ABBAS SEE,1 MANJULA MALLIKAGE,1 JACQUELINE MILDRED,2 ANDREA FRIEL,2 MARY GRAY,2 SAYYIED KIRMANI,1 MICHAEL PIERIDES3
1 Department of Trauma and Orthopaedics, Kettering General Hospital, UK
2 Multi-Disciplinary Diabetic Foot Team, Kettering General Hospital, UK
3 Community Diabetes Centre, Kettering General Hospital, UK
Address for correspondence: Abbas See
Trauma and Orthopaedics Department, Kettering General Hospital, Rothwell Rd, Kettering, NN16 8UZ, UK
E-mail: abbassee@gmail.com
Br J Diabetes 2022;22:ONLINE ONLY
https://doi.org/10.15277/bjd.2023.404
Key words: diabetic foot ulcer, total contact cast, multi-disciplinary team
COVID-19 led to a national crisis. Services needed to change, prevention of contracting COVID-19 becoming paramount. Diabetes is a major problem, of increasing prevalence, faced by the NHS.1 Diabetes is associated with increased risk of COVID-19 mortality.2 A major complication of diabetes is diabetic foot ulceration (DFU) secondary to peripheral neuropathy and vascular insufficiency as well as mechanical factors such as reduced joint mobility or foot deformity.3 Left untreated, these ulcers can lead to amputation.
A mainstay of treatment is offloading, to reduce pressure on the ulcer and the surrounding soft tissue and to precipitate wound healing. There are a number of different removable devices for offloading but non-removable total contact casts (TCCs) are widely regarded as the gold standard.3-5 A TCC is a semi-rigid or rigid fibreglass cast that extends from the toes to just below the knee. Minimal padding is applied to the malleoli and the DFU: this allows total contact of the whole foot while isolating the DFU to reduce pressure and promote healing.3 However, despite a large volume of evidence,3,6-9 TCCs remain unpopular with most patients. TCCs can also be further modified by attaching a Bohler iron hoop to the plaster. The hoop rests below the plantar surface to allow for greater offloading.10
In our institution, DFU is managed by a multidisciplinary team (MDT) approach (diabetologists, antimicrobial pharmacists, orthopaedic foot and ankle surgeons, podiatrists and plaster technicians). Due to COVID-19 measures there was a significant reduction in use of plaster, which gave an opportunity to provide TCC treatment.
The aims of this study were to assess healing and cost-effectiveness of treatment with TCC.
All patients who had a TCC for DFU after January 2020 were identified. Selection criteria for TCC treatment included being ambulatory, having a chronic non-healing DFU, exhaustion of other conventional offloading treatments and an adequate vascular supply. TCCs were changed on a weekly basis to monitor wound progression, with sharp debridement and redressing. Retrospective data collection included baseline characteristics and costs of treatment.
Five patients were included. The mean age of the patients was 56 years. All patients had a diagnosis of Type 2 diabetes (T2D). In all cases, the ulcers healed after TCC treatment and the average time to healing was seven weeks. The average BMI was 31 kg/m2. There were no requirements for surgical debridement.
A summary of each patient can be found below.
During the time period of this study, none of the patients developed a new ulcer. Following successful treatment of the DFU, the patients went on to wear therapeutic footwear with bespoke total contact insoles.
The results clearly show a positive outcome as all patients had fully healed ulcers after application of a TCC. Patients also had fewer courses of antibiotics after starting treatment, which indicates a lower infection rate. The improvements in healing rate in this cohort have been positively received within the team and further work has been undertaken in consolidating service pathways for the optimal patient journey. In particular, patient 4 is a prime example to show that the early use of TCC can facilitate rapid healing.
Cost of treatment was far greater prior to TCC administration in all five patients. The average cost of treatment was approximately 13 times higher prior to TCC. This is unsurprising given that all the patients had fewer outpatient appointments and fewer courses of antibiotics after commencing TCC. Despite the higher cost of TCC compared to other offloading devices, overall cost was reduced due to the lower demand on outpatient services. The reduced number of appointments also have the added benefit of reducing the risk of contracting COVID-19.
A potential risk of TCC is that the ulcer cannot be regularly reviewed due to the presence of the cast. To circumvent this, casts are often windowed or removed and reapplied to assess the patient for any ongoing infection. Although this incurs a greater cost in materials, the overall cost is reduced as it avoids inpatient admissions.
In conclusion, an MDT approach was delivered successfully to a group of patients who had long-term foot ulceration. The use of TCC provided adequate offloading and in turn fewer hospital bed stays, less antibiotic therapy, fewer outpatient appointments and improved patient quality of life and patient experience. The result was substantial cost savings. The use of TCC would greatly improve our service as it both enhances patient care and reduces the financial strain on our department.
Conflict of interest MP has received payment or honoraria from Adtec, Novonordisk and Eli Lilly. The rest of the authors have no competing interests to declare.
Funding None.