Windowed Angled Total Contact Casting for Resistant Weight-Bearing Plantar Ulcers in Charcot Neuroarthropathy: A Prospective Single-Center Study

Abstract

Plantar ulcers associated with Charcot neuroarthropathy (CNO) are difficult to treat because of persistent abnormal pressure distribution and foot instability. Although traditional non-removable total contact casting (TCC) remains the standard offloading method, it limits direct wound inspection and routine dressing care. This prospective study evaluated the effectiveness and safety of a modified windowed angled TCC technique for resistant weight-bearing plantar ulcers in patients with Charcot deformities. This prospective single-center study was conducted between May 2024 and March 2026. Forty-eight diabetic patients with midfoot or hindfoot Charcot neuroarthropathy and chronic weight-bearing plantar ulcers resistant to previous conservative offloading methods were included. Adequate distal perfusion was confirmed in all patients using vascular assessment. Windowed angled total contact casts were customized by adjusting the ankle position according to ulcer location to reduce plantar pressure while maintaining direct wound access for regular inspection and dressing changes. The primary outcome was complete ulcer healing. Secondary outcomes included secondary infection and cast-related pressure complications. A total of 48 patients (23 males and 25 females) were evaluated; 29 patients (60.4%) had clinically infected ulcers. Complete ulcer healing was achieved in 44 patients (91.7%). Among healed ulcers, 9 patients (20.4%) healed within 12 weeks, 29 patients (65.9%) healed within 12-24 weeks, and 6 patients (13.6%) required more than 24 weeks. Four patients (8.3%) remained unhealed because of extensive tissue loss and severe deformity. Secondary infection during treatment occurred in 4 patients (8.3%), while minor cast-related pressure sores developed in 2 patients (4.1%). Windowed angled total contact casting was an effective and safe offloading technique for resistant plantar ulcers in patients with Charcot neuroarthropathy. The technique combines rigid immobilization with direct wound access, allowing effective pressure redistribution and regular wound care during treatment.