Total Contact Casting – It Shouldn’t Be So Hard to Do the Right Thing

Introduction: Offloading pressure is a key component in managing diabetic foot ulcers (DFUs). The International Working Group on Diabetic Foot (IWGDF) recommends a non-removable or total-contact cast (TCC) system as the first choice for off-loading plantar forefoot or midfoot DFUs1. Even though a TCC is considered the gold standard for off-loading plantar DFUs, less than 6% of patients with DFUs receive TCC for a variety of reasons, including the time required to apply the cast, and the perceived technical requirements for applying a TCC2.

Lower Limb amputation in diabetics is frequently preceded by a DFU, as high as 84% of the time, and patients with DFUs have been reported to have a 30.5% five-year mortality rate3. Despite the high mortality rate associated with DFUs, clinicians are not utilizing TCC as often as they should. Considering the morbidity associated with DFUs, the author poses the question: why are we not using TCC more often in our DFU patients?

Here, we present a case series of 5 patients with DFUs who were treated with a roll-on TCC system that was quick and easy to apply (and remove), had a short technical learning curve, that had reproducible results, and took all patients in this series on to closure.

Methods: Five diabetic patients presented with chronic DFUs, some of whom had initially refused or did not receive treatment with a TCC. Patients' risk factors included poorly-controlled diabetes, obesity, diabetic peripheral neuropathy, hypertension, chronic nicotine use, coronary artery disease, COPD, HIV, and hepatitis C. Average wound size prior to application was 3.1 cm2. Results: TCC off-loading provided successful outcomes; wound healing occurred in all patients with an average time to closure of 46 days.

Discussion: This study provides evidence supporting the use of a TCC system over conventional wound healing treatments for DFUs. TCC positively impacted wound healing and the length of time required for complete closure. The TCC system used in this case series was a roll-on system that was easy to apply, had a short technical learning curve, and demonstrated reproducible results.