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A Clinical Minute: Taking the Pressure Off Diabetic Wound Care
With the growing diabetes epidemic, management of diabetic foot ulcers (DFUs) has become crucial, given they precede 85% of all nontraumatic lower extremity amputations.1 Furthermore, there is a 68% mortality rate 5 years post-lower-extremity amputation.2
Total contact casting (TCC) is considered the gold standard in the management of DFUs, and numerous randomized, controlled trials validate its efficacy with healing rates of 89.5% in a mean of 33.5 days.3-6
Despite the evidence supporting TCC, a recent study found that only 2.2% of eligible patient visits utilize offloading.7 Clearly, a gap exists between evidence and practice, suggesting that, as wound care practitioners, we need to increase awareness and utilization of this highly effective treatment modality. One of the main barriers associated with TCC is that it is considered cumbersome and time-consuming; however, with the development of the TCC-EZ® Total Contact Casting System (Derma Sciences, Inc, Princeton, NJ) (see Figure 1), it has become easier to use and a wide variety of patient needs can be met. This is supported by the fact that clinics that use TCC-EZ were found to be four times more likely to use TCC for DFUs.7
I work in a busy metropolitan wound care center, and we use TCC-EZ to heal challenging DFUs. The following two cases illustrate how patients can quickly experience the benefits of using TCC-EZ.
Case 1. A 49-year-old female post-renal transplant patient presented to the hospital with a heel wound (see Figure 2) on her right foot. She was diagnosed with osteomyelitis and peripheral artery disease. She underwent stent placement, then debridement, and was given 6 weeks of IV antibiotics. She resisted TCC because it involved her dominant foot. After discussing the benefits of proper offloading and the risks of ineffective treatment, she tried TCC-EZ. She experienced marked improvement and her wound healed in 8 weeks (see Figure 3).
Case 2. A 58-year-old female patient was admitted with a medial foot wound (see Figure 4) and osteomyelitis of the first metatarsal head and toe. She refused toe amputation. She was given 6 weeks of IV antibiotics and negative pressure wound therapy. She initially refused TCC because she lived far from the clinic and wanted to limit visits to every 2 weeks. After discussing the benefits of proper offloading and the risks of ineffective treatment, she initiated TCC-EZ. Her wound progressed and healed in 8 weeks (see Figure 5).
Conclusion
In our experience, even reluctant patients will rapidly see the benefits of TCC-EZ. Therefore, we believe all practitioners treating DFUs should discuss this treatment option with their patients. In fact, TCC-EZ has become so commonplace in our clinic it is part of waiting room conversations.
As for reluctant healthcare professionals, although there is a learning curve for new users, clinicians can become proficient with TCC-EZ in a matter of weeks (see Figure 6). Given the positive experiences in our clinic combined with the healing outcomes, our staff are ready and willing to cast patients when appropriate.
TCC-EZ should be an integral part of a comprehensive wound care regimen for DFU, because it’s time to take the pressure off healing DFUs.
For more information on, TCC-EZ Total Contact Casting System visit www.dermasciences.com/products/advanced-wound-care/tcc-ez/.
A Clinical Minute is made possible through the support of Derma Sciences, Inc, Princeton, NJ. The opinions and statements provided in A Clinical Minute are specific to the respective authors and not necessarily those of OWM or HMP Communications. This article was not subject to the Ostomy Wound Management peer-review process.
1. Jaakola A, Weber A. Current concepts in total contact casting in DFUs. Podiatry Today. 2014;27(4);22-25.
2. Armstrong DG, Wroebel J, Robbins JM. Guest Editorial: Are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007;4(4):286–287.
3. Armstrong DG, Nguyen HC, Lavery LA, von Schie CHM, Boulton AJM, Harkless LB. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care. 2001;24(6):1019-1022.
4. Armstrong D, Lavery LA, Wu S, Boulton AJ Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized clinical trial. Diabetes Care. 2005;28(3):551–554.
5. Katz IA. A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care. 2005;28(3):555–559.
6. Piaggesi A. An off-the-shelf instant contact casting device for the management of diabetic foot ulcers. Diabetes Care. 2007;30(3):586–590.
7. Fife CE, Carter MJ, Walker D, Tomson B, Eckert KA. Diabetic foot ulcer off-loading: the gap between evidence and practice. Data from the US Wound Registry. Adv Skin Wound Care. 2014;27(7):310–316.
