Elastic Compression Under TCC, A MUST!!

BackgroundSkin shear injury and pressure necrosis are feared complications of total contact casting (TCC). Leg edema caused by comorbid conditions such as congestive heart failure, obesity, venous insufficiency and others, compounds risk of TCC skin injury. A molded, padded TCC distributes body weight forces to the pretibial and calf, thereby off-loading the weight bearing surface of the foot, to enable healing of plantar neurotropic ulcers. The calf is cone shaped and therefore the skin usually can bear the body weight without damage.

We have observed that edema, during TCC therapy can take one to four weeks to normalize, which decreases the effectiveness of offloading and increased risk of skin shear

injury and pressure necrosis, commonly in our experience in the distal toe area and pretibial area. Our experience with fuzzy wale elastic textile compression for control of lymphedema, lymphorrhea, UE edema and for venous leg ulcers treatment led us to try using fuzzy wale stockinet as a skin contact layer, to control edema, under TCC.

THIS ANECDOTAL CASE SERIES ASKS THREE QUESTIONS: 1. Does fuzzy wale elastic compression stockinet under TCC reduce skin shear injury and pressure necrosis?2. Is fuzzy wale textile compression comfortable?3. Does fuzzy wale elastic compression stockinet under TCC speed neurotrophic ulcer healing?

Methods Three neurotrophic ulcers were treated with TCC**and fuzzy wale stockinet*in contact with the skin.

ResultsPhotos illustrate therapy details and document complete healing of all ulcers. No complication occurred. Patient satisfaction was validated.

ConclusionsFuzzy wale elastic stockinet* appears to decrease edema under total contact casts and to improve neurotropic ulcer healing times. No skin complication occurred. Patient comfort and compliance was excellent.

References1. Armstrong DG, Total contact casts and removable cast walkers.Mitigation of plantar heel pressure., Am Podiatric Medical Association, 89:50-3,1999.

2. Traditional Total Contact Casting Made Easy:http://kineticcasting.co/uploads/kcsbrochurellcmarch2013.pdf

*EdemaWear®, longitudinal fuzzy wale elastic compression stockinet, Compression Dynamics LLC, Omaha, NE 68102,www.EdemaWear.com

**MaxCast Plus Total Contact Casting System, Kinetic Casting Solutions, Lower Limb Concepts , Bozeman, MT 59715, www.kineticcasting.co

***Hydrofera Blue(R) Polyvinyl chloride foam with methylene blue, Hollister Wound Care, Libertyville, IL 60048

****Endoform™ Dermal Template, sheep stomach derived collagen sacrificial matrix, Hollister Wound Care, Libertyville, IL 60048

*****Vashe® topical hypochlorous acid, SteadMed Medical, Fort Worth, TX 76107

MARTA OSTLER PT, CWS, CLTSheridan Memorial Hospital, Northeast Wyoming Wound Clinic, Sheridan, WY

TOM RICHARDS MDSheridan Memorial Hospital Emergency Medicine, Sheridan, WY

Problem• Ulcer 4 weeks old, Wagner Grade 2• Cellulitis of Left Leg

Treatment• Inpatient antibiotics for infected bone• Offloading total contact cast, debridement

Day #8. Treatment is debridement, biofilm control with topical Hypochlorous Acid*****, a collagen sacrificial matrix derived from sheep foregut ****, fuzzy wale elastic compression stockinet* and a traditional, cost effective total contact cast constructed from rolls of cast material with a rubber walker on the base.**

Outcome:• Great toe healed at day #39• Fuzzy Wale elastic stockinet* resolved problem edema and skin shear under Total Contact Cast**

Day #4. Offloaded with “heel weight bearing only with transfers, and no walking!” Debrided and dressed with vital dyes and polyvinyl sponge*** and total contact casting.**

Day #18. Wound edges are flattening and wound base is filling in. Great toe is less inflamed. Day #25.

Day #39. Ulcer healed at day 39, a great result in face of exposed bone in base of ulcer with presumed bone infection. Skin chafing under the contact cast was a problem for first weeks of therapy. Fuzzy wale elastic stockinet at week #3 protected the skin and problem chafing disappeared.

Problem• Wagner Grade 2 Recurrent L heel ulcer, 7 months duration• Hypertension• Edema • ABI: 0.93

Treatment Day #0. Patient complained of pain under a Charcot Restraint Orthotic Walker (CROW) used to treat severe neuropathic feet. Wound neglected for 7 months. Epiboly is the term that describes the round shoulder wound edge seen in this photograph.

Treatment• Fuzzy wale elastic compression stockinet* to control edema and protect at risk skin• Cost effective total contact cast** constructed from rolls of cast material

Problem• 59 year old male with diabetic great toe ulcer present for over one year • Chronic pain with depression

Day #0. Comorbidities: HTN, obesity, degenerative arthritis, Congestive Heart Failure and gastric bypass for obesity.

Treatment• Fuzzy wale elastic compression stockinet* to control edema and protect at risk skin• Cost effective total contact cast** constructed from rolls of cast material

Outcome“Complete” closure of great toe wound at 21 days

Day #0.Great toe ulcer dressed before total contact casting. Contact layer is size medium fuzzy wale elastic compression textile* used to control edema and protect skin from shear injury under the total contact cast.

Day #0.Photo shows fuzzy wale elastic stockinet* folded down over the total contact cast** to dress the top edge of the cast and prevent “muffin top” chafing between a rough cast edge and edematous at risk skin above.

Day #7. Observe cornrow furrows in the skin after one week of fuzzy wale elastic stockinet under a well padded contact cast. Erythema, redness of the skin, is worrisome. A great deal of edema fluid is still in the subcutaneous fat beneath the cast.

Day #15. Great toe ulcer is well on its way to healing. Observe longitudinal cornrow furrows visible on the ankle skin. Note that after 15 days skin redness has disappeared. Skin inflammation, redness in this patient seen above, can be due to multiple wound comorbidities including stasis dermatitis, inflammatory mediators released from Charcot changes in the bones of the foot and arterial insufficiency.

Day #21. Great toe wound declared healed by staff. Deep shoes with inserts ordered. Wound has not reoccurred over two months.

Day #4. At the first Total Contact Cast change, heel pressure and shear area is resolving. Day #28. Photo shows a healthy granulating heel wound. Treatment offloading with total contact cast(TCC) **, polyvinyl chloride foam with vital dyes ***, cotton gauze, and longitudinal fuzzy wale elastic compression stockinet* was used as skin contact layer to prevent skin chaffing and to control edema.

Day #35. Cast change #7. Observe the flat wound edge that has resulted from offloading. Epiboly is the term that describes the round shoulder wound edge seen at presentation. Patient reports he “enjoys the cast”.

Day #55. cast change #13.

Outcome• Complete healing Day #67• 15 total contact cast changes

Day #67. A great result, healing in 67 days. Observe the beautiful healed wound and the cornrow furrows in the now healthy appearing skin below the wound. See insert.