Hexcelite(R) versus plaster of Paris: a controlled trial of the below-knee walking cast
U. Jřrgensen *
P. Nordkild *
Abstract
HexceliteŽ and plaster of Paris below-knee walking casts were compared in a controlled clinical trial, involving 82 patients.
Fewer bandage complications, problems and better comfort was found with Hexcelite compared to plaster of Paris (P<0.05). If all costs relating to materials, transportation, complications and extra visits due to these, were taken into account, plaster of Paris was found more expensive than HexceliteŽ. Based on the above an increased use of HexceliteŽ is recommended.
Introduction
Over the years various types of plaster of Paris have been developed (Nielsen et al, 1973), as well as alternative bandage materials such as polyurethane and HexceliteŽ (a thermo-plastic polyester). Of these, HexceliteŽ has found favour in Danish orthopaedic departments but only as an alternative to plaster of Paris in those special cases where a lighter bandage is indicated, (Nielsen, and Lauritzen, 1981; Rosetzsky, 1982). The argument for not using HexceliteŽ is mainly based on the work of Nielsen and Lauritzen (1981) who reported that HexceliteŽ bandages were more expensive and more difficult to apply than plaster of Paris. The authors' experience however, is that there are more bandage complications and problems using plaster of Paris than with Hexcelite(R). As patients treated by using HexceliteŽ seemed to be more satisfied, the authors' have questioned, whether it really is more profitable, in the long run, to avoid using HexceliteŽ.
A randomized trial was designed, with the aim of comparing HexceliteŽ and plaster of Paris (Cellona), when used for the most frequently applied bandage in the out-patient clinic, the below-knee walking cast. This weight-bearing cast demands the optimum of material and comfort.
Patients and methods
During the period 1st January to 31st December 1983, 82 patients in the out-patient clinic took part consecutively in the investigation, having given their informed consent. Excluded from the investigation were patients who were specifically prescribed HexceliteŽ, patients with limited mobility and patients with acute injuries of less than 24 hours-due to post-traumatic oedema. All bandages were applied by random sample by the same technician, who had wide previous experience with plaster of Paris and HexceliteŽ. All bandages were applied according to the manufacturer's instructions.
The number of bandages and application time was recorded, and the patient was given a form, so that technical changes or improvements could be recorded at any subsequent consultation due to complications, as could the appointed removal of the bandage at the clinic. After removal of the bandage, the patients were given a final examination for bandage problems or sequelae, and were interviewed about comfort and activity level.
Eleven out of the 82 patients were excluded, three because of incomplete information, and eight who were lost at follow up. Thus the final material consisted of 71 patients (87 per cent)-34 with plaster of Paris (10m/24f) and 37 with HexceliteŽ (10m/27f), mean age 34.8 years, range: 15-70 years.
The 34 plaster of Paris and 37 HexceliteŽ patients were comparable as far as sex, age, activity level, bandage wearing time (3.9 weeks for plaster of Paris and 4.0 weeks for HexceliteŽ) and reasons for treatment were concerned, (malleolar fracture, ligamental rupture and rupture of the Achilles tendon).
The results have been prepared statistically with chi-square test and Fischer's exact test.
Results
The mean application time was 20 minutes for plaster of Paris, 21 minutes for HexceliteŽ.
Bandage complications
As seen in
Table 1
, 46 per cent (16) of the plaster of Paris patients and 19 per cent (7) of the HexceliteŽ patients (P<0.05) had bandage complications, which were mainly broken plaster of Paris at malleolar level and loose foot plates (seen in both groups). With plaster of Paris, re-application of a complete new below-knee walking cast was often necessary, while most of the Hexcelite cases could be repaired by heating and remodelling.
No patients had thrombo-embolic complications or prolonged bandage time. Complications due to the bandage were seen in 20 per cent (14/71) (
Table 2
). These were significantly more frequent with plaster of Paris (P<0.05).
Bandage comfort with HexceliteŽ was found to be significantly better (P<0.01) than with plaster of Paris (
Table 3
).
Bandage economy
The associated expenses can be divided into the following items:
- Material costs.
- Application time.
- Transportation costs.
- Costs of extra consultations due to problems/complications.
The average total material cost for HexceliteŽ was found to be 2.6 times that of plaster of Paris (
Table 4
). There was no difference in the application time. The transportation costs varied from area to area, so the calculations in
Table 4
are based on an average of 241 DKK for stretcher cases, 142 DKK for patients able to sit up in an ambulance and 126 DKK for transportation by taxi.
For extra visits to the clinic or emergency ward a previously calculated cost of 250 DKK (Sonne-Holm and Sřrensen, 1977) has been used. When all costs are taken into consideration, HexceliteŽ expenses were found to be 0.89 times that of plaster of Paris.
Discussion
The results reveal a great number of bandage complications and problems. The reliability of these figures is difficult to evaluate, since the only other reference is Rosetzsky (1982), who found bandage complications in 36 per cent (8/22) of his polyurethane forearm casts. In this trial an attempt has been made to reduce the application bias to a minimum, as all casts were applied by the same professional bandage technician, and the findings seem to confirm the hypothesis that initiated the study, namely that there are more complications and problems with the below-knee walking cast made of plaster of Paris than with HexceliteŽ.
HexceliteŽ has previously been criticised (Bachmann, 1977; Nielsen and Lauritzen, 1981), because it was found more difficult to apply than plaster of Paris, especially due to the following: 1) It stiffens more quickly than plaster of Paris (after 1 to 2 minutes), which may cause problems in accurate anatomical application. 2) The temperature of the water, 65°C, in which HexceliteŽ is kept, may cause problems during application. 3) The intermediate plaster tape in the HexceliteŽ rolls delays application. In practice these criticisms were found to be justified, but experience with the material demonstrates that the disadvantages can be reduced, and the first can be used positively, if only one is aware of it; fast bandage stiffening can be employed for quick anatomical application, without pressure marks. The warm water problems can be reduced by using smooth gloves, careful squeezing out of excess water and covering the part of the patient closest to the bandage with a towel. The intermediate plastic tape can be removed by an assistant. In the new HexceliteŽ it has been removed.
Another reason for Hexcelite being considered difficult to use, is lack of training and experience in its application. It appears from Nielsen and Lauritzen (1981), that only 18 Hexcelite below-knee walking casts had been applied in a year (and most probably not by the same person).
The material cost of HexceliteŽ was found to be 2.6 times the price of plaster of Paris, but when expenses for transportation and complications were taken into account, plaster of Paris was found to be 1.13 times more expensive than HexceliteŽ. Furthermore the use of HexceliteŽ must mean fewer days off work for the patients.
Conclusion
Based on the above results, the HexceliteŽ below-knee walking cast was found to have significantly better bandage comfort, with fewer complications and problems, was less expensive than plaster of Paris, and thus serves the patient and society best. For these reasons an increased use of HexceliteŽ, is recommended together with research in the area of alternatives to plaster of Paris.
Acknowledgements
Special thanks to bandage technician Verner Rasmussen, without whom this project would not have been possible.
References:
- Bachmann, O. (1977). Erfahrungen mit einem neuartigen Gipseratz-Fixationsmaterial zur Frakturbehandlung. Ther. Umsch. 34, 744-747.
- Nielsen, K., Lauritzen, J. (1981). A new thermoplastic casting material. A comparison between plaster of Paris and Hexcelite. Acta Orthop. Scand. 52, 27-29.
- Nielsen, J. B., Nielsen, M. L., Sneppen, O. (1973). Plaster of Paris bandages. An experimental investigation of the strengths of different types of plaster of Paris during the drying phase. Ugeskr. Laeger. 135, 1365-1369.
- Rosetzsky, A. (1982). Colles fractures treated by plaster of Paris and polyurethane braces: a controlled clinical study. J. of Trauma. 22,910-913.
- Sonne-Holm, S, Sřrensen, C. H. (1977). Social costs of sports injuries. Ugeskr. Lćger. 139, 2596-2598.
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