The C-TCC was used in a 54-year-old woman who had diabetes, obesity, and a flexible cavovarus foot with a recurring wound at the plantar fifth metatarsal base. Informed consent was obtained before the initiation of treatment at the Healogics Wound Care Center at Montefiore Mount Vernon Hospital, Mount Vernon, NY. The patient consented to treatment in addition to photographic documentation of the wounds, which were added to the patient’s chart for monitoring the healing process, measuring treatment outcomes, and educational purposes. All patient identifiers were excluded from this case report to maintain anonymity.
Each clinical encounter spanned 45 minutes for treatment, which included removal of the existing cast and dressings, wound measurement and cleansing, wound debridement, wound and cast application. An experienced clinician, with the help of an assistant, can apply the C-TCC in 10 minutes (15 minutes if no assistant is available). It takes approximately 5 minutes for the final layer of fiberglass to dry before the surgical shoe is applied, and the patient may then begin ambulation. The total time for application and cast drying was 15 to 20 minutes.
Weekly debridement, 1-week dressings, and cast applications were performed under the supervision of a single physician. Casting materials were used from a plastic and synthetic TCC system (Cutimed Off-Loader Select Total Contact Cast System; Essity, Stockholm, Sweden). The C-TCC is made from a combination of general casting and dressing supplies with attention to application technique. The cast is not currently a marketed product because it focuses on technique rather than product. The progression of the wound and timeline of healing were documented and analyzed through i-Heal, an electronic medical record system used by Healogics (Jacksonville, FL).
C-TCC application technique. After sharp debridement, obtaining adequate hemostasis, and completing local wound care, the plantar ulcer is dressed with a sterile, nonadhesive 4" × 4" foam dressing and secured with wound closure strips or nonreactive paper tape. The patient is placed in a comfortable seated position in the examination chair, and a cotton stockinette is slipped over the foot and lower leg. The stockinette should extend proximally to the level of the knee and distally several inches beyond the digits. Adhesive felt padding (1/8") is secured as a strip along the anterior tibial crest down to the dorsum of the metatarsals and as 2 circles to the bony prominences of the medial and lateral malleoli. Excess stockinette at the digits is folded over to the dorsum of the foot, with at least a 1-cm width between the toes and excess stockinette.
Next, an adhesive, perforated, open cell foam is secured to the distal digits from plantar to dorsal with at least a 1-cm width between the digits and foam. Excess foam is trimmed medially and laterally to conform to the forefoot. To ensure proper padding and reduce friction from the cast, abdominal (ABD) pads are layered along the dorsum of the foot and anterior tibia. A heel pad (made by creating 2 slits on either side of an ABD pad) is applied to the heel, protecting the calcaneus and Achilles tendon (Figure 1).
A 4" roll of Webril cast padding (AliMed; Dedham, MA) is laid on circumferentially from the distal to proximal foot, locking the ankle. The next roll of 4" padding starts 2 finger-widths from the fibular head (or just inferior to the tibial tuberosity) and extends distally to meet the ankle. A final roll of padding is applied to the foot, ensuring the distal forefoot is protected medially and laterally. The proximal stockinette at the knee is folded down over the padding layers to create a protective edge. Special attention is paid to avoid any wrinkles throughout the process to ensure proper conforming structure and molding to the lower extremity.
The patient is repositioned to a flat, prone position with the lower leg flexed at the knee and the foot in neutral position, with the ankle placed at neutral or slightly plantarflexed depending on ulcer location and etiology. If the patient cannot be in a prone position during C-TCC cast application, the cast may be applied with the examination chair elevated and the affected leg hanging off the side of the chair, such that the knee is flexed 90 degrees and the foot is not in contact with the weight-bearing surface. The same order of application for the C-TCC is executed, and an assistant may be required to maintain a neutral position and ensure patient saftey if the cast is applied in a seated position. A posterior splint spanning the length of the proximal edge at the posterior leg to the distal plantar forefoot is made out of 1 roll of 4" plaster of paris. The posterior splint is wetted and excess water is removed. The splint is applied and constantly molded closely to the lower extremity. Additional strips of plaster are applied to fill the arch and to correct any structural deformities of the foot (Figure 2).
First, a roll of 4" elastic-plaster is applied circumferentially to the foot and up the leg. If any flexible frontal plane deformities exist, the casting tape is pulled medial to lateral, or lateral to medial, to bring the plantar surface to neutral position. A standard roll of 4" plaster is applied on top in similar fashion, and a final third layer of standard plaster is conformed to the foot and leg. During the curing process, all layers are molded to the leg without wrinkles while maintaining proper position and a plantigrade surface. Constant molding of the plaster layers also prevents excessive motion within the cast and allows for optimal redistribution of pressure from the plantar foot to the leg.
A similar technique is used to lay on the fiberglass layers. First, a roll of 4" fiberglass cast tape is applied from the distal foot to the ankle. Next, a 3" fiberglass roll is applied from the proximal to the distal lower leg. A final roll of 3" fiberglass is applied to the foot to secure all layers and ensure a flat, plantigrade surface with a strengthened construct. A minimum of 3 fiberglass rolls are recommended depending on foot and leg size. The foot is held in the corrected position until the fiberglass layers are dry.
A stockinette is used to cover the entire cast to prevent irritation to the other lower extremity, and a surgical shoe is applied for assistance in ambulation (Figure 3). Gait is analyzed before the patient leaves to ensure proper cast positioning and prevent falls due to possible instability caused by the added height and weight of the cast. The C-TCC is worn for 1 week and must be removed at a follow-up appointment. A standard cast cutter is used to cut the cast along the medial and lateral sides of the cast from proximal to distal, similar to the standard short-leg cast removal technique.