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Just reading around total contact casting and note that dialysis seems to be a contraindication, as far as I can tell due to swelling/fluid related fluctuations.

The prospective client has a chronic ulcer beneath the 1st mtp, neuropathy , good palpable pulses and is dialyised . I haven't noted any significant changes with fluid about the limb.

The lack of progress is frustrating and not having any real experience in total contact casting am wondering if anyone out there could share there experiences with clients on dialysis.

Kind Regards
Greg

ps I don't know if he has tried any prefab' boots that offload, it's on my list to check out. Unfortunatley I'm not in the region regularly

 

Contact casting (TCC) is probably not rigidly contraindicated in people on dialysis. However, as with anything in this most fragile patient population, managing their integument is very important. For this reason, one might want to change the TCC more frequently, particularly at first, to reduce the risk for any sliding in the cast resulting from its ability to reduce edema.

Another alternative might be the "instant" TCC (taking a DH pressure relief walker and wrapping it with plaster to make it less easily removable). The same precautions apply, however. Either way, I do wish you and your patient well.

Cheers, -DGA




David G. Armstrong, DPM, PhD
Professor of Surgery and Director
Southern Arizona Limb Salvage Alliance (SALSA)
University of Arizona College of Medicine

http://DiabeticFootOnline.com/
http://DiabeticFootOnline.blogspot.com/ (blog)
http://Twitter.com/dgarmstrong (Twitter feed)

 

Greg, I guess it's horses for courses. Your patient assesment has determined which offloading methodology is suitable for that patient. My concern with any modality which covers the heel and has the patient lying down (during dialysis, in bed at night) with the heel under pressure, is that it may cause a pressure sore. (Recent experience has this in the forefront of my mind !)
Regards Laurie Foley
Chief Podiatrist
Fremantle Hospital

 

Daer Laurie

Was this "recent experience" involving a TCC or some other dressing/device?

Yours truly,


Richard Kuhn
Valley, Alabama, uSA

 

Hi Richard,
The device was a CAM Walker (aka Air cast walker) . It was a complicated situation. Diabetic, neuropathic feet, successful kidney/pancreas transplant of 5 years. He had an ulcer on the Left mid foot (quiesent Charcot ,using an alternate lightweight device) when he fractured his RIght navicular so was in the Air Cast walker for that. He had used the device for many weeks without incident when he presented with a necrotic Right heel pressure ulcer and Right 5th toe necrosis.
The attending vascular surgeons were of the view that his lower limb vasculature had decreased in the last 12 months. I think he may have been resting at home with his leg elevtated so the heel was in contact with the base of the device.
Regards Laurie Foley
Fremantle Hospital
Western Australia

 

Dear Laurie,

Just trying to make sure in my mind what was going on. If the patient had swelling in a TCC, then if it reduced, I could see how a pressure point would develop, but barring that, I figured it would have to be misapplied to rub. The non-compliant patient can certainly take the walker off, unless it is secured as Dr. Armstrong wrote with overlying plaster. Of course, patients always listen and obey our instructions and when they develop a problem, calling immediately is high on their priority list.

I had to wonder in the original thread, just how much equinus is involved with the patient. If it is significant, then having a TAL or gastroc recession might be of significant benefit. Where I practice in Alabama, we do not have this allowed in our license, so I have to refer those patients to orthopedists, but the results have been uniformly satisfactory and resistant ulcers have cleared.

Y'all have a great weekend as I run on to watch some soccer games in Mississippi with daughter. She's preparing to play in college and that takes us around the Southeast USA to play against the better teams.

Yours truly,


Rick Kuhn
Auburn, AL, USA

 

TCC can be very useful in managing/healing chronic foot wounds that fail to respond to regular wound care In particular Neuropathic ulcers where pain is either deminished or not present. I work with a very good othotist who oftern uses a diabetic walker or simular combined with a custom total contact insole fitted to the the walker.

have not tried a instant total contact cast by applying synthetic casting tape to make it not removable but i believe there are benifits to doing this.

re clients on dialysis I would think it bepends on the individual client. the fluid balance is a problem. I think a daibetic walker might be easier to remove if there is a problem, of course the walker needs to be the correct one and fitted but may be worth a try.

Suggest you might want to discuss with the renal team regarding your client

Chris