Under the Off-Load: A Pilot Case Series to Identify
Ideal Dressings to use Under Total Contact Casts

Introduction:
It is well stated in the literature that Total Contact Casting is a standard of care for off-loading of neuropathic ulcers of the plantar surface. Another standard of care is to provide a moist wound healing environment. Evidence to support appropriate wound dressings under Total Contact Casting is currently unavailable despite recognition that the wound environment and thus the amount of drainage changes as the wound progresses towards healing. This pilot case series of three patients with plantar based diabetic neuropathic ulcers uses two dressings, a five layer silicone foam with absorbent polymer and moisture retentive backing dressing (SF)* for low to moderate drainage and a non-adherent super-absorbent (SAP)† polymer dressing for moderate to high exudate levels.

Clinical Problem:
Many Total Contact Casting kits include a generic, open-cell, polyurethane foam dressing (OCF). These dressings do not absorb or retain fluid in a moderate to high exudate environment which can lead to maceration and non-healing. Furthermore, due to the high moisture vapor transmission rate of OCF, wounds with low exudate may experience desiccation and result in the development of slough and biofilm.1

Methods:
This pilot case series evaluates the performance of two dressings under a Total Contact Cast‡. The 1st dressing is a five-layer silicone foam with super-absorbent polymer and moisture retentive backing for low to moderately exuding wounds (SF)*. The 2nd dressing is a non-adherent absorbent (SAP)† polymer dressing for moderate to high exudate levels. A total of 3 Wounds were assessed, cleansed, debrided if necessary, categorized by exudate level, and Total Contact Casting was applied for 7 days. The expected outcomes were to avoid maceration, increase in healthy granulation/epithelial tissue, and achieve maximum wear time of a Total Contact Cast.

Results:
All three of the pilot cases healed completely in acceptable time with no untoward complications. The important feature was that the changes in the amounts of drainage which were identified as the healing progressed were compensated for by changing the dressings based on the amounts of exudate identified. This effectively minimized associated peri-wound maceration, damage to the increasing granulation tissue and improved tolerance of their feet to the total contact cast.

Conclusion:
Total Contact Casting kits should consider including dressings for low-moderate and moderate-high exudate and cease adding the one-dressing-fits-all generic foam into the kit. Additionally, although foam dressings are lumped into single category, their individual traits such at total volume handling, exudate retention, and MVTR have erratic variation in function. The SF in this case series exceeded expectation and can be a standard of care unless exudate overwhelms the dressing in the 7 day expected wear. At that time, SAP should be used in place of SF to manage high exudate. Our experience is that this combination of dressings progresses wounds towards healing, enhances the clinical benefits and wear time of Total Contact Casting, and decreases the potential for wound healing complications.

Case History 1 45 year old Insulin-dependent diabetic male (IDDM) with a history of poor compliance presented with a plantar ulcer of 2 years duration. He had developed an acute Charcot's Arthropathy, misdiagnosed as osteomyelitis and had surgery to remove "infected" bone. He had ongoing significant drainage with periwound skin maceration and no evidence of healing. Course of Treatment: Aggressive debridement of the ulcer was performed with identified bone at the base of the ulcer. However, further workup did not demonstrate osteomyelitis. He was placed in a Total Contact Cast and SAP used due to concerns about the excessive drainage. With the drainage controlled, maceration resolved and offloading successfully managed, he went on to heal completely.

Initial Appearance – 4/20/16 Day 22 – 5/12/16 Day 45 – 6/06/16 Day 60 – 6/20/16

Case History 2 64 year old IDDM with a history of a Diabetic Neuropathic foot ulcer of the plantar heel. He had undergone surgery years before leaving him with a soft tissue deformity predisposing him to recurrent ulcers. Course of Treatment An aggressive debridement was performed with no bone exposure noted. He had moderate serous drainage from the ulcer and so SF was used to control the drainage without creating a dry wound base. Total Contact Casting was performed weekly with changes of the SF dressing. With the drainage controlled and offloading accomplished, he went on to heal completely. Initial Appearance 5/17/16 Day 14 – 5/31/16 Day 21 – 6/7/16

Case History 3 A 64 year old female with advanced rheumatoid arthritis and foot deformity presented with a 6 month history of a nonhealing ulcer of the right plantar foot. A surgery to correct this had incisional dehiscence. Topical dressings and an offloading boot were previously used unsuccessfully. Course of Treatment An aggressive debridement was performed with no bone exposure noted. Her significant serous drainage was treated with SAP and Total Contact Casting applied weekly for offloading. Over the next several weeks, the drainage decreased and the dressing was changed to SF due to decreasing wound drainage. With the drainage controlled and offloading in place, she went
	Initial Appearance – 5/17/16	Non-healing ulcer, initial appearance Side View	Day 7 – 5/24/16
	Day 35 – 6/21/16	Weekly SF Application	Day 63 – 7/19/16 Complete Healing