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Total Contact Casting and DFU related Articles

Empowering Limb Salvage: The Essential Role of Total Contact Casting in Diabetic Foot Care
Diabetic foot ulcers (DFUs) are a leading cause of lower extremity amputations, with approximately 85% of diabetes-related amputations preceded by a foot ulcer. Total Contact Casting (TCC) stands out as the gold standard for offloading pressure from these ulcers, promoting healing and preventing amputations. ....
TCC vs Removable Boots: What Wound Care Providers Should Know
When it comes to offloading diabetic foot ulcers (DFUs), the choice of modality can significantly impact healing outcomes. Two of the most common options are Total Contact Casting (TCC) and removable walking boots. While both aim to reduce pressure on the affected area, they are not equal in terms of clinical efficacy, patient compliance, or long-term healing....
Back To Basics: How To Ensure Effective Offloading With Total Contact Casting
I recently had the opportunity to speak at a dinner meeting to a group of wound care clinicians. During a question and answer session, the topic of discussion drifted toward the use of total contact casting (TCC). I asked the meeting participants to indicate, with a show a hands, how many of them were using this modality regularly in their practice. I was shocked to see that the number was less than 10 percent... Numerous authors have described the underlying pathology in the development of lower extremity ulcerations. Perhaps one of the greatest difficulties in managing complex lower extremity ulcerations is offloading the wound site effectively. A review of the literature demonstrates that TCC is the "gold standard" for offloading non-infected, non-ischemic plantar foot ulcerations...
Under the Off-Load: A Pilot Case Series to Identify Ideal Dressings to use Under Total Contact Casts
It is well stated in the literature that Total Contact Casting is a standard of care for off-loading of neuropathic ulcers of the plantar surface. Another standard of care is to provide a moist wound healing environment. Evidence to support appropriate wound dressings under Total Contact Casting is currently unavailable despite recognition that the wound environment and thus the amount of drainage changes as the wound progresses towards healing. This pilot case series of three patients with plantar based diabetic neuropathic ulcers uses two dressings, a five layer silicone foam with absorbent polymer and moisture retentive backing dressing (SF)* for low to moderate drainage and a non-adherent super-absorbent (SAP)† polymer dressing for moderate to high exudate levels....
Don't get diabetes in Ontario Canada
a $70,000 Amputation or a $250 Offloading Procedure? Easy choice right? Not for the Government of Ontario Canada. The vast majority of the 2,000 amputations that occur per year in that country would be preventable with common offloading practices (total contact casting*). Doris Grinspun, CEO of the Registered Nurses' Association of Ontario was assured three years ago by government 'premieres' that they would begin to cover such procedures ... that's three years or 6,000 legs or $420,000,000 ago. "We're willing to pay for the amputations but we're not willing to pay for the prevention," offered Grinspun.

Cost and human suffering aside, mortality rates jump significantly after an amputation especially in older patients, diabetes further increases mortality rates. In one rather grim study** 390 patients that had undergone lower extremity amputations were reviewed, of the patients with diabetes "the median time to death was 27.2 months".

So if you are suffering from diabetic neuropathy and experience a diabetic foot ulcer and happen to be living in Ontario Canada you need to get your affairs in order. But there is hope as The Ontario Health Technology Advisory Committee is currently assessing total contact casting to treat foot ulcers, check back in three years....
Conservative and surgical treatment of the chronic Charcot foot and ankle
Charcot neuroarthropathy (CN) is a severe joint disease in the foot and ankle that can result in fracture, permanent deformity, and limb loss... Eichenholtz stage I CN is successfully treated with immobilization and non-weightbearing in a total contact cast ... Stage II (coalescence-subacute phase) is typically treated with protected weight bearing with a total contact cast ... Total contact casting has been considered as the gold standard in the treatment of neuropathic diabetic plantar foot ulcers. The utilization of a TCC reduces the mechanical forces, inflammation, and edema; redistributes the plantar pressure; limits bone and joint destruction; and can consolidate the progression of deformity ... total contact cast should encase the entire foot and ankle, with all major bony prominences well-padded with cotton-based bandages ...
A comparison of two total contact cast constructs with variable body mass
OBJECTIVE: There is a growing body of evidence implicating obesity as having a negative effect on the development and treatment of diabetic foot disease. The aim of this study was to increase the body of knowledge on the effects of obesity on foot function, specifically as it relates to peak plantar pressures in the total contact cast (TCC). Our investigational objectives were to compare the effect of two different TCC designs on mean peak plantar pressures, and to evaluate the efficacy of two TCC constructs with increasing body mass.

METHOD: The primary outcome measure was mean peak plantar pressure in the heel, midfoot, forefoot and first metatarsal as measured with an in-shoe pressure measurement system. The variables were patient weight (from'normal' body mass index (BMI) to 'overweight','obese' and 'morbidly obese') and the TCC construct (with both a standard and alternate cast design). The standard TCC is considered the gold standard for off-loading of the diabetic foot. The alternate TCC was designed to use the essential offloading component of the traditional TCC, namely the total contact leg section, with use of an open cell polyurethane foam to transfer load from the foot to the lower leg, thereby offloading the foot by suspending it within a padded fiberglass walking cast.

RESULTS: We did not observe statistically significant differences in mean peak plantar pressures in any plantar foot anatomic area or with any body mass between the two TCC designs.

CONCLUSION: Based on the results, we concluded that the alternate TCC design provides another viable TCC construct option for practitioners working with the neuropathic foot. This investigation also provides specific data on changes that occur in peak plantar pressures with use of the total contact cast and variable BMIs.
It's Not What You Put On, but What You Take Off: Techniques for Debriding and Off-Loading the Diabetic Foot Wound
The basic etiology of neuropathic diabetic foot wounds involves pressure in conjunction with cycles of repetitive stress, leading to failure of skin and soft tissue. The central tenet of any treatment plan addressing neuropathic diabetic foot wounds is the appropriate debridement of nonviable tissue coupled with adequate pressure relief (off-loading with a total contact cast) ... Off-loading is best achieved by spreading force over a wide area of contact while ensuring compliance, such as with a total contact cast ... Total contact casts (TCCs) are considered by most diabetic foot specialists to be the reference standard for off-loading ... Total contact casting is effective in treating a majority of noninfected, non-ischemic plantar diabetic foot wounds, with healing rates ranging from 72% to 100% over a course of 5–7 weeks ... total contact casts are effective for a number of other reasons besides their ability to off-load. They may help reduce or control edema that can impede healing and, thus, potentially protect the foot from infection ...
Clinical and Economic Benefits of Healing Diabetic Foot Ulcers With a Rigid Total Contact Cast
A total contact cast is considered the gold standard for healing diabetic foot ulcers. Numerous studies have demon- strated the excellent healing success of a total contact cast; however, its adoption in routine clinical use does not match its success rate. This lack of implementation is due to several factors ...
Total contact casting reduces foot amputations, study finds
Those who are treating diabetic foot ulcers should evaluate modern total contact casting techniques, according to a new analysis. ... Researchers led by Caroline Fife, M.D., looked at a wound care registry with 11,784 patients with more than 25,000 diabetic foot ulcers. Outcome measures studied included whether the ulcers were healed/not healed, amputation, percent of off-loading, percent use of total contact casting and infection rates ... The most common off-loading option was the postoperative shoe (37%) and total contact casting (16%). There were significantly more amputations within a year for those with diabetic foot ulcers who did not have total contact casting when compared with those who did, according to results in the July issue of Advances in Skin & Wound Care ... "Total contact casting is vastly underutilized in DFU wound care settings, suggesting that there is a gap in practice for adequate off-loading," the authors wrote.
Off-Loading the Diabetic Foot Wound
OBJECTIVE—To compare the effectiveness of total-contact casts (TCCs), removable cast walkers (RCWs), and half-shoes to heal neuropathic foot ulcerations in individuals with diabetes.

RESEARCH DESIGN AND METHODS—In this prospective clinical trial, 63 patients with superficial noninfected, nonischemic diabetic plantar foot ulcers were randomized to one of three off-loading modalities: TCC, half-shoe, or RCW. Outcomes were assessed at wound healing or at 12 weeks, whichever came first. Primary outcome measures included proportion of complete wound healing at 12 weeks and activity (defined as steps per day).

RESULTS—The proportions of healing for patients treated with TCC, RCW, and half-shoe were 89.5, 65.0, and 58.3%, respectively. A significantly higher proportion of patients were healed by 12 weeks in the TCC group when compared with the two other modalities (89.5 vs. 61.4%, P = 0.026, odds ratio 5.4, 95% CI 1.1–26.1). There was also a significant difference in survival distribution (time to healing) between patients treated with a TCC and both an RCW (P = 0.033) and half-shoe (P = 0.012). Patients were significantly less active in the TCC (600.1 ± 320.0 daily steps) compared with the half-shoe (1,461.8 ± 1,452.3 daily steps, P = 0.04). There was no significant difference in the average number of steps between the TCC and the RCW (767.6 ± 563.3 daily steps, P = 0.67) or the RCW and the half-shoe (P = 0.15).

CONCLUSIONS—The TCC seems to heal a higher proportion of wounds in a shorter amount of time than two other widely used off-loading modalities, the RCW and the half-shoe.
Surgical Treatment of Diabetic Foot Complications: Clinical Review
Off-loading of the affected area is the standard of care and commonly results in healing the noninfected neuropathic ulcer. Methods of off-loading can be broadly categorized as external (nonweightbearing, casting, braces, orthotics, and shoes) or internal (surgical intervention to correct the deformity). A common frustration for the clinicians involved in surgical management of neuropathic ulcers is encountering a patient who has undergone months, if not years, of expensive local wound treatment in the presence of obvious deformity and/or osteomyelitis requiring surgical intervention. Generally, if an intervention has not made substantial gains in ulcer healing within four to six weeks of its inception, then other treatment options must be explored ... The total contact cast is considered the gold standard for off-loading the neuropathic forefoot ulcer. A removable cast-brace has the advantage of allowing for continued ulcer care while the forefoot is effectively off-loaded. The disadvantage is the risk of poor compliance--diabetic patients need only to walk on the unprotected foot for a short period of time to negate any healing ...
Clinical and Economic Benefits of Healing Diabetic Foot Ulcers With a Rigid Total Contact Cast
The physician reimbursement model indicates a steeper reimbursement capture rate and a higher aggregate reimbursement using the Total Contact Cast in the first 7 weeks of ulcer management (Figure 7). The Total Contact Cast graph is terminated at 7 weeks because of the 80%–90% probability of healing Wagner 1 and 2 ulcers versus < 56% probability with noncast healing modalities.[11,15] Although a clinician may be incentivized to maximize revenue by prolonging healing, this approach will compromise patient care and reduce turnover volume, resulting in reduced capacity to see new patients ...
The Contact Cast: An Update and Case Study Report
Sensory loss and moderate repetitive walking stress are the primary mechanisms of plantar ulcerations, which are common in patients with diabetes and other neuropathic conditions. The contact walking cast has been shown to be an effective method of off-loading plantar stress and promoting wound healing ... The technique was not used in the United States until 1965 when Dr. Paul Brand introduced the total contact cast to the National Hansen's Disease Center, in Carville, Louisiana ... The total contact cast was described as a minimally padded cast that conformed to the shape of the foot and leg and did not compress over time. The total contact cast was designed to reduce pressure over plantar ulcers by distributing weight-bearing forces over the entire foot and lower leg ...
Panel of experts develops new guidelines for diabetic foot care
To address the growing problem of diabetic foot care, the Society for Vascular Surgery has collaborated with the American Podiatric Medical Association and the Society for Vascular Medicine to develop a clinical practice guideline for the care of feet in people with diabetes ... In patients with a plantar foot ulcer - that is, an ulcer on the sole of foot caused by repeated injury - the researchers recommend using a total contact cast (TCC) or fixed ankle walking boot, which cannot be removed ...
Total contact casting reduces foot amputations, study finds
Those who are treating diabetic foot ulcers should evaluate modern total contact casting techniques, according to a new analysis.

Researchers led by Caroline Fife, M.D., looked at a wound care registry with 11,784 patients with more than 25,000 diabetic foot ulcers. Outcome measures studied included whether the ulcers were healed/not healed, amputation, percent of off-loading, percent use of total contact casting and infection rates ...
Getting a leg up
Maybe it started as a blister caused by a wrinkled sock in a too-tight shoe. Or perhaps the resident's toe was nicked during a recent toenail trimming ... foot ulcers are among the most common reasons diabetic patients in long-term care are hospitalized ... Some physicians use total contact casts ... One 2014 study in Advances in Skin & Wound Care found there were significantly more amputations within a year for those with diabetic foot ulcers who did not have total contact casting when compared with those who did ...
Diabetic neuropathy more harmful to the brain than expected (diabetes.co.uk)
Nerve damage caused by diabetes may be more harmful to the brain than previously thought, according to new research which could pave the way for better assessment, monitoring and treatment of diabetic neuropathy ... Until now it was widely believed that the impact of diabetes-related nerve damage on the brain was limited to peripheral areas.
BEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS (Evidence Based Nursing)
This document focuses on wound management best practice for diabetic foot ulcers (DFUs). It aims to offer specialists and non-specialists everywhere a practical, relevant clinical guide to appropriate decision making and effective wound healing in people presenting with a DFU.
Total contact casts were better than removable cast walkers or half shoes for healing diabetic neuropathic foot ulcers (Evidence Based Nursing)
In patients with diabetes, what is the effectiveness of total contact casts (TCCs), removable cast walkers (RCWs), and half shoes for healing neuropathic foot ulcerations? ... The total contact casting group had a higher incidence of wound healing than the half shoes group or the RCW and half shoes groups combined (table), and were less active than those in the half shoes group ... In patients with diabetes, total contact casts were more effective than removable cast walkers or half shoes for healing neuropathic foot ulcerations. Patients who used total contact casts were less active than those who used half shoes ...
Orthotist urges early intervention for Charcot foot
(Northern Ontario Medical Journal)
Marc Tessier, an orthotist and prosthetist practicing in North Bay, is on a mission to educate family doctors about the importance of early diagnosis of Charcot foot, one of the most devastating complications of diabetes.... "Our default position should be ultracautious when we suspect Charcot until it is ruled out completely," counsels Tessier. "Immobilization stops the deformity from progressing. You have to lock the foot up immediately with a total contact cast or an air cast walker, often for as long as 24 months ...

Back To Basics: How To Ensure Effective Offloading With Total Contact Casting

There are several mechanisms that combine to provide the reduction of peak plantar pressures via the use of Total Contact Casting. Studies have established that the use of Total Contact Casting decreases altered gait mechanics with shortened stride length and an overall reduction of walking velocity, both of which contribute to the reduction of plantar pressures.3 Furthermore, given the "cone effect" provided by the physical structure of the patient's leg (an inverted cone), the Total Contact Casting (a conical receptacle) also allows more even distribution of the patient's weight ...

Diabetic Foot Disorders
The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes associated complications are expected to rise in prevalence.
Off-Loading the Diabetic Foot Wound
A comparison of the effectiveness of total-contact casts (Total Contact Casts), removable cast walkers (RCWs), and half-shoes to heal neuropathic foot ulcerations in individuals with diabetes.
Diabetes Facts
Etiology, pathophysiology and classifications of the diabetic Charcot foot
Charcot foot is a specific manifestation of peripheral neuropathy that may involve autonomic neuropathy with high blood flow to the foot, leading to increased bone resorption ...
Diabetic Foot Disorders - A Clinical Practice Guideline
The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, dia betes-associated complications are expected to rise in prevalence.
Best practice guidelines: Wound management in diabetic foot ulcers
This document focuses on wound management best practice for diabetic foot ulcers (DFUs). It aims to offer specialists and non-specialists everywhere a practical, relevant clinical guide to appropriate decision making and effective wound healing in people presenting with a DFU.
Total contact casting combined with human fibroblast-derived dermal tissue in 15 DFU patients

An investigation into the use of a cryopreserved human fibroblast-derived dermal substitute (Dermagraft; DG) in combination with total contact casting in patients with diabetic foot ulcers, compared with previously published rates of healing with total contact casting alone.

Clinical and Economic Benefits of Healing Diabetic Foot Ulcers With a Rigid Total Contact Cast (Medscape)

A total contact cast is considered the gold standard for healing diabetic foot ulcers (DFU). Numerous studies have demonstrated the excellent healing success of a total contact cast; however, its adoption in routine clinical use does not match its success rate. This lack of implementation is due to several factors: Medicare's payment structure, lack of clinical training, and a variety of patient factors. These factors have reduced clinicians' use of total contact cast to approximately 25% of DFU. The aim of this review was to analyze and demonstrate common scenarios for outpatient wound centers where a total contact cast may be beneficial to both patients and hospital systems, and to expand its usage to more closely reflect its healing success rate ...

A comparative study of zoledronic acid and once weekly Alendronate in the management of acute Charcot arthropathy of foot in patients with diabetes mellitus (National Library of Medicine)
Charcot arthropathy (CA) is a chronic and progressive disease of bone and joints, characterized by painless bone and joint destruction in limbs that have lost sensory innervation. The main cause of CA is diabetic polyneuropathy with the joints of foot being most commonly affected. The condition is rare, however, affecting perhaps only 1% of all people whose diabetes is complicated by neuropathy. The actual incidence of CA is perhaps greater than that reported. ...
The total-contact cast for management of neuropathic plantar ulceration of the foot (The Journal of Bone and Joint Surgery) Registration Required
Seventy-one neuropathic ulcers of the foot in sixty-six patients were treated with the use of a total-contact cast. The ulcers had been present for an average of five months (range, one to twenty-nine months) and were graded according to the Wagner classification ...

Charcot and Total Contact Casts (Intersting forum discussion concerning Total Contact Casting usage for the treatment of Charcot Foot - PRESENT Podiatry)
Just curious what people are using to treat their Charcot foot patients with--total contact casts, cam walkers, crow walkers...? Every article I read about Charcot mentions total contact cast as the mainstay of treatment, sometimes almost exclusively, but ...

Complications of Total Contact Casting
The benefits of using TCC still far outweigh any risks. (Podiatry Management)
D Drs. Milroy Paul and Joseph Kahn first utilized total contact casting for trophic ulceration secondary to Hansen's disease in Ceylon, India. Khan published his technique and case series on total contact casting in 1939.1 Dr. Paul Brand was the first to adopt the total contact casting, which he learned in India, for the treatment of diabetic foot ulcerations.2 ...

Total Contact Casting in Daily Practice: Clinical Results from a Prospective Study
A prospective follow-up study published in Diabetes Care evaluated the effectiveness of Total Contact Casting (TCC) in managing neuropathic plantar diabetic foot ulcers (DFUs) under real-world clinical conditions …
A peek under the Cast, a Total Contact Casting Primer with Dr. Michael Miller
(a diatribe in four verses)
Okay fans, let's talk about the science behind Total Contact Casting. But before we talk about the science, what is a Total Contact Cast? Well, before we talk about Total Contact Casting, let's talk about the key to not just healing wounds but preventing them. But before we talk about preventing and healing them, we need to talk about them … wounds that is ... Wound is a term that usually means a defect in the epithelium, which is a five syllable word for skin. Another term you might hear is the word "ulcer". The simplest way to differentiate these two is to remember that an ulcer arises from the inside and comes out whereas a wound starts on the outside and progresses inside. The key to understanding this is by example's …
Playing the Long Game with Diabetes
For individuals living with diabetes, protecting foot health is a long-term investment. Even small wounds or unnoticed blisters can escalate into serious complications due to reduced sensation and slower healing. This makes prevention—through daily habits and medical guidance—an essential part of diabetes care.
New Study, Same Conclusion. It is time to take another look at Total Contact Casting
The most recent and perhaps the most conclusive study of for treatment of the diabetic foot is a collaboration of three prominent organizations, The Society for Vascular Surgery, the American Podiatric Medical Association and the Society for Vascular Medicine. The guidelines, “The Management of the Diabetic Foot,” were developed after three years of studies and are published online and in print in the Journal for Vascular Surgery. Dr. Anil P. Hingorani is the lead author that researched and wrote the guidelines. With diabetes a major worldwide problem and little data on treatments, the need for detailed, diabetic foot clinical guidelines from multiple disciplines was great, said Hingorani ...
The Repeatability of Total Contact Cast Applications: Implications for Clinical Trials
The purpose of this study was to determine the repeatability of total contact cast application for clinical trials using plantar pressure measurement. Nine healthy volunteers consented to be tested while wearing a running shoe and two applications of a total contact cast ... Although numerous devices have been researched concerning their off-loading abilities, the total contact cast (TCC) remains the gold standard ...
Pressure Point Offloading in the Diabetic Foot
The formation of diabetic wounds has been discussed, with an emphasis on the effects of force on the plantar tissues and the theoretical response of those tissues. As pressure reduction is an integral part of the healing process for diabetic wounds, many types of offloading strategies in the medical literature have been examined ... Often referred to as 'total contact casting', it involves minimal padding, to ensure a close fit against the tissues. Considered the most effective off-weighting strategy for diabetic wounds, total contact casting redistributes pressures across the foot more efficiently ...
Pressure Point Offloading in the Diabetic Foot
The first randomized clinical trial on different modes of off-load diabetic foot wounds by Armstrong et al. (1) was long awaited. The total contact cast (TCC) turned out to be better than a removable cast walker (RCW) or a half-shoe for the off-loading of neuorpathic plantar ulcers ...
Nonremovable, Windowed, Fiberglass Cast Boot in the Treatment of Diabetic Plantar Ulcers

OBJECTIVE—To compare the efficacy, safety, and compliance of a nonremovable fiberglass cast boot and off-loading shoes in the treatment of diabetic plantar ulcers.

RESEARCH DESIGN AND METHODS—Patients (n = 93) with noninfected, nonischemic plantar ulcers were included in this prospective nonrandomized study. Treatment used a nonremovable fiberglass cast boot for longer standing and deeper ulcers (n = 42) and a half shoe or heel-relief shoe for other ulcers (n = 51). We evaluated off-loading therapy, compliance, and complications in both groups.

RESULTS—The healing rate was significantly higher with the cast boot than with the off-loading shoe (81 vs. 70%, P = 0.017), with healing times of 68.6 ± 35.1 vs. 134.2 ± 133.0 days, respectively, and hazard ratio 1.68 (95% CI 1.04–2.70); complete compliance with treatment was 98 vs. 10% (P = 0.001), respectively. Secondary osteomyelitis developed in 3 patients in the cast boot group and 13 patients in the off-loading shoe group (P = 0.026).

CONCLUSIONS—A nonremovable fiberglass cast boot was effective in healing diabetic plantar ulcers and in decreasing the risk of secondary osteomyelitis. The cast boot forced compliance with off-loading, thus promoting healing.

Clinical studies have established that off-loading by a total contact cast (TCC) is the reference standard in the treatment of noninfected, nonischemic plantar ulcers related to diabetic neuropathy
The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review

BACKGROUND:
Footwear and offloading techniques are commonly used in clinical practice for the prevention and treatment of foot ulcers in diabetes, but the evidence base to support this use is not well known. The goal of this review was to systematically assess the literature and to determine the available evidence on the use of footwear and offloading interventions for ulcer prevention, ulcer treatment, and plantar pressure reduction in the diabetic foot.

METHOD:
A search was made for reports on the effectiveness of footwear and offloading interventions in preventing or healing foot ulcers or reducing plantar foot pressure in diabetic patients published prior to May 2006. Both controlled and uncontrolled studies were included. Assessment of the methodological quality of studies and data extraction was independently performed by two reviewers. Interventions were assigned into four subcategories: casting, footwear, surgical offloading and other offloading techniques.

RESULTS:
Of 1651 articles identified in the baseline search, 21 controlled studies were selected for grading following full text review. Another 108 uncontrolled and cross-sectional studies were examined. The evidence to support the use of footwear and surgical interventions for the prevention of ulceration is meagre. Evidence was found to support the use of total contact casts and other non-removable modalities for treatment of neuropathic plantar ulcers. More studies are needed to support the use of surgical offloading techniques for ulcer healing. Plantar pressure reduction can be achieved by several modalities including casts, walkers, and therapeutic footwear, but the diversity in methods and materials used limits the comparison of study results.

CONCLUSIONS:
This systematic review provides support for the use of non-removable devices for healing plantar foot ulcers. Furthermore, more high-quality studies are urgently needed to confirm the promising effects found in both controlled and uncontrolled studies of footwear and offloading interventions designed to prevent ulcers, heal ulcers, or reduce plantar pressure.
Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part One -- Diabetic Foot Ulcerations
Reduction of pressure, or offloading, is another essential aspect of diabetic wound care. Foot pressures, shock, and shear can be reduced with appropriately fitted shoes, insoles, and socks.[10,40] Total nonweight bearing using a wheelchair or crutches is the most effective method of relieving pressure although most patients have difficulty complying with these modalities. Total contact casts (TCCs) and removal casts are effective in significantly reducing pressure ...
Off-loading Essential to Diabetic Foot Ulcer Healing
Diabetes mellitus has become more common in the United States as the rates of overweight and obesity have increased among adults. Limb amputation is one of the most feared complications of diabetes, and Driver and colleagues described the epidemiology, economic costs, and best practices for care of diabetic foot ulcers (DFUs) in a review article published in the September/October 2010 issue of the Journal of the American Podiatric Association ... The article also makes it clear that total contact casting (TCC), not shoe gear or removable casts, is the optimal off-loading method... Although both removable cast walkers and total contact casts can achieve this, the panel agreed that the total contact cast is ideal because it ensures constant use ...The total contact cast has also been found cost-effective, with data from the US Wound Registry showing that the average per patient cost of treatment with the cast was $11,946 vs $22,494 when the cast was not used ... Dr Snyder told Medscape Medical News, "There was very strong agreement that total contact cast should be the gold standard.... It was very clear from the literature that the devices that could not be removed were far and away better, because [they] forced compliance." ...
The Contact Cast: An Update and Case Study Report
Most insensate foot ulcers close when proper off-loading methods such as casting are used. As many as 34 percent of these cases, however, will experience ulcer recurrence within one year.[20] A plantar ulcer may recur if normal walking activity is resumed before a wound is fully matured. Scar tensile strength increases during the remodeling phase of wound healing ... A contact cast was applied and the patient was instructed in partial weight-bearing ambulation with a walker. The cast was reapplied at one week, and within three weeks, the wounds were fully closed. At wound closure, the patient was fitted ...
Offloading Foot Wounds in People With Diabetes
Up to 25% of people with diabetes will develop a foot ulcer at some point during their lifetime, and 1 in 5 will require an amputation ... Total contact casting (TCC) is considered by most diabetic foot specialists to be the gold standard offloading modality ... Plaster casting to treat neuropathic foot wounds was first described by Milroy Paul and later popularized in the United States by Dr. Paul Brand at the Hansen's Disease Center, in Carville, Louisiana ... Besides its capacity to offload, total contact casting serves to protect the foot from infection and helps control edema ...
Clinical and Economic Benefits of Healing Diabetic Foot Ulcers With a Rigid Total Contact Cast
A total contact cast (TCC) is considered the gold standard for healing diabetic foot ulcers (DFU). Numerous studies have demonstrated the excellent healing success of a TCC; however, its adoption in routine clinical use does not match its success rate. This lack of implementation is due to several factors: Medicare's payment structure, lack of clinical training, and a variety of patient factors ...The rising incidence and prevalence of diabetes in the United States has resulted in a synonymous escalation of nonhealing diabetic foot ulcers ... To date, a rigid total contact cast (TCC) has demonstrated the lowest peak plantar pressure on an ambulatory patient ... Numerous published studies and clinical workshops over the last few decades have demonstrated the superiority of a total contact cast system in healing DFU ...
New Comprehensive Guidelines Tackle Diabetic Foot Management
New evidence-based clinical-practice guidelines on diabetic foot management cover five areas: ulcer prevention, off-loading, osteomyelitis diagnosis, wound care, and peripheral arterial disease ... In patients with plantar diabetic foot ulcer, the panel recommends off-loading with a total contact cast ... "The evidence for total contact casting for diabetic foot wounds is very, very strong. One of the most important recommendations is off-loading and it's one of the least utilized," Dr Hingorani noted ...
New Guidelines Stress Need for Diabetic Foot Ulcer Offloading
Offloading is essential to diabetic foot ulcer healing, according to new podiatry consensus guidelines ... Dr Jan Ulbrecht (Mount Nittany Medical Center, State College, Pennsylvania) agreed. "Adequate offloading absolutely has to be at the core of care of every single foot ulcer," he told Medscape Medical News ... Total contact casting is the preferred method for offloading plantar diabetic foot ulcers because it has most consistently demonstrated the best healing outcomes and is a cost-effective treatment ... In a study, total contact casting reduced plantar pressure by 32%, 63%, and 69% on the fifth, fourth, and first metatarsal heads, respectively, and by 65% on the great toe and 45% on the heel (J Rehabil Res Dev. 1995;32:205-209) ...
Hyperbaric Oxygen Does Not Help Chronic Diabetic Foot Ulcers
Among 103 diabetic patients with a nonhealing foot ulcer who received standard care, those who additionally received hyperbaric-oxygen therapy were just as likely to need an amputation as patients who also received sham therapy, in a new randomized controlled trial ... Moreover, adjuvant hyperbaric-oxygen therapy did not improve wound healing compared with added sham therapy, in this study by Ludwik Fedorko, MD, associate professor of anesthesiology and pain management at the University of Toronto, Ontario, and colleagues, which was published online January 6, 2016 in Diabetes Care. ...
Study Seeks to Further Understand Pressure Reduction Mechanism of the Total Contact Cast
The total contact casting is an effective intervention to reduce plantar pressure in patients with diabetes and a plantar forefoot ulcer. The walls of the total contact cast have been indirectly shown to bear about 30 percent of the plantar load. A method to measure inside the total contact cast walls with capacitance sensors has shown that the anterodistal and posterolateral-distal regions of the lower leg bear the highest load. The objective of an open access study published January 7 in the Journal of Foot and Ankle Research was to directly measure these two regions in patients with diabetes and plantar forefoot ulcers to further understand the mechanism of pressure reduction in the total contact cast. ...
What is Charcot Foot (FootHealthFacts.org)
A novel approach to mapping load transfer from the plantar surface of the foot to the walls of the total contact cast: a proof of concept study
Total contact casting is regarded as the gold standard treatment for plantar foot ulcers. Load transfer from the plantar surface of the foot to the walls of the total contact cast has previously been assessed indirectly ...
Implementation Of Total Contact Casting As Standard Of Care For Diabetic Foot Ulcers
In patients with diabetic foot ulcers, removable device options for pressure relief include wider footwear, an Arco boot or an air cast.However, these types of removable devices are often ineffective ... the literature notes that they are unsuccessful in relieving pressure and resolving wounds in approximately 50% of patients ... When footwear and removable devices are ineffective, noted Dr. Garceau, a viable option for pressure relief is total contact casting ...
Total contact casting of the diabetic foot in daily practice: a prospective follow-up study.

A limited number of clinical trials have shown that the total contact cast (TCC) is an effective treatment in neuropathic, noninfected, and nonischemic foot ulcers. In this prospective data collection study, we assessed outcome and complications of Total Contact Cast ...

Plantar pressures with total contact casting
Total contact casting has been used to aid in the healing of plantar neurotrophic ulcerations . The efficacy of total contact casts in promoting ulcer healing is presumably due to a reduction in the load ...
Total Contact Cast for Neuropathic Diabetic Foot Ulcers
To determine the outcome of diabetic neuropathic foot ulcers treated with Total Contact Cast in terms of percentage of ulcers healed and time to heal ...
Pressure-relieving interventions for treating diabetic foot ulcers

Diabetes-related foot ulceration is a major contributor to morbidity in diabetes. Diabetic foot ulcers are partly a consequence of abnormal foot pressures and pressure relief is a widely used treatment for healing diabetes-related plantar foot ulcers, but the most effective method for healing is unclear.

Clinical and Economic Benefits of Healing Diabetic Foot Ulcers With a Rigid Total Contact Cast

Revisiting the Total Contact Cast

Although the benefits of total contact casting for healing plantar neuropathic ulcers are consistent throughout a large body of available literature, the method of cast application varies). Cast structure at the ulcer site provides one major variance, i.e., should the cast create total contact with the entire plantar surface of the foot or should the wound be isolated? This article aims to resolve this issue by examining the differences in plantar pressure at the wound site between total contact casting using full contact with the plantar aspect of the foot and wound isolation. ...

Efficacious Treatment of Diabetic Foot Ulceration with Total Contact Casting (Todays Wound Clinic)
Diabetic foot ulcerations (DFUs) pose a considerable financial bur- den for the US healthcare system and impart an enormous emotional toll on people who live with these complex wounds ... Many modalities and therapies are utilized during the management and treatment of DFUs, but none has shown more efficacious outcomes than offload- ing with total contact casting ... Yet, it has been reported that less than 2% of practitioners utilize this basic mo- dality during the treatment of DFUs ... Several reasons were reported for not utilizing TCC, including resis- tance to casting by the patient, inappro- priateness for select patients, difficulty in application, lack of training, and low reimbursement