FOOT & ANKLE INTERNATIONAL Copyright 2003 by the American Orthopaedic Foot & Ankle Society, Inc. A Protocol for Treatment of Unstable Ankle Fractures Using Transarticular Fixation in Patients with Diabetes Mellitus and Loss of Protective Sensibility Mihir M. Jani, M.D.; William M. Ricci, M.D.; Joseph Borrelli, Jr., M.D.; Susan E. Barrett M.D.; Jeffrey E. Johnson, M.D. Saint Louis, MO ABSTRACT 23% (3/13). These are lower than previously reported rates between 30% (3/10) and 43% (9/21) for diabetic patients with and without neuropathy. The amputation rate for all fractures was 13% (2/16) and for closed fractures alone was 8% (1/13). These are similar to previously reported rates of 10% (2/10) to 20% (2/21). There were no deaths or Charcot malunions in this series. The combination of transarticular ﬁxation and prolonged, protected weightbearing provided 13 of 15 patients with a stable ankle for weightbearing. Conclusion: Although these fractures remain a treatment challenge, this study presents a successful, multidisciplinary protocol for treatment of unstable ankle fractures in the most challenging group of diabetic patients – those with loss of protective sensibility. Background: Surgical treatment of ankle fractures in patients with diabetes mellitus is associated with a high complication rate. Diabetic patients with peripheral neuropathy are a particularly difﬁcult group to treat because of their inability to sense deep infection, repeat trauma, and wound complications. The purpose of this study was to evaluate a protocol that included transarticular ﬁxation and prolonged, protected weightbearing in the treatment of unstable ankle fractures in diabetic patients with peripheral neuropathy and loss of protective sensibility. Methods: The authors retrospectively reviewed the records of 15 patients with diabetes mellitus, unstable ankle fractures (AO classiﬁcation 44B), and loss of protective sensibility conﬁrmed via testing with a 5.07 Semmes-Weinstein monoﬁlament. Retrograde transcalcaneal-talar-tibial ﬁxation using large Steinmann pins or screws in conjunction with standard techniques of open reduction and internal ﬁxation was used. The postoperative treatment protocol included: 1) short leg, total contact casting and nonweightbearing status for 12 weeks; 2) removal of the intramedullary implants between 12 and 16 weeks; 3) application of a walker boot or short leg cast with partial weightbearing for an additional 12 weeks; and 4) transition to a custom-molded ankle-foot orthosis (AFO) or custom total-contact inserts in appropriate diabetic footwear. Results: The major complication rate for all fractures was 25% (4/16) and for closed fractures was Key Words: Ankle Fracture; Complications; Diabetes Mellitus; Internal Fixation; Operative Treatment; Peripheral Neuropathy INTRODUCTION Surgical treatment of ankle fractures in patients with diabetes mellitus is associated with major complication rates ranging from 30% (3/10) to 43% (9/21).1,10,13 These complications include amputation [0 – 20% (2/10)] as well as infection, malunion, nonunion, and death [0 – 11% (2/19)] as a result of impaired healing, deep infection, and sepsis.1,10,11,13 Nonoperative treatment of ankle fractures in diabetic patients has also been associated with a higher infection rate compared to patients without diabetes or diabetic patients treated surgically.6 Peripheral vascular disease and peripheral neuropathy associated with diabetes mellitus have been implicated as the main reasons for the higher incidence of these complications.6 Although these complications are well known, a successful protocol for the treatment of such fractures in diabetic patients with advanced peripheral neuropathy has not yet been established. Loss of protective Department of Orthopaedic Surgery, Barnes-Jewish Hospital, The Washington University School of Medicine, Saint Louis, MO Corresponding Author: Jeffrey E. Johnson, M.D. Associate Professor Department of Orthopaedic Surgery Barnes-Jewish Hospital The Washington University School of Medicine 660 South Euclid Avenue Campus Box 8233 Saint Louis, MO 63110 E-mail: [email protected] For information on prices and availability of reprints call 410-494-4994 X226. 838 Foot & Ankle International/Vol. 24, No. 11/November 2003 sensibility often results in the inability of these patients to sense deep infection, repeat trauma, ulceration, wound problems, and progression to neuropathic arthropathy. In addition, the loss of protective sensibility often leads to noncompliance with the treatment recommendations for these patients.6 For these reasons, diabetic patients with unstable ankle fractures and advanced peripheral neuropathy are a particularly difﬁcult group to manage. The purpose of this study was to evaluate a protocol that included transarticular ankle ﬁxation and prolonged, protected weightbearing in the treatment of unstable ankle fractures in this most difﬁcult group of diabetic patients — those who have lost protective sensibility. METHODS A retrospective review of medical records and radiographs of 18 patients with diabetes mellitus who underwent surgical treatment for an unstable ankle fracture (AO classiﬁcation 44B)15 between the years 1997 and 2000 was performed. Treatment was conducted at a single institution by three orthopaedic surgeons. Inpatient records from the time of surgery and all outpatient records up to the time of latest follow-up were fully reviewed. In addition, all available radiographs were reviewed and included those from the time of injury, immediately after surgical treatment, and latest follow-up. Of note, no patients were found to have clinical or radiographic evidence of Eichenholtz stage I neuropathic arthropathy before the start of treatment.5 All patients were found to have loss of protective sensibility via testing with a 5.07 Semmes-Weinstein (10 g) monoﬁlament.12,14 Testing was performed on the injured extremity in four locations (plantar surface of ﬁrst, third, and ﬁfth metatarsal heads and the great toe) by applying the monoﬁlament perpendicular to the skin until it buckled for 1 second. Patients were visually blinded from testing and were instructed to say ‘‘yes’’ if the monoﬁlament was sensed. Patients were considered to have lost protective sensibility if they failed to sense the 5.07 monoﬁlament at one or more sites.12,14 Each patient was treated according to a protocol that included ankle and subtalar joint transarticular ﬁxation and prolonged, protected weightbearing. All patients underwent closed reduction and percutaneous, retrograde, trans-calcaneal-talar-tibial ﬁxation with screws (7.3 mm cannulated) or large ( 1/8 – 5/32 inch) Steinmann pins engaged into a cortex of the tibia (Figs. 1 and 2). The distal end of the pins were cut off to rest 1 cm beneath the skin and the skin was closed to prevent a portal of entry for bacteria. This ﬁxation was used alone, or as an adjunct to standard techniques of open reduction and internal ﬁxation of ankle fractures.7 TREATMENT OF UNSTABLE ANKLE FRACTURES 839 Fig. 1: Right ankle of patient PM. Anterior-posterior, oblique, and lateral radiographs at time of injury demonstrating displaced distal ﬁbular and medial malleolar fractures and lateral subluxation of the talus. Fig. 2: Right ankle of patient PM. Anterior-posterior, oblique, and lateral radiographs postoperatively showing plate ﬁxation of the ﬁbula, tension band ﬁxation of the medial malleolus, and retrograde trans-calcaneal-talar-tibial ﬁxation with one smooth and one threaded Steinmann pin. The ankle was immobilized for 10 weeks in a total contact cast. The Steinmann pins were then removed and the ankle was immobilized for 7 more weeks. The patient was then transitioned to an ankle-foot orthosis. Three patients presented with open fractures and were treated with intravenous antibiotics, urgent irrigation, and debridement of open wounds, along with fracture ﬁxation, repeat irrigation and debridement, and ﬁnally delayed wound closure within 48 hours. The rationale for using retrograde, transarticular, intramedullary ﬁxation alone in three patients involved several factors. Two patients (AA and NM, Table 1) were noncompliant with nonweightbearing status between the times of closed reduction and splinting in an emergency room and the ﬁrst ofﬁce visit for surgical planning. The third patient (TB, Table 1) was obese and essentially nonambulatory and had a history of psychosis. She failed nonoperative treatment with total contact casting for several weeks. All three patients presented with further displacement of the talus, signiﬁcant ankle swelling, and breakdown of the skin L Bimalleolar R Bimalleolar R Bimalleolar R Bimalleolar L Bimalleolar L Bimalleolar R Bimalleolar equivalent L Bimalleolar L Medial Malleolar R Bimalleolar equivalent L Bimalleolar equivalent R Bimalleolar equivalent L Bimalleolar TB (71) MB (79) CG (65) PM (69) PM (69) NM (67) KM (47) RW (56) SG (48) CD (57) GP (52) TA (66) JS (54) Closed Closed Closed Open Closed Closed Closed Closed Open Closed Closed Open Closed Closed Closed Closed IDDM IDDM IDDM NIDDM IDDM IDDM IDDM IDDM NIDDM IDDM NIDDM IDDM IDDM IDDM IDDM IDDM Open Insulin or Closed Dependence HTN, s/p renal transplant (receiving chronic immunosuppressive therapy) CAD, COPD, PVD HTN Obesity, COPD HTN, COPD HTN, CHF, ovarian carcinoma As above Seizure disorder HTN CAD, CRF, HTN Obesity, Psychosis CAD CAD, HTN, atrial ﬁbrillation, CHF Sarcoidosis Obesity, HTN HTN, atrial ﬁbrillation Medical Comorbidities (see Key) None None None Post-traumatic arthritis IM + ORIF IM + ORIF IM + ORIF IM + ORIF IM + ORIF IM + ORIF IM + ORIF IM only IM + ORIF IM + ORIF IM only IM + ORIF IM + ORIF None None Deep infection, retained pin in tibia, post-traumatic arthritis Retained pin in tibia Broken pin in tibia Nonunion of medial malleolus (not ﬁxated) None None Post-traumatic arthritis Transtibial amputation Deep infection, nonunion of medial malleolus, post-traumatic arthritis Transtibial amputation Complications IM only IM + ORIF IM + ORIF Fixation (IM ± ORIF) JANI ET AL. Bimalleolar equivalent, displaced lateral malleolar fracture and medial joint space widening; IDDM, insulin-dependent diabetes mellitus; NIDDM, non-insulin-dependent diabetes mellitus; HTN, hypertension; CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CRF, chronic renal failure; PVD, peripheral vascular disease; IM, intramedullary; ORIF, open reduction and internal ﬁxation. R Bimalleolar equivalent R Bimalleolar L Bimalleolar equivalent Side and Type of Fracture (R-right, L-left) AA (69) RB (66) LB (60) Patient and Age at Surgery (years) Table 1: Patient data 840 Foot & Ankle International/Vol. 24, No. 11/November 2003 Foot & Ankle International/Vol. 24, No. 11/November 2003 over the medial malleolus. Given these patient factors and physical exam ﬁndings, it was decided to pursue closed reduction and retrograde, intramedullary ﬁxation alone to avoid the incisions needed for open reduction and internal ﬁxation and thus decrease the risk of wound complications and possible infection. The postoperative treatment protocol included: 1) short leg, total contact casting and nonweightbearing for 12 weeks using crutches, walker, or a wheelchair; 2) removal of the intramedullary implants between 12 and 16 weeks; 3) application of a walker boot or short leg cast with partial weightbearing for an additional 12 weeks; and 4) transition to a custommolded ankle-foot orthosis (AFO) or total contact foot orthoses in appropriate diabetic footwear. Casting was performed following the principles of total contact casting often used for treatment of diabetic neuropathic ulcers.8,16,19,20 Near the end of cast immobilization, consultation with a certiﬁed pedorthist and orthotist determined the bracing and shoe modiﬁcations needed to accommodate any deformity of the foot and/or ankle. Often a polypropylene clamshell-type AFO or a double-upright modiﬁed calf-lacer AFO attached to an extra-depth shoe with an extended steel shank and rocker sole was recommended for both short-term and/or long-term use.9 Diabetic foot care education ensued during and after the immobilization period. Emphasis was made upon daily inspection of feet, keeping skin soft and supple with moisturizing creams, use of in-depth shoes made of soft leather and appropriate to foot width and deformity, and use of total contact foot orthoses to accommodate the foot and reduce plantar pressures. Major and minor complications were deﬁned according to previous studies.1,10,13 Major complications were deﬁned as those that required further surgical or medical treatment and were considered possibly limb or life threatening. These included Charcot neuropathic malunion, wound dehiscence, deep infection requiring operative debridement, amputation, and death. Minor complications were all other complications including stable malleolar nonunions, retained intramedullary implants and post-traumatic arthritis (as evidenced by joint space narrowing and subchondral sclerosis). RESULTS Three patients were lost to follow-up and therefore 16 ankles in 15 patients were followed for an average of 69 weeks (range, 16 – 156 weeks) (Table 1). Of those lost to follow-up, one patient had since died of renal failure and two patients could not be contacted. Retrograde, transcalcaneal-talar-tibial, intramedullary ﬁxation was used alone in three ankles and as an adjunct to standard TREATMENT OF UNSTABLE ANKLE FRACTURES 841 Fig. 3: Right ankle of patient PM. Anterior-posterior, oblique, and lateral radiographs at 78 weeks follow-up demonstrating healed fractures and maintenance of joint space. No complications occurred during the treatment and follow-up period. techniques of open reduction and internal ﬁxation in 13 ankles (Figs. 1 –3). Mean intraoperative estimated blood loss was 41 ± 35 mL. Average time of ankle immobilization from surgery to removal of transarticular ﬁxation was 12.0 ± 3.2 weeks. Average time from removal of transarticular ﬁxation to discontinuation of immobilization was 10.7 ± 6.4 weeks. Mean total immobilization time was 22.4 ± 8.3 weeks. Fracture union occurred on average at 18.9 ± 6.4 weeks. The major complication rate was 25% (4/16) for all fractures and 23% (3/13) for closed fractures alone. These included two deep infections requiring operative irrigation and debridement, and two deep infections necessitating transtibial amputation (Table 2). Including all fractures and closed fractures alone, the amputation rate was 13% (2/16) and 8% (1/13), respectively. One amputation occurred in patient KM who presented with an open fracture and an associated large, medial open wound (Gustilo grade II). Deep infection developed within 4 weeks, and despite intravenous antibiotics, Table 2: Major complications Closed Open All Fractures Fractures Fractures (n = 13) (n = 3) (n = 16) Deep infection (requiring and cleared by irrigation & debridement only) Transtibial amputation Total rate of major complications 2 0 2 1 1 2 23% 33% 25% 842 JANI ET AL. serial operative debridements, and removal of implants, his infection could not be cleared and amputation was performed. A second amputation occurred in patient SG, who was receiving chronic, immunosuppressive therapy (azathioprine and prednisone) for a renal transplant. She developed purulent drainage from the pin sites in the plantar heel at 8 weeks postoperatively. Pins were removed and after 6 weeks of treatment with a culture-speciﬁc, intravenous antibiotic (vancomycin), the drainage resolved. The patient then presented 3 weeks later with a deep infection in the ankle and in septic shock, and thus an amputation was performed urgently. Patient RW was not compliant with nonweightbearing status and developed a deep calcaneal infection requiring operative irrigation and debridement. Minor complications (all clinically asymptomatic) included four cases of post-traumatic arthritis, three cases of retained intramedullary implants, and two stable medial malleolar nonunions. No Charcot malunions or deaths occurred in our series. Except for the two patients (KM and SG, Table 1) who underwent amputation, all patients obtained a foot and ankle on which they were able to bear weight, ambulate [except patient TB (Table 1) who was nonambulatory preoperatively], and remain free of ulcers during the follow-up period. DISCUSSION The high complication rate associated with both nonoperative and surgical treatment of ankle fractures in diabetic patients has been clearly established. In a retrospective review of ankle fractures treated surgically, Low and Tan reported four wound infections in 10 diabetic patients, two of which resulted in transtibial amputation.11 Several case-control studies of surgical treatment of ankle fractures in diabetic patients have also shown an overall major complication rate of approximately 43% (9/21) 1,13 and infection rates as high as 30% (3/10).10 Transtibial amputations [20% (2/10)] and death [11% (2/19)] are the most severe of the major complications reported.1,11,13 These studies do not report the percentage of their patients who had peripheral neuropathy and loss of protective sensibility. The presumed contributing factors leading to these higher complication rates are a combination of peripheral vascular disease and/or peripheral neuropathy. In a retrospective review of closed ankle fractures in patients with diabetes mellitus, Flynn et al. found a signiﬁcantly higher rate of infection associated with 1) closed (as opposed to surgical) treatment, 2) peripheral vascular disease, 3) poor patient compliance with treatment, Foot & Ankle International/Vol. 24, No. 11/November 2003 and 4) the presence of peripheral neuropathy.6 Although diabetic patients with a combination of ankle fractures, peripheral neuropathy, and peripheral vascular disease have been established as the most difﬁcult group to treat,6 no study has evaluated an even more difﬁcult subset of these patients — those with loss of protective sensibility. Loss of protective sensibility results in the inability to sense deep infection, repeat trauma, ulceration, wound problems, and development of neuropathic (Charcot) arthropathy. This level of advanced peripheral neuropathy can be objectively established by testing with the 5.07 Semmes-Weinstein (10 gm) monoﬁlament. Loss of protective sensibility at the 5.07 level has been associated with a signiﬁcant increase in the incidence of neurotrophic ulceration.12,14 Although development of neuropathic arthropathy has not been associated with an absolute level of insensibility, when diabetic patients cannot detect the 5.07 monoﬁlament, we employ a unique and aggressive regimen for treatment of ankle fractures. Our treatment protocol includes the use of retrograde, percutaneous, trans-calcaneal-talar-tibial ﬁxation with or without the use of standard techniques of open reduction and internal ﬁxation of ankle fractures. The use of vertical transarticular pin ﬁxation for unstable ankle fractures was introduced in Europe and popularized in the United States by Childress.2 – 4,21 Childress recommended the use of this ﬁxation alone when either local soft tissues were not amenable to standard incisions for open reduction and internal ﬁxation or when patients were minimally ambulatory or medically unstable. Overall he reported successful results using vertical transarticular pin ﬁxation in treating 92 unstable ankle fractures in nondiabetic patients.3 More recently, Scioscia and Ziran discussed similar, successful results in treating 14 severe ankle fractures with vertical transarticular ﬁxation.18 The application of this technique in the treatment of ankle fractures in diabetic patient with loss of protective sensibility has been described, but no clinical series has yet been published.9 Another technique as a method of limb salvage has been described in the treatment of ankle fractures in diabetic patients with peripheral neuropathy. Perry et al. noted successful limb salvage in six patients with diabetes, peripheral neuropathy, and failed initial ﬁxation of ankle fractures, by using a laterally placed 4.5-mm dynamic compression plate (DCP) and multiple syndesmotic screws. Two patients in this series developed wound dehiscence necessitating further operative wound management including eventual plate removal.17 Given this complication, the use of a large compression plate (along with multiple syndesmotic screws) on the lateral side of the ankle would likely not succeed as a method of primary ﬁxation of unstable ankle fractures Foot & Ankle International/Vol. 24, No. 11/November 2003 in diabetic patients because of 1) a thin or damaged lateral soft-tissue envelope, or 2) a fracture pattern that necessitates stabilization of the medial side of the joint. Our treatment protocol includes a comprehensive, multidisciplinary approach to the treatment of unstable ankle fractures in patients with diabetes mellitus and loss of protective sensibility. Following our protocol, we found a lower overall major complication rate of 25% (4/16) among all patients and a major complication rate of 23% (3/13) among the subset of patients with closed fractures. Although an amputation occurred in two patients following our treatment protocol [overall amputation rate of 13% (2/16)], each patient had extenuating factors that further compromised his or her immune status. Patient KM presented with an open fracture and an associated large, open medial wound (Gustilo grade II) and patient SG was taking chronic immunosuppressive therapy for a renal transplant. Among the patients with closed fractures, our amputation rate was 8% (1/13). No Charcot neuropathic malunions and no deaths (as a direct result of surgical treatment of the ankle fracture) occurred in our series. There were few minor complications overall and all were clinically insigniﬁcant. Retained intramedullary implants are a unique complication to our protocol. Although leaving the end of the pins outside the skin with a 90◦ bend (as reported by Childress)3 would likely prevent migration proximally, we cut the pins beneath the skin and closed the associated wound to decrease the risk of pin site infection and possible development of deep infection. In addition, the large size of the pins used ( 1/8 – 5/32 inch) made bending of the pin tip difﬁcult. To help prevent proximal migration, pins were placed such that they would engage either the anterior or posterior cortex of the tibia (Fig. 2). The use of large cannulated screws obviates the problem of migration, although they are more difﬁcult to remove. Our ultimate goal of treating ankle fractures in diabetic patients with loss of protective sensibility was to maintain a foot and ankle that could be braced and allow weightbearing. The certiﬁed pedorthist and orthotist played a critical role in evaluating and treating our patients after the immobilization period following an ankle fracture. They implemented both custom foot orthoses and various forms of AFOs (as indicated by presence of deformity and functional status) and reinforced education in regards to diabetic footwear and general foot care.9 We have developed a successful protocol for treatment of unstable ankle fractures in the most challenging group of diabetic patients — those with loss of protective sensibility. As a multidisciplinary approach, TREATMENT OF UNSTABLE ANKLE FRACTURES 843 our protocol emphasizes 1) aggressive surgical treatment using retrograde, trans-calcaneal-talar-tibial ﬁxation alone or as an adjunct to traditional ankle fracture ﬁxation; 2) prolonged, protected weightbearing and immobilization that includes total contact casting to counter swelling, development of deformity, and noncompliance; 3) involvement of the pedorthist and orthotist to provide postoperative foot and ankle stability and protection; and ﬁnally 4) patient education on prevention of further injury to the diabetic foot and ankle. REFERENCES 1. Blotter, RH; Connolly, E; Wasan, A; Chapman, MW: Acute complications in the operative treatment of isolated ankle fractures in patients with diabetes mellitus. Foot Ankle Int. 20:687 – 694, 1999. 2. Childress, HM: Vertical transarticular-pin ﬁxation for unstable ankle fractures. J. Bone Joint Surg. 47-A:1323 – 1334, 1965. 3. Childress, HM: Vertical transarticular pin ﬁxation for unstable ankle fractures. Clin. Orthop. 120:164 – 171, 1976. 4. Duke, RFN: Severe fracture-dislocation of ankle treated by transarticular Steinmann pin. Lancet 2:1251 – 1253, 1963. 5. Eichenholtz, SN (ed): Charcot Joints, Springﬁeld, IL, Charles C Thomas, 1966. 6. Flynn, JM; Rodriguez-del Rio, F; Piza, PA: Close ankle fractures in the diabetic patient. Foot Ankle Int. 21:311 – 319, 2000. 7. Hahn, DM; Colton, CL: Malleolar fractures. In: TP Ruedi, WM ¨ Murphy, eds, AO Principles of Fracture Management, Davos, Switzerland, AO Publishing, 2000, pp. 559 – 581. 8. Helm, PA; Walker, SC: Total contact casting in diabetic patients with neuropathic foot ulcerations. Arch. Phys. Med. Rehabil. 65:691 – 693, 1984. 9. Johnson, JE: Operative treatment of neuropathic arthropathy of the foot and ankle. J. Bone Joint Surg. 80-A:1700 – 1709, 1998. 10. Kristiansen, B: Results of surgical treatment of malleolar fractures in patients with diabetes mellitus. Dan. Med. Bull. 30:272 – 274, 1983. 11. Low, CK; Tan, SK: Infection in the diabetic patients with ankle fractures. Ann. Acad. Med. Singapore 24:353 – 355, 1995. 12. Mayﬁeld, JA; Sugarman, JR: The use of the Semmes-Weinstein Monoﬁlament and other threshold tests for preventing foot ulceration and amputation in persons with diabetes. J. Fam. Pract. 49:S17 – 29, 2000. 13. McCormack, RG; Leith, JM: Ankle fractures in diabetics (complications of surgical management). J. Bone Joint Surg. 80B:689 – 692, 1998. 14. Mueller, MJ: Identifying patients with diabetes mellitus who are at risk for lower-extremity complications: use of Semmes-Weinstein monoﬁlaments. Phys. Ther. 76:68 – 71, 1996. 15. Murphy, WM; Leu, D: Fracture classiﬁcation: biological signiﬁcance. In: TP Ruedi, WM Murphy, eds, AO Principles of Fracture ¨ Management, Davos, Switzerland, AO Publishing, 2000, pp. 45 – 57. 16. Myerson, M; Papa, J; Eaton, K; Wilson, K: The total-contact cast for management of neuropathic plantar ulceration of the foot. J. Bone Joint Surg. 74-A:261 – 269, 1992. 17. Perry, M; Taranow, WS; Manoli II, A: Multiple syndesmotic ﬁxation for neuropathic ankle fractures with failed traditional ﬁxation. Proceedings of the Annual Winter Meeting of the 844 JANI ET AL. American Orthopaedic Foot and Ankle Society, Dallas, TX 2002. 18. Scioscia, TN; Ziran, BH: Use of a vertical transarticular pin for stabilization of severe ankle fractures. Am. J. Orthop. 32:46 – 48, 2003. 19. Sinacore, DR: Total contact casting for diabetic neuropathic ulcers. Phys. Ther. 76:296 – 301, 1996. Foot & Ankle International/Vol. 24, No. 11/November 2003 20. Sinacore, DR; Mueller, M; Diamond, JE; Blair III, VP; Drury, D; Rose, SJ: Diabetic plantar ulcers treated by total contact casting. Phys. Ther. 67:1543 – 1549, 1987. 21. 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