Forefoot Offloading: Removable Cast Walkers Superior?!

This compelling study from our colleagues at Washington University in St. Louis, USA. 

In essence:
Forefoot offloading: RCW > TCC
Time to healing: RCW = TCC
Proportion of patients healing: RCW < TCC
Therefore: We might keep trying to make our devices less easily removable in neuropathic, non-infected, non-ischemic forefoot ulcers. 

Clin Biomech (Bristol, Avon). 2011 Apr 13. [Epub ahead of print]

Removable cast walker boots yield greater forefoot off-loading than total contact casts.

Source

Applied Kinesiology Laboratory, Program in Physical Therapy, Washington University School School of Medicine, St. Louis, MO 63110, USA.

Abstract

BACKGROUND:

Elevated plantar loading has been implicated in the etiology of plantar ulceration in individuals with diabetes mellitus and peripheral neuropathy. Total contact casts and cast walker boots are common off-loading strategies to facilitate ulcer healing and prevent re-ulceration. The purpose of this study was to compare off-loading capabilities of these strategies with respect to plantar loading during barefoot walking.

METHODS:

Twenty-three individuals with diabetes, peripheral neuropathy, and plantar ulceration were randomly assigned to total contact cast (n=11) or removable cast walker boot (n=12). Each subject underwent plantar loading assessment walking barefoot and wearing the off-loading device. Analysis of covariance was used to compare loading patterns in the off-loading devices for the whole foot, hindfoot, midfoot, and forefoot while accounting for walking speed and barefoot loading.

FINDINGS:

For the foot as a whole, there were no differences in off-loading between the two techniques. Subjects wearing cast walker boots had greater reductions in forefoot peak pressure, pressure-time integral, maximum force, and force-time integral with respect to barefoot walking. Healing times were similar between groups, but a greater proportion of ulcers healed in total contact casting compared to cast walker boots.

INTERPRETATION:

In subjects with diabetes, peripheral neuropathy, and plantar ulceration, cast walker boots provided greater load reduction in the forefoot, the most frequent site of diabetic ulceration, though a greater proportion of subjects wearing total contact casts experienced ulcer healing. Taken together, the less effective ulcer healing in cast walker boots despite superior forefoot off-loading suggests an important role for patient compliance in ulcer healing.

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