Total Contact Cast after Sole Free Flap Reconstruction for Early Ambulation

Abstract

Background Free flap reconstruction can be performed in patients with chronic limb-threatening ischemia (CLTI). However, early walking training may increase the risk of wound dehiscence and prolong hospitalization. Total contact cast (TCC) treatment effectively addresses diabetic plantar ulcers by immobilizing the foot and distributing weight away from the ulcer area. This study aimed to assess the effect of postoperative TCC use on early limb loading and hospital stay in patients with CLTI with free flaps.

Methods Patients with CLTI who underwent free flap reconstruction between 2006 and 2023 were enrolled in this study. Postoperative time until weight-bearing initiation was compared between the TCC (n = 5) and non-TCC groups (n = 7).

Results The time to the initiation of weight-bearing on the affected limb was 52.3 ± 33.2 days in the non-TCC group and 19.8 ± 3.56 days in the TCC group (p = 0.105). The wound dissection rates were 42.9% (3/7) in the non-TCC group and 20% (1/5) in the TCC group (p = 0.408). At discharge, 28.6% (2/7) of the non-TCC group and 20% (1/5) of the TCC group had ulcers (p = 0.735). The average flap size was 149 ± 69.1 cm² in the non-TCC group and 95.6 ± 73.1 cm² in the TCC group (p = 0.268).

Conclusion Postoperative TCC use after free flap foot reconstruction may lead to early weight-bearing of the affected limb. Further studies with larger numbers of cases are needed.

Keywords

chronic limb-threatening ischemia - total contact cast - free flap - diabetic foot ulcer

Authors' Contributions

Y.Y.: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Visualization; Writing: original draft; Writing: review and editing, Y.A.: Resources; Supervision. M.B.: Investigation; Resources. S.M.: Investigation; Resources. H.Y.: Investigation; Resources. S.N.: Investigation; Resources. K.M.: Supervision. I.H.: Supervision; Funding acquisition; Project administration.

Ethical Approval

This study was approved by the Ethics Committee of Tokushima University Hospital (approval number: 3943-2).

Patient Consent

Informed consent has been obtained from the patients for the use of clinical photographs and medical images.

Publikationsverlauf

Eingereicht: 12. April 2024

Angenommen: 03. November 2024

Artikel online veröffentlicht:
11. März 2025

• References

• 1 Centers for Disease Control and Prevention. Methods for the National Diabetes Statistics Report. 2023. Accessed October 26, 2023 at: https://www.cdc.gov/diabetes/data/statistics-report/index.html
• 2 International Diabetes Federation. IDF Diabetes Atlas, 10th ed. Brussels: International Diabetes Federation; 2021. Accessed October 26, 2023 at: https://diabetesatlas.org/data/en/
• 3 Aboyans V, Ricco JB, Bartelink MEL. et al. Editor's Choice - 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg 2018; 55 (03) 305-368
• 4 Conte MS, Bradbury AW, Kolh P. et al; GVG Writing Group. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69 (6S): 3S-125S , e40
• 5 Hashimoto I, Abe Y, Morimoto A, Kashiwagi K, Goishi K, Nakanishi H. Limb salvage and vascular augmentation by microsurgical free flap transfer for treatment of neuropathic diabetic foot ulcers. J Med Invest 2014; 61 (3–4): 325-332
• 6 Santanelli F, Tenna S, Pace A, Scuderi N. Free flap reconstruction of the sole of the foot with or without sensory nerve coaptation. Plast Reconstr Surg 2002; 109 (07) 2314-2322 , discussion 2323–2324
• 7 Han Y, Han Y, Song B, Guo L, Tao R, Chai M. Free medial plantar flap versus free dorsal myocutaneous flap for the reconstruction of traumatic foot sole defects. Ann Plast Surg 2020; 84 (5S Suppl 3): S178-S185
• 8 Abdelfattah U, Elbanoby T, Elmofty AM. et al. The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: clinical experience with 18 cases. Microsurgery 2022; 42 (08) 800-809
• 9 Lee ZH, Daar DA, Stranix JT. et al. Free-flap reconstruction for diabetic lower extremity limb salvage. J Surg Res 2020; 248: 165-170
• 10 Yamashita Y, Hashimoto I, Goishi K, Fukunaga Y, Abe Y, Nakanishi H. Reconstruction of metatarsal bone defects with a free fibular osteomyocutaneous flap incorporating soleus muscle. J Plast Reconstr Aesthet Surg 2013; 66 (02) 277-280
• 11 Bus SA, Armstrong DG, Crews RT. et al. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40 (03) e3647
• 12 Armstrong DG, Stacpoole-Shea S. Total contact casts and removable cast walkers. Mitigation of plantar heel pressure. J Am Podiatr Med Assoc 1999; 89 (01) 50-53
• 13 Tickner A, Klinghard C, Arnold JF, Marmolejo V. Total contact cast use in patients with peripheral arterial disease: a case series and systematic review. Wounds 2018; 30 (02) 49-56
• 14 Sibbald RG, Ayello EA. Total contact cast for diabetic foot ulcers: an underused “gold standard”. Adv Skin Wound Care 2019; 32 (06) 247
• 15 Mills Sr JL, Conte MS, Armstrong DG. et al; Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 2014; 59 (01) 220-34.e1 , 2
• 16 Riopelle A, LeDuc R, Wesolowski M, Schiff AP, Pinzur MS. Risk of complications with the total contact cast in diabetic foot disorders. Foot Ankle Spec 2021; 14 (01) 25-31
• 17 Yamashita Y, Abe Y, Nagasaka S. et al. Relationship between fluctuations in skin perfusion pressure values and wound healing in patients with chronic limb-threatening ischemia undergoing hemodialysis. J Med Invest 2022; 69 (3.4): 294-298