Recurrence and prevention of diabetic foot ulcers after total contact casting

Total contact casting (TCC) has become established as standard treatment for Wagner grades 1 and 2 diabetic foot ulcers. However, the recurrence rate after TCC is unacceptably high, and a clear concept to prevent recurrences is still lacking. The purpose of this study was to evaluate recurrences and the effectiveness of preventive measures in a group of diabetic patients treated with TCC.

From January of 1999, to June of 2004, 28 patients (20 men and 8 women; average age 63 years) with 34 ulcers were treated using TCC. Thereafter, orthopaedic shoes were provided and patients were followed regularly. Recurrences were treated first by TCC, and operative correction was carried out in patients with an underlying foot deformity. Mean followup was 2.8 (1 to 5) years.

Primary TCC treatment lasted 4 (1 to 17) months. Complete healing was achieved in 85% of ulcers; 57% of patients had a total of 26 recurrences, and 18 new ulcers were found in a different area or on the other foot. Sixteen recurrences were treated successfully by TCC, but the rate of new recurrences during followup was 50%. Eight recurrences were treated by operative correction of foot deformities. Most patients stayed ulcer-free thereafter. An unloading shoe was applied twice. No amputations were required.

The first TCC showed an effective healing rate of 85%. The high recurrence rate of 57% in the presence of optimal instruction, shoes, and followup suggests that these measures are not sufficient. However, because patients who had operative corrections stayed ulcer-free thereafter, it is suggested that foot deformities should be operatively corrected immediately after primary healing rather than waiting until further recurrences occur.