Guyton Gregory P
Department of Orthopaedic Surgery, Union Memorial Hospital, 3333 North Calvert Street #400, Baltimore, MD 21218, USA.
Foot Ankle Int. 2005 Nov;26(11):903-7. doi: 10.1177/107110070502601101.
Many physicians continue to fear iatrogenic complications of the total contact cast, and use of this modality has remained restricted to a segment of the orthopaedic and podiatric communities. I examined the actual rate of complications and the factors associated with them in a large consecutive series of total contact casts drawn from the practice of a single surgeon to determine whether this modality is safe for multiple conditions in the neuropathic foot and ankle.
A consecutive series of 398 total contact casts spanning a 28-month period from the practice of a single physician were analyzed. All casts were placed by the same team of orthotists. This study comprised 70 patients with severe peripheral neuropathy; an average of 5.69 sequential casts per patient were placed. Three-hundred and sixty-seven casts were placed in diabetic patients, and 31 in patients with idiopathic peripheral neuropathy. By protocol, the initial cast was changed at an interval of no more than 1 week. On occasion, subsequent casts were left on longer, but on average casts were left in place for 7.69 days. Logistic regression analysis was used to analyze the contribution of patient factors to the chance of ulceration.
Complications occurred in 22 casts, including six new pretibial ulcers, six new midfoot ulcers, four forefoot or toe ulcers, five hindfoot ulcers, and one malleolar ulcer. In no case was a preexisting ulcer made worse. This corresponds to an overall complication rate of 5.52% per cast. Overall, 30% of patients suffered one complication during the course of their treatment. With one exception, all new ulcers healed with simple modalities within 3 weeks, often with continued total contact casting. A single cast led to a proximal interphalangeal ulceration that exposed the joint and eventually required toe amputation. The rate of permanent sequelae from cast-related injuries was therefore 0.25%. In no case were the resultant odds ratios statistically different from 1.0, but several trends were observed. Charcot arthropathy represented the highest risk (odds ratio 1.46), while the presence of neuropathic ulceration was surprisingly benign (odds ratio 0.69). The presence of diabetes as opposed to other causes of neuropathy was associated with increased risk (odds ratio 1.34). The use of a cast after deformity-correcting surgery in a neuropathic patient was remarkably safe (odds ratio 0.44), as were casts in which the patient was instructed to remain nonweightbearing (odds ratio 0.27). Patient age was not a factor (odds ratio 1.03). The length of time the cast was left on was not statistically important (odds ratio 0.99), although strict protocols for cast changing likely altered this data.
A frequently changed total contact cast is a safe modality for the offloading and immobilization of the neuropathic foot, albeit with an expected constant rate of minor, reversible complications. Patients should be informed of these complications and risks before cast application.
许多医生仍担心全接触石膏会引发医源性并发症，这种治疗方式的应用仍局限于部分骨科和足病科领域。我对一位外科医生连续大量使用全接触石膏治疗的病例进行研究，以确定其实际并发症发生率及相关因素，从而判断这种治疗方式对神经性足踝多种病症是否安全。
分析一位医生在28个月内连续使用的398例全接触石膏病例。所有石膏均由同一支矫形师团队安装。本研究包括70例严重周围神经病变患者，每位患者平均使用5.69次连续石膏。367例石膏用于糖尿病患者，31例用于特发性周围神经病变患者。按照规定，最初的石膏每隔不超过1周更换一次。有时，后续石膏留置时间更长，但平均留置时间为7.69天。采用逻辑回归分析来分析患者因素对溃疡发生几率的影响。
22例石膏出现并发症，包括6例新的胫骨前溃疡、6例新的中足溃疡、4例前足或趾溃疡、5例后足溃疡和1例内踝溃疡。原有溃疡无一恶化。这相当于每次石膏的总体并发症发生率为5.52%。总体而言，30%的患者在治疗过程中出现一种并发症。除一例例外，所有新溃疡在3周内通过简单方式愈合，通常是继续使用全接触石膏。一例石膏导致近端指间关节溃疡，关节暴露，最终需要截趾。因此，与石膏相关损伤导致的永久性后遗症发生率为0.25%。结果的优势比在任何情况下均无统计学差异，但观察到一些趋势。夏科氏关节病风险最高（优势比1.46），而神经性溃疡的存在出人意料地良性（优势比0.
