50-65 OWM0608 Farid · Callista Roy’s1 perspective on the human experience can be easily applied in wound care. On the sensitive relationship between man and the environment, Sister

50 OstomyWound Management

FEATURE

Providing care for patients with challenging

wounds and comorbidities requires an open

mind. When Ms. T, an elderly woman with

schizophrenia and a chronic diabetic foot ulcer that

was not responding to treatment, presented at Victory

Memorial Hospital Diabetic Foot Clinic (VMH DFC),

Brooklyn, NY, care providers needed a plan that

allowed consideration of all available care options to

achieve the best outcomes.

The well-known nursing theorist/researcher Sister

Callista Roy’s1 perspective on the human experience

can be easily applied in wound care. On the sensitive

relationship between man and the environment, Sister

Roy writes about an ongoing adaptation, survival, and

resilience as part of a journey through life. Similarly,

wound care clinicians continually address the issue of

maladaptation as a factor in the breakdown of the

integumentary system. When the skin — the organ of

temperature regulation and the major barrier to

microbial invasion — has been compromised, the

body is in danger of invasion by organisms that can

lead to sepsis and death. In this case study of a patient

Total Contact Casting as Part ofan Adaptive Care Approach: A Case Study Karen Farid, RN, MA, CWON, CNS/ET; Mark Farid, MA, CO, BCP; and Claire M. Andrews, PhD, CNM, FAAN

Although total contact casting provides pressure relief and a moist wound-healing modality that allows patients to resumemobility while the wound is healing, it is not as widely used as it should be, in part because Board-certified pedorthists withrelevant skills are scarce. As a result, clinicians may not appreciate the positive impact total contact casting has on thepatient’s overall condition. This case study of a 75-year-old woman with a potentially life-threatening diabetic foot ulcer offersa comprehensive picture of pervasive physiological changes in a context of challenging comorbidities. This multifaceted caseis presented against a backdrop of Sister Callista Roy’s nursing theory of adaptation and a total patient care approach to illus-trate the cascading effects of diabetes on the patient’s well-being, as well as to show that total contact casting is not only aneffective intervention in the management of the patient’s diabetic foot ulcer, but also a way to improve the patient’s overall con-dition by maximizing the benefits of mobility.

KEYWORDS: total contact casting, Charcot foot, adaptational theory

Ostomy Wound Management 2008;54(6):50–65

Ms. Farid is a Certified Nurse Specialist/ET, Staten Island University Hospital, New York, NY, currently pursuing a doctorate at CaseWestern Reserve University. Mr. Farid is a Board Certified Pedorthist; CEO and owner of WALK RIGHT, Staten Island, NY; and man-ager of the Victory Memorial Hospital Diabetic Foot Clinic, Brooklyn, NY. Ms. Andrews is a faculty member, Case Western ReserveUniversity Director of Nursing Practice Program, Cleveland, Ohio. Please address correspondence to: Karen J. Farid, RN, MA,CWON, CNS/ET, 300 Shirley Avenue, Staten Island, NY 10312; email: [email protected].

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June 2008 Vol. 54 Issue 6 51

with a diabetic foot ulcer, the patient’s altered coping

mechanisms were rendered less effective by diabetes

mellitus2 and other comorbidities that required per-

sistence and ingenuity from caregivers.

Offloading is a recognized option for foot ulcers.

One such option — total contact casting (TCC),

which provides pressure relief and and a moist

wound-healing environment and facilitates patient

mobility while the wound is healing — is not prac-

ticed in many centers, primarily because of the scarci-

ty of Board-certified pedorthists (BCPs) competent,

knowledgeable, and experienced regarding application

and modification of the casts. Additionally, to be done

correctly, clinicians using TCC need approximately 45

minutes for the procedure in addition to the time

needed for the initial removal of the cast and dressing,

and assessment of the wound. Thus, experience teach-

es this approach is not widely used.

The authors’ diabetic foot clinic is part of a larger

outpatient department at the facility. Clinicians at this

non-profit clinic do not bill patients privately for any

service. The care team includes a Board-certified

pedorthist (BCP) experienced in TCC; once peripher-

al circulation and perfusion to the lower extremities

are determined to be intact, patients with plantar

ulcers (weight-bearing surfaces) are immediately con-

sidered for TCC. Patients also are evaluated for any

lower extremity weakness, motor imbalances, and

unsteady ambulation that might make TCC unsafe, as

well as for sufficient cognitive ability to follow instruc-

tions regarding the use of assistive devices such as a

cane or walker.

Ms. T presented with an ulcer of >18 months dura-

tion with no evidence of cellulitis or gangrene. She was

evaluated and met the criteria for TCC; cast-

ing was started along with treatment involv-

ing a succession of topical wound dressings

and applications whenever wound healing

showed signs of slowing. The casting stabi-

lized the local wound environment, keeping

the patient infection-free for 5 years until

the wound closed. Moisture-control foam

dressing impregnated with nanocrystalline

addressed moisture balance and bacterial

control necessary to achieve healing within

the closed, protected environment created

by TCC until the wound finally responded. Total con-

tact casting (see “Total Contact Casting: The Details”)

appeared to be the pivotal treatment that provided a

healing environment for this serious wound.

The purpose of this case report is not only to

increase clinician appreciation for the impact TCC can

makes on the progress of the patient’s overall condi-

tion and to acquaint the reader with the purpose and

wound care benefits of TCC for diabetic foot ulcers,

but also to illustrate the overall benefits of mobility

and ambulation for patients with diabetes and healing

wounds. In this case, mobility affected the patient’s

management of her diabetes.

This presentation is not intended to be a study in

topical wound therapies. When considering all the

classifications of dressings and the number of dress-

ings that fall within each classification, it would be

inaccurate to say one particular dressing outperforms

the rest based on one wound. Different classifications

of dressings can be combined and hundreds of phar-

maceutical applications can be added to the mix,

exponentially increasing the choices for topical wound

therapies. The dressing that finally helped heal this

wound serendipitously brought together the elements

needed for that particular wound to the wound envi-

ronment, underscoring Sister Callista’s philosophy of

adaptation and persistence.

Case PresentationAt the time of initial presentation, Ms. T was a 75-

year-old Caucasian woman with a medical history that

included schizophrenia, obesity, diabetes mellitus type

2, and severe Charcot foot deformities of both feet.

She presented at the authors’ clinic in September 2000

KEY POINTS• Patients with multiple chronic health conditions and wounds pres-

ent unique challenges.• The authors of this case study illustrate how physical and mental

health conditions may conspire against healing chronic wounds.• By combining evidence-based care and patient priorities, the

patient continues to be able to ambulate, remain independent,and avoid a lower leg amputation.

Ostomy Wound Management 2008;54(6):50–65


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with a large Wagner Stage III non-tracking diabetic

foot ulcer on the right plantar surface along with local

cellulitis. The ulcer measured 8 cm x 9.5 cm. Ms. T

reported she had been treated at two other wound care

centers for 6 months and 12 months, respectively. She

was de-conditioned from limited exercise (centers

often will off-weight plantar ulcers by recommending

severely restricted ambulation). Her blood cultures

were negative and her immediate and past history was

negative for fevers. Her white blood cell count was ele-

vated (13,500) and the wound periphery appeared

mildly cellulitic. Based on clinical judgment, she was

treated with an antibiotic (ciprofoxacin 500 mg every

12 hours) until her blood count was normal (14 days).

Her blood sugars remained slightly but persistently

elevated (140–180) despite insulin adjustment by the

physician on the diabetic foot clinic team. Ms. T’s

meals were being delivered to her home through a

community agency. This service responds to special

dietary needs and the patient was on a “no concentrat-

ed sweets” diet. However, because she was an outpa-

tient, assessing her dietary intake and its alignment

with her therapeutic goals was difficult. She was seen

monthly by a VMH DFC nutritionist for the first 3

months, after which she was seen as needed at the rec-

ommendation of the wound care nurse.

Charcot foot and perfusion. A series of

lower extremity x-rays supported the diag-

nosis of Charcot collapse of the foot infra-

structure. Peripheral pulses in both Ms. T’s

legs and feet were strong, her feet felt

warm, and capillary refill was positive at 1

second. Gross vascular examination did

not indicate arterial insufficiency — in

particular, arterial-venous Doppler study

revealed no vascular insufficiency to the

lower extremities. The wound was a

healthy red color, moist, and insensitive.

The ulcer on the plantar surface of the foot

was positioned over a bony prominence,

signifying the etiology was due to pressure

as opposed to arterial insufficiency that

usually presents in the toes. Patients with

arterial insufficiency rarely develop

Charcot deformities — Ms. T’s x-rays

showed Charcot deformities in addition to

the thinning of bone cortex associated with autonomic

hyperperfusion. Autonomic hyperperfusion results in

the “wash out” of bone minerals, especially calcium.3-5

Schizophrenia. Three months before coming to the

clinic, Ms. T’s family consulted a private psychiatrist.

This was Ms. T’s son’s effort to take charge of her med-

ical care and have her admitted to a skilled nursing

facility to care for her wound. Evaluation confirmed

she was legally competent. Ms. T had not been “sent”

to the Diabetic Foot Clinic by regular referral channels

— she had heard about the clinic from one of her

neighbors and she had made a conscious decision to

seek help from the center.

The wound had a far-reaching impact on Ms. T’s

overall well-being. Care team members understood

that her psychiatric condition put her at high risk for

relapse after the wound was healed, but they felt her

immediate needs and the danger of eventual sepsis

and amputation outweighed that risk. During prior

treatment in other wound centers, she trialed two

offloading braces without any improvement. She rou-

tinely refused any recommended surgery to speed

healing by removal of abnormal bone protrusions.

One such bony prominence seen on x-ray was situat-

ed immediately under the area of the ulcer and was

identified as the pressure point (see Figure 1).


1a

1b

Figure 1b. The top picture is the affectedfoot. The bottom x-ray photo shows thebone deformities that cause the Charcotfoot. (A) The collapse of the mid-foot. (B)The abnormal bony prominence underly-ing the ulceration. The white and redlines on the x-ray highlight the deformi-ties of the hammer toe hallux and thehyperextended second toe shown in thepicture.

Figure 1a. The crumbled midfoot bones(black arrows) that changed the direc-tion of muscle/tendon action (toes turn-ing laterally — red arrows) and the thincortex of the bones (yellow arrows) areall deformities caused by the Charcotphenomenon.


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During the 3 weeks before starting TCC, a home

care nurse changed Ms. T’s foot ulcer dressings on a

daily basis. Ms. T’s dressings always showed tamper-

ing when she arrived in clinic. Ms. T occasionally

missed clinic appointments but always called the

clinic to inform staff she would not be coming and

to reschedule. The patient’s psychiatric condition

was not judged to be an impediment to immediate

treatment. Before starting the TCC (which previ-

ously had not been considered), Ms. T was present-

ed with all the information regarding the procedure

and alternative options for care. She accepted this

treatment without reservations, especially because

she was told she would be able to resume most of

her normal activities by wearing the cast.

Total contact casting. Having met all the casting

criteria (see “Total Contact Casting: The Details”), Ms.

T was started on TCC in the summer of 2000, 3 weeks

after she presented to the clinic. Casting was a partic-

ularly good choice for her because the cast prohibited

access to the wound. When first casted, the wound

involved much of the plantar surface of the foot,

measuring 8 cm x 9.5 cm.

Ms. T was alert and oriented and remained highly

functional throughout her initial treatment, which

lasted from January 2000 to March 2005. She rehabil-

itated well in the first few weeks of casting using a

walker. Her mobility gradually increased and she

became completely ambulatory with the aid of a cane;

she was comfortable and happy with her freedom. She

could navigate stairs and make almost daily excursions

to the shops in her neighborhood to buy small food

items, something she couldn’t do before. After starting

TCC, increasing her mobility, and improving compli-

ance with her “no concentrated sweets” diet (self-

report), Ms. T’s blood sugar record significantly

improved with only infrequent elevations >120. She

became increasingly vigorous and her weight

decreased, although she remained mildly overweight

(5’8” tall, 190 lb ± 5 lb). Although manifestations of


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54 OstomyWound ManagementOstomyWound Management

TOTAL CONTACT CASTING: THE DETAILS

Background. In the early 1990s, clinicians started to recog-nize a higher incidence of lower extremity amputationsamong persons with diabetes, especially type 2. Researchinitiatives, particularly among podiatrists and vascular sur-geons, sought to determine whether the rate of amputationcould be lowered with prevention, patient education, andearly intervention. Among these initiatives was the LowerExtremity Amputation Prevention (LEAP) program started byHuman Resources and Services Administration (HRSA).1-3

This program advocated a multidisciplinary approach thatcomprised members of podiatric, vascular, andinternal/endocrine medicine and nursing disciplines.4-5 Theinclusion of diabetic nurse educators was stressed.6 Thisbecame the model for diabetic foot clinics across thenation.7

Application. Total contact casting (TCC) is a technique torelieve pressure on the weight-bearing surfaces of the foot.Originally developed by Dr. Paul Brand,8 a foot surgeon inthe US Public Health Service (USPHS), the technique wasused to treat neuropathic ulcers related to Hansen’sDisease. The cast is similar to casts used to immobilize atibial/fibula fracture, extending from below the knee to thetoes (see Feature, Figure 1) but differs from an orthopediccast in the following ways:

1. The toes are completelycovered so the castresembles a boot. Thisis necessary becausethe goal of TCC is touse every available sur-face area of the foot,including the toes andlower leg, to distributeweight and pressure.

2. The wound is dressed,preferably with long-lasting absorbent dress-ings before padding theleg and toes.

3. Thick padding is usedto protect the shin,ankles, toes and anyother bony prominencesthat will be covered bythe cast (see Figure 5).

4. The patient is posi-tioned prone with theknee flexed. An assis-tant holds the foot inneutral position (seeFigures 6 and 7). Thiscauses the soft tissues,blood, and lymphaticsto flow away from thefoot. When the patient puts the foot down to walk, thesoft tissues succumb to gravity and body fluids flowback into the leg, causing the cast to become snug inthe area of the leg above the ankle (see Figure 8).

Figure 5. For TCC, thepatient lies prone with thefoot elevated behind him.This causes all the soft tis-sues to drape down withgravity toward thepatient’s knee. One mem-ber of the team holds thefoot in neutral position —ie, the knee is flexed atright ankles and the foot isat a 90-degree angle tothe leg, neither plantarflexed nor dorsiflexed.

Figure 6. After the cast ison and the patient isstanding, the soft tissuesflow back into the cast, fill-ing the upper part of thecast, making it snug, like afitted socket. This causesthe pressure that wouldnormally be placed on theplantar foot to be dis-placed to the leg abovethe ankle, leaving the plan-tar foot almost entirelywithout pressure.

Figure 7. The patient is alert, oriented, and ambulatory. Notethe prior amputation sites (A,B), and the deformed shape ofthe feet from multiple old, healed Charcot fractures. (C) is thesite being treated with TCC. The original wound in this casehad extended along the entire mid-plantar region.

Figure 8. The wound is dressedand then the entire foot, includ-ing between the toes, is wrappedwith cotton undercast padding.

Figure 9. The stockinette is put onand secured over the leg andadditional felt adhesive padding isplaced over the bony prominencesand the toes.


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5. The cast is changedevery 7 days, toexamine the woundand change thedressing (Figures 9through 14).

Indications for use. Thecriteria at VMH DFC forusing TCC on a patientare based on recom-mendations found inthe literature and havebeen adapted to thespecific needs of thepopulation treated inthe clinic.9

1. The advantage ofTCC is that it per-mits the patient to remain ambulatorywhile off-weighting the wound. It facili-tates the beneficial pumping action of legmuscle use while preventing edema underthe cast. The patient must be ambulatory.If the patient needs a steadying assistivedevice — eg, a cane or a walker — physi-cal therapy can be consulted. If thepatient is not ambulatory, TCC should notbe performed and other offloading strate-gies should be applied.

2. Total contact casting is used only forulcers on weight-bearing areas of thefoot.

3. The area under the cast must be free ofinfection or cellulitis. Pre-casting evalua-tion should include clinical assessment(visual, palpation of the tissues, x-ray torule out osteomyelitis, white blood count with dif-ferential, and pain assessment [neuropathy evalu-ated and taken into consideration]).

4. Total contact casts are not used on patients witharterial insufficiency. Generally, if necrosis forma-tion is not persistent, strong pulses are present,capillary refill is normal, and no resting pain orclaudication on ambulation occurs, further vasculartesting is not necessary.10-13 However, if the patienthas leg/foot lesions that are not attributable topressure or known recent trauma and look chronic,further vascular assessment is warranted beforestarting TCC.14

5. Edema in the affected leg or foot is not a con-traindication unless it exceeds 2+ or if an acuteprocess like deep vein thrombosis is suspected.

Such issues would need to beresolved before using TCC. Also, TCC is contraindi-cated in cases of gross chronic edema such aslymphedema or elephantitis. If the cast is appliedover edema, the edema may decrease under thecast, making the cast too loose and allowing a“pistoning” movement of the limb inside the cast,causing severe soft tissue damage from poundingand friction. In these cases, the first cast ischanged and edema assessed every few days untilresolved. Then the time between casting can beextended to every 7 days.15,16 The clinician mustnever forget that the patient has diminished sensa-tion.17-19

6. Total contact casting means that the cast is in totalcontact with all the surfaces of the foot and legduring the entire wear time.

Figure 10. The layers of fast-drying plaster are applied to the footand up the leg to just under the tibial protuberance.

Figure 11. One member of the team isalways supporting the foot at the correctangle.

Figure 12. It is preferable to use anorthopedic walking heel designed to beused with casts in order to protect thecast from damage. Walking heel posi-tion is important to proper distributionof the weight inside the cast and alsoto minimizing the work of walking withthe cast. The rubber heel also cushionsthe impact on the knee and hip joints.Before placing the heel, a piece of ply-wood is attached to the plantar sur-face of the cast. This serves as a plat-form for the rubber heel. This adds toweight distribution and prevents theheel from loosening.

The Board-certified pedorthist (BCP)is the person in charge of the TCC pro-cedure and makes sensitive decisionssuch as the position of the heel.


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Ms. T’s schizophrenia were noted in long conversa-

tions during casting when she exhibited flight of ideas,

disorganized thinking, and secretiveness, she was able

to travel to and from clinic alone, live alone, and self-

manage her finances.

Fitful progress. The wound rapidly decreased in size

to 3.5 cm x 2.5 cm within 2 months after starting cast-

ing, which was attributed largely to pressure relief.

Initially, the dressing applied under the cast during this

healing period was silver sulfadiazine cream 1% (SSD)

with a dry cover dressing. A moderate amount of serous

drainage was noted on the dressings when the cast was

changed. Drainage is expected with each cast change,

although the amount differs from patient to patient,

due to an accumulation from the whole week. The

experience at the VMH DFC has been that the better

the arterial perfusion to foot wounds, the moister the

wound bed tends to be and the greater the accumula-

tion of drainage inside the cast at the time of change.

Nevertheless, preventing maceration of the normal

tissues was a challenge in this case. Maceration caused

by drainage or perspiration occurred around the

wound, between the toes, and on other parts of the

foot and was treated with gentian violet solution 1%.


References1. Van Damme H, Rorive M, Martens De Noorthout BM,

Quaniers J, Scheen A, Limet R. Amputations in dia-betic patients: a plea for footsparing surgery. ActaChiropedia Belgium. 2001;101(3):123–129.

2. Bureau of Primary Health Care, Health Resourcesand Services Administration. Lower extremity ampu-tation prevention. Available at: www.hrsa.gov/leap.Accessed April 23, 2007.

3. Ollendorf DA, Kotsanos JG, Wishner WJ, et al.Potential economic benefits of lower-extremityamputation prevention strategies in diabetes.Diabetes Care. 1998;21(8):1240–1245.

4. Morris AD, McAlpine R, Steinke D, et al. Diabetesand lower-limb amputations in the community. A ret-rospective cohort study. DARTS/MEMO collabora-tion. Diabetes Audit and Research in TaysideScotland/Medicines Monitoring Unit. Diabetes Care.1998;21(5):738–743.

5. Donohoe ME, Fletton JA, Hook A, et al. Improvingfoot care for people with diabetes mellitus — a ran-domized controlled trial of an integrated careapproach. Diabetes Med. 2000;17(8):581–587.

6. Ooi GS, Rodrigo C, Cheong WK, Mehta RL, Bowen G,Shearman CP. An evaluation of the value of groupeducation in recently diagnosed diabetes mellitus.Int J Lower Extrem Wounds. 2007;6(1):28–33.

7. Van Gils CC, Stark LA. Diabetes mellitus and theelderly: special considerations for foot ulcer prevention and care.Ostomy Wound Manage. 2006;52(9):50–56.

8. Department of Health and Human Services/Health Resources andServices Administration. Bureau of Primary Health Care. NationalHansen’s Disease Programs. Available at: ask.hrsa.gov/orgdetail.Accessed April 23, 2007.

9. Baker N, Green A, Krishnan S, Rayman G. Microvascular and c-fiberfunction in diabetic charcot neuroarthropathy and diabetic peripheralneuropathy. Diabetes Care. 2007;30(12):3077–3079.

10. Grey JE, Harding KG, Enoch S. Venous and arterial leg ulcers. BMJ.2006;332(7537):347–350.

11. Hopf HW, Veno C, Aslam R, et al. Guidelines for treatment of arterialinsufficiency ulcers. Wound Rep Regen. 2006;14(6):693–732.

12. Hafner J, Shaad I, Schneider E, Seifert B, Burg G, Cassina PC. Leg ulcersin peripheral arterial disease (arterial leg ulcers): impaired wound heal-ing above the threshold of chronic critical limb ischemia. J Am AcadDermatol. 2000;43(6):1001–1008.

13. Marston WA, Davies SW, Armstrong B, et al. Natural history of limbs witharterial insufficiency and chronic ulceration treated without revascular-ization. J Vasc Surg. 2006;44(1):108–114.

14. Guyton GP. An analysis of iatrogenic complications from the total con-tact cast. Foot Ankle Intern. 2005;26(11):903–907.

15. Humphrey LL, Palumbo PJ, Butters MA, et al. The contribution of non-insulin-dependent diabetes to lower-extremity amputation in the com-munity. Arch Intern Med. 1994;154(8):885–892.

16. Wukich DK, Motko J. Safety of total contact casting in high-risk patientswith neuropathic foot ulcers. Foot Ankle Int. 2004;25(8):556–560.

17. Sinacore DR. Total contact casting for diabetic neuropathic ulcers. PhysTher. 1996;76(3):286–295.

18. Baker RE. Total contact casting. J Am Podiatr Med Assoc.1995;85(3):172–176.

19. Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ,Harkless LB. Off-loading the diabetic foot wound: a randomized clinicaltrial. Diabetes Care. 2001;24(6):1019–1022.

Figure 13. This patient is fully ambu-latory in the TCC with the aid of awalker. He is encouraged to returnto full activity. He is wearing a cus-tom-molded diabetic shoe on the leftfoot that manages the additionalstress on that foot.

Figure 14. The cast is removed every 7days (preferably) to do wound care. Thelonger the cast is on, the more drainageaccumulates inside the cast. Thisincreases the amount of bacteria andfungi at the wound site. No dressing indi-cations claim to manage the drainingwound therapeutically for >7 days.


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This is not only an effective drying agent, but also

highly antifungal and effective against methicillin-

resistant Staphylococcus aureus and other bacteria

when applied to maceration and fungal eruptions.6-9

Routine bacterial blood counts performed every 2

months were normal.

When healing failed to continue after 4 months, the

SSD was changed. Various absorbent dressings, either

impregnated with antimicrobials or in combination

with antimicrobial topical dressings and applications,

were tried with little success.

To address cast-related maceration, attempts to dis-

continue casting and try other forms of off-weighting,

including braces and splints, were tried without suc-

cess. The status of the wound declined — for example,

cellulitis and sepsis developed after 2 weeks in a “half-

cast” (a custom-molded plaster half-shell).10 With this

device, the patient’s dressing can be changed more

often because the cast can be removed and reapplied.

This change in treatment was made after 1 year of

TCC when wound healing seemed to plateau at 3.5 cm

x 2.5 cm. The rationale was that more frequent dressing

changes might promote further healing. A silver-impreg-

nated alginate dressing was used during the 2 weeks out

of the TCC, before Ms. T’s hospital admission for sep-

ticemia. During Ms. T’s hospital stay, a full vascular con-

sultation and workup was performed to evaluate any

possible changes in her perfusion status since the begin-

ning of treatment. Results indicated no large vessel vas-

cular disease was present except for a benign varicose

vein on the medial aspect of the right leg.

One week after Ms. T’s discharge from the hospital,

TCC was resumed. Dressings were chosen according

to their ability to absorb and control the drainage for

the 7 days between cast changes11,12 and reported man-

ufacturer claims regarding effective management of

bioburden within the wound. Each new dressing (now

including variations of foam and silver dressings) was

tried for at least 3 weeks — a period based on general


2a

Figure 2a. The wound as itappeared when nanocrys-talline moisture barrier foamdressing was started.

2b

Figure 2b. After 4 weeks(weekly cast and dressingchanges).

2c

Figure 2c. After 6 weeks ofnanocrystalline therapy.

2d

Figure 2d. After 8 weeks ofnanocrystalline therapy.

2e

Figure 2e. Healed on the 10th week. Zoom shows discolored cal-lous formation.


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recommendations of the New York State Department

of Health for skilled nursing facilities regarding

wound care practices; state oversight sets an expecta-

tion that wounds will be carefully monitored for

progress and that treatments will be changed in a judi-

cious manner once wound progress stops or declines.

Ms. T’s wound remained stable, free of infection, and

granular while casted; it also remained the same size

(3.5 cm x 2.5 cm ± 1-2 mm). This trial-and-error peri-

od lasted approximately 5 years, including time the

patient was in the cast and short periods while off-

weighting alternatives to TCC were tried.

A new dressing that combined a high-density

absorbent foam and ionic silver nanocrystalline thera-

py was tried with better results.13,14 The response to the

new therapy was immediate and dramatic, reducing

wound area from 8.8 cm2 to 6 cm2 (30%) the first

week. The wound healed within 10 weeks of initiating

the new therapy and with weekly re-casting (see

Figure 2). It is not clear what specific properties of the

dressing had such a positive impact on the wound —

the properties of the foam itself, the unique delivery

system of the ionic silver, or both combined. Subtle,

subclinical, intrinsic changes in the patient’s overall

condition or locally in the foot may have been factors.

DiscussionDiabetes mellitus. Diabetes mellitus is an

endocrine dysfunction that affects every fiber of the

human internal physical environment, resulting in the

denaturing of proteins and collagen (glycolysation),

accelerated aging of the organ systems, and a short-

ened lifespan in the affected individual.15 Early in the

disease process, the skeletal muscles in the body

become insulin-resistant, resulting in poor glucose

utilization. It is increasingly apparent that insulin

resistance as a metabolic syndrome precedes beta cell

failure in the pancreas16; the inhibition of the renin-

angiotensin system in the pathogenesis of diabetes

also may be a factor.17 These changes in the normal

glucose regulatory mechanisms in the body cause ele-

vations in blood glucose that impact the pancreatic

beta cells over time, resulting in beta cell apoptosis.18-20

As blood glucose becomes chronically elevated and

continues untreated, the diabetic metabolism starts to

breakdown fats and proteins for energy production,

sending the person into ketoacidosis and coma. In

some cases, diabetes even blocks nutritional absorp-

tion from the gut — ie, peripheral neuropathy-

induced gastroparesis.21,22 Thus, diabetes mellitus is a

maladaptive syndrome in the most molecular, physio-

logical sense — if not addressed properly, the condi-

tion shortens the life of the affected person.

According to Roy,1 the inability to adapt to the

external physical environment — ie, the inability to

assimilate energy producing and restorative nutri-

tion — ultimately results in death. However, if

caught early and treated aggressively, including

planned, successful nutrition, weight loss, and a

regular exercise schedule — that is, if the input and

assimilation within the system changes positively —

the output will be a normal, active life.

Total contact casting. In 1998, Armstrong and

Lavery,23 having noted a preponderance of wound lit-

erature addressing topical wound care and research on

dressings, published a comprehensive review of evi-

dence-based options for offloading diabetic wounds.

The salient theme behind this review was that without

offloading, all other treatment modalities would be

“less than effective.”23 Many patients with chronic dia-

betic foot ulcers come into the VMH DFC with histo-

ries of non-healing wounds they have had for years.

Total contact casting has become the “gold standard”

of off-weighting in lower extremity amputation pre-

vention.24,25 Rarely do patients with diabetic foot ulcers

with similar presentation have to be casted more than

3 months before they are healed.

In 1999, Inlow et al26 postulated that offloading is

the most important component in prevention and

treatment of diabetic foot ulcers, citing peripheral

neuropathy as a major contributing factor to more

than 90% of diabetic foot ulcers. He developed a mod-

ified Carvelle Classification System that offered prac-

titioners offloading options for different types of

deformities and pressure points. An additional catego-

ry for patients with diabetes and foot ulcers or acute

Charcot events helps clinicians identify which patients

would benefit from TCC.26

Literature27-29 describing the value and safety of

TCC commonly cites the work done by Brand, the

originator of the technique. Sinacore et al’s30 retro-

spective study of 30 patients with a total of 33 foot



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ulcers showed a healing rate with TCC of 82%, aver-

age size = 2.3 cm2, and an average of 44 days healing

time for wounds that healed. In a retrospective

study by Birke et al31 of 80 neuropathic ulcers, aver-

age size 1.7 cm2, 90% healed with a complication

rate of 6%.

For decades, TCC was considered unsafe for use

on plantar ulcers related to ischemia. However a

prospective longitudinal study by Nabuurs-

Franssen et al32 of 98 consecutive patients to assess

the outcome and complications of TCC for neuro-

pathic ulcers with present and absent peripheral

arterial disease (PAD) and also with and without

superficial infection found that ulcers with moderate

ischemia or infection can be

treated effectively with cast-

ing. This study showed that

69% of the patients with

PAD healed with TCC, while

only 36% healed when

superficial infection was

present in the ulcer.

However, when heel ulcers

were added to the mix

(regardless of PAD and

infection status), outcome

was found to be poor.

Overall, the non-infected

group with no PAD and no

heel ulcers had the highest

healing rate (90%). Of note:

in the treatment algorithms

used at the authors’ clinic,

ischemic ulcers are not casted

and are followed by a vascular

consultant because of a high

incidence of complications

when treated with TCC.25

In Ms. T’s case, TCC was

so effective clinicians were

able to salvage her limb, keep

her infection-free, and pre-

vent amputation for 5 years

in the presence of a chronic

open wound and diabetes.

Keeping her actively ambula-

tory the entire time she was casted is credited with

effectively controlling her blood sugar, as supported

by the literature.33-40

Topical therapy. When clinicians choose a topical

therapy and apply a dressing to a wound, they are essen-

tially providing an alter-environment for that wound

that introduces new conditions to promote healing and

protect the wound from external factors. However,

despite appropriate dressing, additional events and

conditions can impact on the wound — eg, an increase

in pressure, edema in the extremity, uncontrolled blood

glucose, and disruption of the dressing, including tam-

pering. In Ms. T’s case, TCC was crucial in controlling

these variables until healing occurred.


Figure 3. Pathogenesis of Charcot foot-related diabetic foot ulcers.


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Addressing Charcot foot. One common challenge

in a diabetic foot center is management of the

Charcot foot.28 This phenomenon involves the crum-

bling of the infrastructure of the foot, classically seen

in persons with diabetes and peripheral neuropathy.

The denatured proteins caused by glycolysation in

persons with diabetes find their way into collagen,

producing an inferior quality of collagen fibers. This

causes poor cross-linking of collagen fibers in the

bone matrix, which leads to inferior patterns of min-

eralization in the bone.41 Decreased vitamin D3

hydroxylation also relates to the deranged mineral

homeostasis and skeletal morphology seen in per-

sons with diabetes (see Figure 3),42-50 making persons

with diabetes more prone to fractures, especially

when compounded with autonomic abnormalities in

the peripheral circulation.

Abnormal proteins also affect the quality of the col-

lagen in the connective tissue in the walls of the blood

vessels, in some cases causing peripheral arterial insuf-

ficiency and in others venous insufficiency and yet in

others a combination of both. The abnormal collagen

also affects the arterioles and capillaries of almost all

persons with diabetes, regardless of what is happening

to their macro-vasculature. This is called small vessel

disease.51 When the skin is broken, this capillary dys-

function renders persons with diabetes vulnerable to

infection by preventing a fast, adequate immune

response.52,53 This same small vessel disease affects the

blood supply to small peripheral nerve endings, caus-

ing a decrease/increase in sensation and also affecting

the autonomic nerves regulating the general blood

flow through the larger arteries. Even clinicians not

specialized in wound care are familiar with the devas-

tating effects of arterial insufficiency, vascular con-

striction, and chronic occlusive disease. These condi-

tions are more common in persons with diabetes due

to autonomic abnormalities. However, an opposite

autonomic vascular condition exists in some persons

with diabetes that causes a hyperperfusion of the

lower extremities. This condition effects a washout of

bone minerals, resulting in Charcot fractures, collapse


Figure 4. Roy’s adaptation model applied to case study: both Ms. T’s psychological inability to assess her health status or appreciate thedanger of infection from the ulcer and the restriction on her ambulation placed by primary care physicians most likely would have result-ed in a rapid deterioration of her general condition from immobility, psychological condition from isolation, and glycemic control, poten-tiating maladaptation and accelerating her demise. Intervention provided by a multidisciplinary Diabetic Foot Clinic approach was ableto return Ms. T to her pre-ulceration state. Follow-up potentially will build on this relationship and prevent future ulcerations as well asfacilitate better diabetic control.


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of the weight-bearing bones of the feet, and deformi-

ties.54,55 These patients frequently have unusual pres-

sure points along the plantar surface of their feet as

part of these deformities.56,57 Pressure ulcerations in

these patients can be very persistent and because of

the good blood supply, these ulcerations resist infec-

tion. It is not uncommon for a patient to report an

ulcer persisting for a year or longer.

People with arterial insufficiency and claudication

may progress to ischemia, requiring surgical interven-

tion where possible. People who have arterial insuffi-

ciency usually do not have Charcot fractures and

deformities. Commonly, they present with other types

of foot deformities such as bunions, hammer toes, and

the like but their ulcerations are less likely to develop

on the plantar surface. The pain these patients experi-

ence in their feet and legs from chronic ischemia leads

to decreased ambulation unless accompanied by

decreased sensation from neuropathy. These patients

are not good candidates for TCC and complete assess-

ment by a vascular surgeon is required as part of the

full therapeutic work-up.32,58-60

Applying Roy’s perspective. Roy’s nursing theory

of adaptation breaks environmental “fields” down into

focal, contextual, and residual stimuli.1 The diagram in

Figure 4 illustrates how the particular focal issue is the

wound; the contextual issues include the elements in

the vicinity of the wound that have an immediate

impact, including the patient’s physical reaction to the

wound. The residual stimuli are the uninvolved envi-

ronmental factors. The TCC contained the focal and

contextual stimuli and created a rigid “wall” separat-

ing the residual stimuli, keeping the contextual stimuli

constant. Roy’s principles of adaptation to the external

environment, or even more importantly, how isolating

the focal maladaptive element (the wound) and

adjusting the environment to effect healing of the

organism underscore the approach to Ms. T’s care.


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Because the TCC is changed only once a week, the

high levels of moisture and microbes needed to be

addressed. Many different dressings and combina-

tions of dressings were tried. A combination of

nanocrystalline technology and moisture-control

foam seemed to provide the sensitive balance need-

ed to heal this wound. Careful weekly assessments

of each successive treatment revealed the wound

healing dynamic. By adhering to Roy’s nursing the-

ory principles, the wound finally was healed.

Initially, the goal for treating Ms. T’s foot ulcer

was complete healing. However, as time passed, this

goal changed to preventing the ulcer from worsen-

ing. This change in prognosis was carefully and

clearly discussed with Ms. T and her family on sev-

eral occasions at the behest of the clinic staff. They

were content with continuing casting with this new

goal in mind, but also maintained a realistic but

reserved hope that some new dressing would even-

tually heal the wound. In the meantime, Ms. T and

her family were happy with her lifestyle while she

was wearing the cast, expressing feelings of confi-

dence that the cast was protecting her wound and

preventing infection and possible amputation. Once

the ulcer healed, Ms. T was carefully assessed on a

regular basis so new ulcerations would be treated

promptly while they were still small, effecting rapid

healing and allowing her to return to wearing her

custom-molded shoes.

Case Report PostscriptMs. T was casted for and received diabetic cus-

tom-molded shoes 5 years after she first presented

at the VMH DFC and the subsequent initiation of

the TCC. Her psychiatric idiosyncrasies are a chal-

lenge and a barrier to her learning and following

instructions.61,62 She continues to refuse home care

visits or assistance. She chooses to stay in her own

apartment rather than become a resident in an

adult care or skilled nursing facility. She remained

ulcer-free for 7 months, then over a period of 15

months, re-opened her wound three times.

However, because she is reliable about checking for

drainage on her socks when retiring and immedi-

ately arrives in the clinic when drainage appears, the

wounds are addressed while they are still small and

superficial. Nanocrystalline moisture control barri-

er foam dressing has been used with TCC to re-heal

the ulcer two more times and she is currently

receiving the same therapy for the third recur-

rence.10 She has been re-casted for a new pair of cus-

tom-molded shoes to prevent another recurrence.

Ms T’s blood sugars for the most part have

remained within normal range. She attributes occa-

sional elevations to dietary indiscretions, especially

during holidays and visits to her family who, thanks

to the care provided, she now can frequently visit.

Avoiding amputation is the underlying premise and

goal of diabetic foot centers modeled after the HRSA

LEAP program. Ms. T will require close maintenance

care and foot assessments every 6 weeks, but this is a

slight inconvenience to the patient and small cost to

her health insurance compared to that of an amputa-

tion and the comorbidities that frequently accompany

that drastic alternative.

ConclusionHealing foot ulcerations can be frustrating and

tedious, especially when clinicians are tempted to

view success in narrow time frames. Yet clinicians

dealing with diabetic foot ulcers find that even with

fast-healing ulcers, the underlying chronic condi-

tion frequently causes repeated breakdown of the

same wounds or the appearance of new wounds in

other areas of the feet and legs. A harsh reality at

many for-profit wound centers is the termination of

treatment before achieving closure of an ulcer to

keep wound closure statistics competitive. One of

these for-profit centers had discharged Ms. T as

soon as it became apparent that her wound-healing

time would extend beyond their longest statistic.

True to the message of Sister Roy, the authors’

clinic is committed to its patients regardless of how

long it takes to heal their wounds. Sometimes goals

have to be adjusted and patients and clinicians must

be resigned to the inevitability of a non-healing

wound. The goal might be to keep the wound as sta-

ble as possible, mobilized, and free of infection,

using treatments that maximize the quality of the

patient’s life. This does not mean that new strate-

gies, different clinician consultants, or additional

referrals will not be sought. The mission of the



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authors’ clinic is to provide the highest quality of

care possible while keeping patients informed of all

options and respecting their care choices.

Total contact casting afforded Ms. T’s clinicians

some measure of control of her wound, keeping all

the variables constant and the pressure off to facili-

tate accurate assessment of each local wound treat-

ment. Consideration of the whole patient and

understanding the interactions, the ebb and flow

that is ongoing among the focal, contextual, and

residual stimuli as in Roy’s model, is key to treating

any patient, especially those with complex condi-

tions such as diabetes mellitus. - OWM

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50-65 OWM0608 Farid · Callista Roy’s1 perspective on the human experience can be easily applied in wound care. On the sensitive relationship between man and the environment, Sister

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