ± 2%). Healing criteria for the diabetic foot were: total epithelization for the group 1, clinical improvement of local findings as skin temperature decrease and/or improvement of scintigraphic parameters for the group 2 and total X-ray healing of fracture for group 3.

Patients with diabetic foot ulcers were treated by removable TCC for 6 ± 4.2 month, patients with acute Charcot osteoarthropathy for 5.1 ± 4 month and patients with pathological fractures for 3.9 ± 2.6 month on average (NS). The significantly highest percentage of completely healed patients during the observed period was found in the group of patients with neuropathic fractures in comparison with the group of patients with the diabetic foot ulcers and acute Charcot osteoarthropathy (83% vs. 30% vs. 37%, respectively; p < 0.01). Significant improvement of foot ulcers was found in 12 patients from 19 non-healed patients with diabetic foot ulcers during TCC therapy (ulcer size 5.6 ± 6.8 vs. 1.56 ± 2 cm2, p < 0.01), 4 patients had the same clinical finding and local worsening was seen in 3 patients with diabetic foot ulcers. 19 patients from 22 non-healed patients with acute Charcot osteoarthropathy had improved local findings and significantly reduced skin temperatures during the observed period (2.74 ± 1.3 vs. 2 ± 1.3 °C; p < 0.05), local findings were worsened in 3 patients. Non-healed neuropathic fractures were found only in 2 patients from this group (17%). TCC complications, which lead to interruption of TCC therapy, were found in 7 patients from the group 1 (26%), in 3 patients from the group 2 (9%) and in 1 patient from the group 3 (8%); NS.

Removable TCC is suitable method for lower limb off-loading in patients with the diabetic foot, since this therapy accelerates healing as of acute Charcot osteoarthropathy or neuropathic fractures and of diabetic foot ulcers. Rational indication, education and regular control are essential for patients with neuropathic foot ulcers; whose have higher risk for development of complications.

Key words:
diabetic foot - total contact cast - off-loading


1. Armstrong DG, Nguyen HC, Lavery LA et al. Off-Loading the Diabetic Foot Wound. Diabetes Care 2001; 24: 1019-1022.

2. Armstrong DG, Stacpoole-Shea S. Total contact casts and removable cast walkers. mitigation of plantar heel pressure. J Am Podiatr Med Assoc 1999; 89: 50-53.

3. Armstrong DG, Todd WF, Lavery LA et al. The natural history of acute Charcot´s arthropathy in a diabetic foot specialty clinic. Diabetic Med 1997; 14: 357-363.

4. Bém R. Neuropatické fraktury u pacientů s diabetem. HPB 2003; 11: 8-10.

5. Berg EE. Charcot arthropathy after acetabular fracture. J Bone Joint Surg Br 1997; 79: 742-745.

6. Brunerová L, Anděl M. Kalkulace nákladů na léky, zdravotní materiál, některé vybrané léčebné výkony a služby sociální oblasti u pacientů se syndromem diabetické nohy. Vnitř Lék 2003; 49(6): 457-464.

7. Caravaggi C, Faglia E, De Giglio R. Effectiveness and safety of a non-removable fiberglass off-bearing cast versus a therapeutic shoe in the treatment of neuropathic foot ulcers: a randomized study. Diabetes Care 2000; 23: 1746-1751.

8. Čechurová D, Lacigová S, Rušavý Z et al. Ekonomický pohled na syndrom diabetické nohy. Vnitř Lék 2003; 49(6): 453-456.

9. Diamond JE, Mueller MJ, Delitto A. Effect of total contact cast immobilization on subtalar and talocrural joint motion in patients with diabetes mellitus. Phys Ther 1993; 73: 310-315.

10. Dzieciuchowicz L, Checinski P, Waliszewski K et al. The value of total contact casting in treatment of neuropathic foot ulcers in diabetic patients. Pol Merkuriusz Lek 1997; 3: 132-134.

11. Fabrin J, Larsen K, Holstein PE. Long-Term Follow-Up in Diabetic Charcot Feet with Spontaneous Onset. Diabetes Care 2000; 23: 796-800.

12. Gill G, Benbow S, Tesfay S et al. Painless stress fractures in diabetic neuropathic feet. Postgrad Med J 1997; 73: 241-242.

13. Helm PA, Walker SC, Pullium GF. Reccurence of neuropathic ulceration following healing in a total contact cast. Arch Phys Med Rehabil 1991; 72: 967-970.

14. Jirkovská A. Aktuální problematika syndromu diabetické nohy. In: Trendy soudobé diabetologie. Praha: Galén 2001; 5. vol: 53-87.

15. Jirkovská A. Stěžejní otázky terapie syndromu diabetické nohy. Vnitř Lék 2002; 48(6): 542-548.

16. Jirkovská A, Hosová J, Wosková V. Diagnostika akutní a subakutní Charcotovy osteoarthropatie u diabetiků. Prakt Lék 1998; 12: 661-664.

17. Jirkovska A, Kasalicky P, Boucek P et al. Calcaneal ultrasonometry in patients with Charcot osteoarthropathy and its relationship with densitometry in the lumbar spine and femoral neck and with markers of bone turnover. Diab Med 2001; 18: 495-500.

18. Laing P. Diabetic foot ulcers. The American Journal of surgery 1994; 167: 31S-36S.

19. Lavery LA, Armstrong DG, Walker SC. Healing rates of diabetic foot ulcers associated with midfoot fractures due to Charcot´s arthropathy. Diabet Med 1997; 14: 46-49.

20. Lavery LA, Fleishli JG, Laughlin TJ et al. Is postural instability exacerbated by off-loading device in high risk diabetics with foot ulcers? Ostomy Wound Manage 1998; 44: 26-32.

21. McGill M, Molyneaux L, Boulton T et al. Response of Charcot's arthropathy to contact casting: assessment by quantitative techniques. Diabetologia 2000; 43: 481-484.

22. Myerson MS, Edwards WH. Management of neuropathic fractures in the foot and ankle. J Am Acad Othop Surg 1999; 7: 8-18.

23. Norman A, Robbins H, Milgram JE. The acute neuropathic arthropathy: a rapid, severe disorganizing form of arthritis. Radiology 1968; 90: 1159-1161.

24. Shaw JE, Hsi WL, Ulbrecht JS et al. The mechanism of plantar unloading in total contact casts: implications for design and clinical use. Foot Ankle Int 1997; 18: 809-817.

25. Sinacore DR. Acute Charcot arthropathy in patients with diabetes mellitus: healing times by foot location. J Diabetes Complications 1998; 12: 287-293.

26. Sinacore DR. TCC: An old therapy with new indications. Biomechanics 1996; 3: 71-74.

27. Syndrom diabetické nohy. Mezinárodní konsensus vypracovaný Mezinárodní pracovní skupinou pro syndrom diabetické nohy. Praha: Galén 2000.

Diabetology Endocrinology Internal medicine
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.


Don‘t have an account?  Create new account