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The Journal of Bone and Joint Surgery (American). 2004;86:2714-2719
© 2004 The Journal of Bone and Joint Surgery, Inc.

Effect of Initial Weight-Bearing in a Total Contact Cast on Healing of Diabetic Foot Ulcers

Charles L. Saltzman, MD1, M. Bridget Zimmerman, PhD1, Ryan L. Holdsworth, BS1, Susan Beck, RN1, Heather D. Hartsell, PhD1 and Rita A. Frantz, PhD1

1 Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics-JPP, 200 Hawkins Drive, Iowa City, IA 52242. E-mail address for C.L. Saltzman: charles-saltzman{at}uiowa.edu

Investigation performed at the Department of Orthopaedic Surgery and Rehabilitation, University of Iowa, Iowa City, Iowa

In support of their research or preparation of this manuscript, one or more of the authors received National Institutes of Health Grant RO1 NR07721-03. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Although total contact casts are highly effective in the treatment of plantar ulcerations in patients with diabetes mellitus, they are not widely used. One reason for this lack of acceptance may be the difficulty in complying with an initial period of non-weight-bearing, as is generally recommended by physicians. We performed this study to assess the effects of early weight-bearing on the healing rates of plantar ulcers in patients with diabetes who were wearing a total contact cast.

Methods: Forty patients with diabetes mellitus who had a noninfected forefoot or midfoot ulcer were treated with total contact casts until healing or for thirteen weeks. The patients were instructed to bear no weight on the cast for forty-eight hours after it was applied. Using an embedded step counter, we measured the number of steps taken during the first twenty-four and forty-eight hours, the first week, and each subsequent two-week period after application of the cast. We removed the cast, measured the radius of the ulcer, and then reapplied the cast at the end of the first week and of each subsequent two-week period after cast application until the ulcer healed or for thirteen weeks. We then determined the effect of the number of steps during various time intervals on the rate of ulcer healing (defined as a change in the ulcer radius).

Results: Most patients walked on the cast in the immediate postoperative period. The effects of modest amounts of early weight-bearing on ulcer healing rates appear negligible. Only excessive walking during the first twenty-four or forty-eight hours after cast application is likely to prolong the duration of cast treatment.

Conclusions: Moderate early weight-bearing retards healing of plantar ulcers only minimally in patients with diabetes mellitus treated with total contact casts. Allowing patients to walk immediately after placement of a total contact cast may improve their acceptance of this form of therapy.

Level of Evidence: Therapeutic study, Level II-1 (prospective cohort study). See Instructions to Authors for a complete description of levels of evidence.


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