The Custom Total Contact Cast to Offload Foot Ulcers in the Presence of Biomechanical Deformities: A Case Report

Although offloading foot ulcers with a total contact cast (TCC) remains the cornerstone of managing these wounds, the TCC is underutilized. Patient intolerance and potential iatrogenic complications due to TCCs' general lack of customizability and the inability to address flexible biomechanical deformities that are not in the sagittal plane may be one of the reasons patients with foot ulcers do not receive this crucial component of care.

To describe the use of a novel approach to the standard TCC technique that uses strategic padding to potentially increase patient compliance and comfort while decreasing the likelihood of iatrogenic ulceration, as well as to correct flexible frontal plane biomechanical deformities with casting tape that is pulled medial to lateral, or lateral to medial, to bring the plantar surface of the foot to neutral position.

The custom total contact cast (C-TCC) was used in a 54-year-old woman who had diabetes, obesity, and a flexible cavovarus foot type with a recurring plantar fifth metatarsal base wound. Weekly debridement followed by silver dressings and C-TCC application were performed. The latter included strategic padding, 2 forms of plaster of paris with contouring, fiberglass, and medial-to-lateral positioning of the foot during application.

This case study describes two (2) treatment episodes, with a focus on the second episode. At initial presentation, the ulcer took 5 weeks to heal. During the second treatment, a 48.7% reduction in wound volume was noted after 1 week. By the fourth week of treatment, a 98.7% wound volume reduction was achieved. By the ninth week, the ulcer epithelialized completely. At 1-month and 12-month follow-ups, the site remained fully epithelialized. No iatrogenic ulcerations, cast discomfort, or ambulatory dysfunction were reported by the patient.

In this case, the C-TCC helped address flexible frontal plane deformities and facilitated healing. Randomized, controlled clinical studies to evaluate the safety and effectiveness of different TCC methods are needed to guide care and improve the utilization of optimal offloading methods for the management of plantar foot ulcers.