The effectiveness of Total Contact Cast Technique to control infection and treat DFU to prevent late presentation and amputation in a rural and isolated setting. An experience from the Solomon Islands.

Amelia Tobias1
Ortho Advantage1

ABSTRACT

Background or Problem/ Issue:

Centralised multidisciplinary healthcare is the preferred model for treating Diabetic Foot Ulcers (DFU). Separation from customary lands and people, cost of transport and accommodation are major barriers faced by indigenous people living in isolated communities located between 2-6 days from a treating healthcare centre. Consequently, patients are presenting late with chronic and often infected DFU, resulting in preventable amputation, causing further lifelong implications affecting lower limb function and quality of life. This case series investigates the effectiveness of training healthcare practitioners in using low cost dressings and Total Contact Cast (TCC) to control infection and treat DFU.

Method or What you did?

Seven patients of Melanesian origins from various isolated communities were selected with the following criteria; SINBAD score >4, late presentation due to geography and income, >1 surgical debridement, and below knee amputation scheduled <1 week. Treatment commenced when a Doctor reviewed the patient. On every treatment occasion, DFU was debrided, cleaned and dressed by a Nurse then a TCC was applied by the Author or a local healthcare practitioner under the Author’s supervision. The DFU was packed to the level of the epidermis followed by a TCC enclosed distally to reduce the sheer and direct forces and control infection. The TCC was changed every two days until the DFU was not infected. The inpatients were then discharged and the TCC was changed as an outpatient between 3-10 days. The patients were non-weight bearing for the total treatment period. Major and minor complications were defined by ones interfering and not interfering with treatment.

Results or Outcomes:

TCC treatment prevented amputation for all seven patients. The data from one patient was excluded due to a regional transfer where treatment proceeded but wasn’t recorded. Local clinicians applied 29% of the casts, no-one caused any major complications. Days to complete skin coverage µ70.1, range 39-89. TCC’s applied per patient µ8, range 3-10. All patients had minor complications, most common were delayed inpatient discharge due to availability of assistive ambulatory devices and accommodation.

Conclusions or Practice Implications:

TCC is an effective treatment option for treating DFU’s in isolated clinics and prevent late presentation leading to lower limb amputation. Remote healthcare clinics have the resources required to use this method of treatment and Solomon Island health practitioners have an aptitude for TCC. However, there are limited opportunities to access the information and technical education which is required to safely apply TCC. This treatment method could be considered for other similar populations.


BIOGRAPHY

Amelia is a senior Orthotist with diverse experience in Peadiatric and Adult Public Health Service in Australia and the Solomon Islands.  She specialises in neuro-muscular conditions and orthopaedic casting with a passion for remote health and preventing amputation. Amelia has established the company Ortho Advantage providing an orthotics service to the South Gippsland Coast community and Total Contact Casting clinical education to remote practitioners.

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