Christopher Bromley DPM discusses statistics about diabetes, obesity and the management of risk factors for diabetic wound ulcers. Dr Bromley examines the advantages and disadvantages of total contact casting with the newer materials and supports his statements with statistics and case studies. Dr Bromley demonstrates in detail the application and follow-up of total contact casts.
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Release Date: 03/16/2018 Expiration Date: 12/31/2018
Christopher Bromley, DPM
Chairman, Foot and Ankle Surgery
Vassar Medical Center
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TAPE STARTS – [00:00]
Male Speaker: Our next speaker is a good friend of mine, Dr. Chris Bromley, from New York. He’s involved with a number of institutions in that area, he is an experienced surgeon, excellent speaker.
And Dr. Bromley is going to share his thoughts with us on contact casting.
So please welcome, Dr. Chris Bromley.
Chris Bromley: I’d like to thank Dr. Schoenhaus for making flat foot great again. Good morning. I always thought this was the early slot until I was at ACFAS when we did the 6:30 lecture, and I’m reasonably sure that most of the people are still out from the night before.
So disclosures, unfortunately, I don’t own any stock in any of these companies. If I did, I would probably be somewhere warm.
Our objectives today is to understand sort of the overall approach to total contact casting. And that is our understanding of the diabetic patient, and some of the wounds concerns that we have. We can’t forget the principles of good wound care, good surgical debridement. It doesn’t matter how great a product is, whether it’s a total contact cast or an amnion graft, we have to still remember the same principles of addressing the risk factors.
Some of the didactic stuff that you guys are probably familiar with, we give this lecture to lots of different specialties. So overall, we know that in United States, we have a huge epidemic in obesity, and the byproduct of that is that a percentage of adults here in the United States and worldwide, the risk factor of diabetes is going up exponentially.
I have, with my own patients, have really been amazed at how important it is to talk about weight, and also blood sugar control and the risk factors. As staggering as this, to me, is the onset of childhood obesity.
Obviously in the previous lecture, we were talking about how to manage flat foot, but I’m willing to bet you that a lot of those kids with flat foot are also morbidly obese. And the fact that there are 41 million children under the age of 5 that are obese as of 2014 is pretty amazing.
So overall, the epidemic reported in 2012 is that about 30 million Americans or almost 10% of our population has diabetes. And the risk factors of that obviously you’re familiar with. And then also, patients are living a lot longer. And obviously, for those of you like me who 25 years ago spent time in nursing homes, nursing homes used to be respite care, now our nursing homes are pretty much skilled facilities where a lot of our patients have diabetes and PAD, and the risk factors of diabetes in reference to what we’re doing.
I mean in those days, we would go and cut their toenails and get out. You know, nowadays, all these patients have pretty significant diabetic foot complications.
So obviously, the factors and overall management of our diabetic patient before we even think about total contact casting, is, you know, what are we doing about their blood sugar? We’re talking to them about what they eat, what supplements they take, how they’re managing their blood sugar, what their hemoglobin A1c looks like, and then what happens to them if they don’t. You know, explaining and taking a few moments to explain to your patient that it’s not just a number, you know, that if your blood sugar is out of control, you know, you’re going to have other risk factors, you’re not going to have the immune function, you’re not going to have the sensation, you’re not going to have the immune function, your cells aren’t going to be able to communicate.
And I may be able to get you back together with the wound care, or total contact cast, but if you’re not managing your underlying disease, it doesn’t matter what I do, you’re going to be back three months with a new problem.
So although most of us are plagued with an EMR and filling out meaningless use, it’s really important for us to spend time with our patients and educate them as to what these risk factors are because if you don’t manage the patient, it doesn’t matter how great you manage their flat foot or manage their total contact cast, you have to take a few extra moments to educate them about their disease and what they can do. And we’re going to talk about that in some of the workshops later this morning.
So overall, these are some of the things that you’re familiar with, but obviously, there’s a big relationship between neuropathy and small vessel disease. I think I have a better understanding now than I even did 10 or 15 years ago when I was speaking about the role of autonomic neuropathy and how most of our patients have autonomic changes long before they even develop sensory changes.
And maybe like you, for many years, the only patients I ever was concerned about, were the ones who came in complaining of neuropathy. The ones that weren’t complaining or had loss of sensation, I wasn’t worried and we would treat them after they got the ulcer or after they got the Charcot. So I implore you to go after some of these risk factors earlier.
So obviously, the reason we’re here is that, we’re all talking about healthcare, whether you like Obama Care or Trump Care, we’re all talking about how well we spend our healthcare resources. And the most recent data on the cost of diabetic limb complications and your healthcare cost is 17 billion, which is huge. And we’re all going to be paid on outcome.
In the old days, you could see a diabetic ulcer every week, month after month after month, and you get paid to debride it every week. The new data that you’re recording through your EMR and the way healthcare is going is, the insurance companies and the governments can start to look at you and if you’re not getting this patient better quickly, the government is going to find something else for you to do.
I sit on a board of a 3-hospital system and we live and die by outcomes, and we live and die by how well we spend our healthcare dollars. And you know that nowadays, if you stay in the hospital more than 3.4 days, you have a problem. And if you get readmitted, you’re not going to be paid for it.
So those changes are coming to us in podiatry very quickly. We’re going to be paid based on how we manage our patients.
So the good news is there’s been some improvement. When I finished my residency in 1992, we used to call it the Bond Score Sequential Reduction [phonetic] [0:06:17], you know, patient would come in for an amputation of a toe and then they might come in for a few more toes, and maybe we would do a transmet and eventually if you were really lucky as a resident, you get to scrub in on the below knee amputation.
The good news is as of 2014, the CDC reports that the amputation rate has declined by 65% in the last decade, which is huge.
And I think the reason it has is that there’s a better understanding of peripheral arterial disease, there’s a better understanding in our community podiatry about what our options are and what we can do to prevent patients.
In our practice, just like yours, we would wait for the Charcot, we’ll wait for the diabetic ulcers. And now, if you take a more aggressive approach for your patients and looking for PAD, screening for it, screening for autonomic neuropathy, screening for sensory neuropathy and getting out in front of these patients and getting them into diabetic shoes. We can prevent a lot of these costs to the health care system and complications where patients by are getting on in front of it. But as I said, the education and awareness is our job.
So most of these numbers, you are familiar with. I mean, it’s a staggering number of diabetic ulcers, although the data is getting better. 20% of diabetics, which is approximately 6 million – I think it’s higher than that – will result in about 3 million hospitalizations, $17 billion we talk about health care dollars. And as there’s only 17,800 of us, we have a lot of work to do.
So the principles of diabetic foot care as we talked about, you are well aware, we need to control the butcher, control the patient, see our patients on a regular basis, implore that they should look after their feet, send letters to the PCP and avoid smoking and exercise.
So the diabetic wound care is as I said, it’s a whole picture. It’s not just the surgical debridement, it’s not just the biologics, it’s the whole picture. So when we talk about these patients, we have to evaluate where they’re at.
And I will tell you I spent a number of years working in a wound care center and I really hated total contact cast. It was messy, there was plaster everywhere, it was a pain more often than not. When I put a total contact cast on patients, I would be treating one wound but because they would walk all over my fiberglass cast or my plaster cast, they would end up with a new wound someplace else. So probably like you, I really was not interested in total contact casting. And over the last few years, there have been a number of companies who are here today have adapted this technology and it’s become a lot more user-friendly to the provider. And it’s obviously a lot more user-friendly because of the nature of the materials that we’ll investigate as for the patient.
So overall, remembering that the application of the total contact cast is only part of the offloading. The good surgical debridement, good wound dressings, controlling infection, controlling the blood sugar, evaluating the PAD, all of these things work together.
So what are our offloading alternatives? In diabetics, the most common offloading used by podiatrists in this room as well as other people is the surgical shoe. Unfortunately, it is the least effective because the patient can take it off. They can walk around their house without it. They may not use it at all.
A diabetic shoe is very helpful in preventing patient, but if they’ve gotten to the point where they’ve got an ulcer, the diabetic shoe really isn’t going to control them. Again, they can take it off.
TORCH walkers and CROW boots are useful but they usually take a long process to get them approved and to get them made. And I don’t know about you but I’m always amazed that I send a patient in and I would have prescription for a TORCH or a CROW and they come back with this Herman Munster-looking device that rarely does a good job.
And I have in very few cases ever had any of them work successfully.
So what happens is the total contact cast has in the literature, not just my opinion, but in the literature, considered to be the gold standard of offloading. It’s indicated for non-infected ulcers, obviously Charcot neuropathy, post-op Charcot reconstruction, delayed or primary closure, and even pre-ulcer. If you’ve got somebody who you think is not controlled, that you can see they’re starting to break down, this is a great way of offloading them and ensuring compliance.
Contraindications obviously infection is the big one. If you have a patient who has severe ischemic disease that you’re concerned that applying a total contact cast may be occluding other circulation worse. The non-compliant patient – we do have occasional non-compliant patients in our practice – if you don’t think you can trust them or they’re going to try to cut it off on their own, again. Allergy to cast material is a contraindication and obviously DVT and compartment syndrome.
So if you have patients, make sure when you’re deciding on a total contact cast that you’ve looked at the contraindications, indications, documented your vascular condition, documented that they don’t have symptoms of DVT or compartment.
So if you look at offloading, if you look at the graphic up here, you’ll see that there is a significant reduction in the barefoot, which is on the left. You can see where the patient is loaded. And when you apply the total contact cast correctly, you’re going to get significant offloading. And this is offloading pressure without using any dispersion padding in that particular area.
The other graphic is showing somebody barefoot weight versus a conventional total contact cast versus one that has got some additional offloading in it, so significant improvement.
This is a picture of one of the total contact casts. Downside of this particular picture is, from a learning perspective, it’s been applied poorly. Before you put the more rigid material on, you’ve got to get this foot and ankle to 90 degrees so that they can actually walk on it.
So what is the evolution of total contact cast? The typical device that I had at the beginning of my practice, as you did, was fiberglass and plaster. Unfortunately, they are rigid. They are rigid construct, there was no pumping involved. The newer total contact cast materials available are flexible and the flexibility makes the difference. And it makes the difference because when the patient weight bears in the flexible cast, it actually acts as a pump, so it affects the venous return as well as the arterial pumping into the periwound area.
And when this particular material and literature were presented to me a couple of years ago, I was really not a believer. But after applying it – and I’ll show you some of my cases – it’s particularly helpful.
On this particular graphic, this is another total contact cast alternative. I always think this is great when I see these pictures. There’s not a chair in my office that I can get a patient in this position. So most of the time, a patient sitting in a chair with a foam block under their knee and I’m applying it by myself without the assistance of anybody else because my staff is usually busy helping either patients or other providers.
So the total contact cast data, why and why not, obviously the total contact cast is supported by a numerous random clinical trials, multilevel studies, and it’s been shown to be at 90% heal rate for diabetic foot ulcers and the typical heal rates reported in the literature, between five and eight weeks.
I will tell you, my experience is that I will typically get ulcer healed even in a difficult Charcot and we’ll look at some cases within two or three applications and I changed my total contact cast weekly. Total contact cast has obviously been a part of these studies in reducing the risk of amputation.
There are a number of diabetic applications. There’s only 4% of diabetic patients that actually receive total contact cast and why is that? I think the reason that the number is so low and the utilization is so low is because total contact cast is really thought to be by a lot of providers to be difficult to apply. And I think that a lot of us weren’t familiar with the newer technology. So hopefully one of the things you’ll take away from today’s lecture is that it’s easy to apply. I'll show you how easy it is and that you don’t have to worry about those other ulcers or other irritations occurring because if you apply it correctly, you’re not going to have that happen.
So this is from diabetes care, an article showing how effective total contact cast is and why you can use it.
It ensures an excellent way to offload. It ensures patient compliance. I can’t tell you enough. I've had patients in CROW boots, TORCH walkers for various ulcers and when I put them in a total contact cast, miraculously they heal.
Well, I thought their TORCH walker or CROW boot was great, but I think it’s the fact that they’re forced to be in it 24 hours a day and it reduces the sheer force, reduces the toe off pressures and reduces pressure in the first metatarsal greater than 70%, which is pretty significant.
I promised you some cases, this is one of my patients. This is a morbidly obese diabetic who’s had previous Charcot reconstruction by an orthopedic friend of mine. He’s had surgery by me and no matter what I do, I can’t get this plantar wound to heal. I have debrided it. I’ve thrown biologics on it. I've taken it to the operating room and it always breaks down.
He’s got a difficult Charcot flat foot to control. The picture here is showing you pre-debridement. This was debrided down. This is probably the least aggressive debridement. Again, it doesn’t matter how great total contact cast, you can’t divert from the principles of good wound debridement.
So in this case, we did a debridement and then you’ll see him in this total contact cast. This is not one of the prettiest ones I've ever applied. You see I've got some K-tape here. This is a flexible total contact cast by one of our sponsors, and then you’ll see him standing in a surgical shoe sort of a higher type with a rocker bottom and this is him coming in for the first change.
Now one of the things that I want you to notice is, I didn’t show you this in the other picture I should’ve. His edema was really uncontrollable, very, very difficult foot to control, and this is him coming in after I removed the total contact cast.
And the one we’re using in this study, you can remove with scissors, so very, very easy to do. I did put a little bit of silver dressing on the wound. This is it before I've removed it. The whole foot contour and light contour has changed, and then we take a close-up look one week out. You can see a significant improvement with just one application.
So this is him coming in the second week. You know, even though the literature says we don’t have to do any offloading, I wanted to show you this case because just by habit, I think I off loaded it and the problem with offloading is you really don’t need to.
And if you look at what happened to the foot when I offloaded it and he was standing on it, the offloading actually is not helping my capillary fill time, because I'm pushing in on the periwound area and that’s going to affect my inflow.
So you got to – because this is one of those early learning curves for me, I wanted to show you some of the successes and I got away from doing offloading even though I didn’t really have a negative effect, but that’s two weeks later, post-debridement, he is pretty much healed.
Here’s another case, a difficult case obviously, this patient has been in the practice for a number of years. He – you know, he’s been offloaded. He was actually in a CROW boot and came in with his wound, claims he wears the CROW boot all the time, and that’s – we know, you and I, that that’s probably not true.
So we get this debrided down. There’s really no pus here, no evidence of infection. The foot is not warm, so none of the contraindications we worry about here. And then this is the day one of total contact cast, get it all measured, get it applied.
I would tell you that subsequently, I would make this a little bit longer to kind of protect that toe. I did put them in surgical shoes that was offloaded as well, and this is his coming in for his second application.
You can see a significant improvement, foot and leg look better. This is using a silver dressing packed in there and then we covered over and then we put him in a cast. And you could see when he came in for that next – there’s a significant reduction in the leg edema. And I think that’s because of the compliance and control, and then also the pumping action. So significant improvement.
This is showing you what it looks like when it comes off. In some of the studies, particularly in Europe, they advocate reapplying a total contact cast. I've tried reapplying them. I don’t think it’s beneficial. You get such significant reduction in the edema by reapplying a total contact cast, you lose that elasticity and you lose that control of the edema. Obviously, you know, when you – this is a week old. This is a week old. We’ve taken them off and they look pretty good where as if you walk on the more rigid cast, you know we get a much different outcome. So this has got a week’s worth of walking on both these.
So how to apply? Obviously, there are a number of different companies out there. It’s a good idea to have these things in your office.
There are some very inexpensive alternatives. No substitute to good debridement, preparing the area. You can use a regular dressing, a silver dressing, whatever your preference is. Managing the periwound area is important. Next thing is as I said, usually patient is sitting on a chair, we put a little foam block under the leg, and you’re going to use a synthetic stockinette, stay away from the cotton stockinette. It does make a difference. And when you put it on, you want to make sure that you put it on that there’s no wrinkles. We do some synthetic padding against synthetic not cotton around the toes, it kind of wrap it around that area because you want to protect them.
And then over top of the first layer of synthetic stockinette, you’re going to put some tape. There’s a number of vendors out here that will help you make the choice that works best for you. It doesn’t have to be particularly thick. All bony prominence is in the back, over the Achilles, on the front of the tibia down over the ankle, medial and lateral malleoli. I’ll put some over the 1st and 5th met.
And then you’re going to put a second level of stockinette over top. Again, it’s synthetic. You want to make sure it’s nice and flat foot. Have the patient hold their ankle at 90 and then you’re going to put the first layer of flexible fiberglass material over top.
In the study guide, in the handout, they’re showing you sort of moving from superior to inferior. The only time I’ve ever had a complication with any of the newer materials is when I went ahead and just out of habit for 25 years did the first layer of stockinette, put a layer of fiberglass on and then, “Oh, I forgot to put the other layer,” and I just put the other layer of stockinette over top, don’t do that. The two layers of stockinette work together to prevent friction. Because the only complication I’ve had creating another wound is when I put it on incorrectly.
After you get that done, you’re going to put some semi-rigid or rigid reinforcement in the area. It’s going to come around the bottom of the foot, not the back of the leg, or up either side, whichever particular brand you’re using.
The reason I like this particular application as opposed to the roll-on application that you’ve seen is that there’s the whole one size fits all thing. I think you can do a much better job adjusting to the contours of the leg with the wrap fiberglass. It looks nice and easy to roll something on like a sock. There’s nothing wrong with that. If it works for you, great.
So once we get the rigid on, we put another layer of fiberglass, is the technique I use, is sort of a U-wrap and a foot bed and then I wrap it all together with another of the semirigid fiberglass.
Holding the position at 90, as I said earlier on the talk, is really important because obviously they’re going to be walking on this, making sure that you’ve left enough room. Now, in the beginning when you wrap those toes, you did that so that you have lots of room, so that your fiberglass is non-impinging on those very delicate toes. And then you’re going to cut out that area and put some padding in it. The ones I showed you, my pictures were not particularly pretty but they worked well.
The advantage of some of the newer systems is that if you need to remove it, you can remove it with a scissor as opposed to a cast cover. I think that makes the patients feel a lot better. And basically, you’re just going to use the scissor. You go right up the front of the cast and because you have two layers of stockinette plus the protective tape that you put on, it comes off very easy.
I do guard the scissors that I use for total contact cast with my life. My associates that are here will tell you that if they touch them they could get in trouble because you do need a nice, sharp pair of scissors and most of the vendors that are here provide them.
Your choice for surgical shoe to offload is sort of up to you. This is more sophisticated. We basically have surgical shoes and casts in our office. We don’t have as many choices as we used to but there are a number of alternatives out there.
This is again showing you how easy it is to remove with a scissor. You kind of come right down the front, you go right down the first layer of fiberglass and then the second. And then because it’s flexible in nature, it’s really easy to get off.
In the literature on the website for a couple of vendors, they talk about re-applying it. It’s real big in Europe to re-apply. I don’t think it’s beneficial. I think you get such significant reduction in the edema, that re-application sort of defeats the purpose because you’re putting something on that we took a mold of last week. So I don’t re-apply. And in a particular literature, they’re taking it off, they’re putting it back on and they put another layer on. I don’t agree with that. It didn’t work for me.
So as a conclusion, total contact casting is the gold standard for offloading a diabetic foot. If you haven’t done it in a while, I encourage you to visit our sponsors and vendors to see what they have.
They’ve got great workshops, great educational materials for you. It’s not particularly hard to do.
The total contact casting that we have now is flexible. So it avoids the impingement and the areas of irritation that the rigid fiberglass and plaster applications that we had. It is very safe with minimal risk. The only total contact cast wounds that occurred in my hands were because I applied it incorrectly. So if you follow the principles, follow the steps the way you’re supposed to, you’re going to do well.
It doesn’t really require a lot of assistance. I basically have a foam block that goes under the knee, patient sitting in a chair. I have everything laid out, a little bit of water, and it takes me about 8 to 10 minutes to apply, and I’m not Edward Scissorhands. It’s not that I’m that fast, it’s pretty easy as long as you follow the stepwise.
The application of the synthetic stockinette is really important. Don’t use your older cotton stockinette that you might have in your practice. Use the newer tapes. They work great, they’ve got some padding. You don’t need a lot of bulky padding. Once the stockinette is on, the total contact cast goes over top of that and it’s molded. It’s really the application and that’s what does the offloading. You don’t have a lot of padding there.
And it’s very inexpensive. These kits don’t cost a lot of money. They don’t cost what a TORCH walker or CROW boot costs. And typically, in my hands, it’s two or three applications and the patient is usually healed. And they do quite well. And as I said, I think it really is about compliance. We’re offloading but it’s also about compliance. In the old days, I said the reason hyperbaric oxygen works so great in our wound care center was because we offloaded the patient for two hours a day, five days a week and we looked after their wounds every week. So I think the reason total contact cast works so well is it stays on, it’s great for compliance, it does good offloading and it’s inexpensive and it gets you the outcomes that you need.
So thank you very much for your attention. Thank you for getting up early. If you have questions, I’m here all weekend. And thanks for coming and thank to the team from Present.
TAPE ENDS - [27:08]