A Clinical Minute: TCC-EZ Healing Chamber: A First-line Therapy

  Diabetic foot ulcers (DFUs) precede 85% of all nontraumatic lower extremity amputations,¹ and there is a 45% mortality rate 5 years post lower-extremity amputation.² Combined with the growing diabetes epidemic, DFU management has become an area of focus and concern. The ultimate goal is to prevent the “amputation stairway” of compounding steps from diabetes and neuropathy through to amputation.

  Offloading to redistribute pressure is a cornerstone in the treatment of DFUs and is recommended by multiple clinical guidelines.^3,4 Among various offloading options, total contact casting (TCC) is considered the gold standard based on its proven efficacy in multiple randomized controlled trials, showing an overall healing rate of 89.5% in a mean of 33.5 days.^5-10

  Furthermore, a recent consensus statement¹¹ on the use of offloading in the management of DFUs concluded adequate offloading increases the likelihood of DFU healing and should be considered part of standard care. Despite this evidence, a recent study found only 2.2% of eligible patient visits utilize offloading.¹² This raises the question: Why is TCC not a first-line therapy for DFUs?

  At our Wound Care Center, complex and challenging wounds of various etiologies are the norm because 80% of the patients have diabetes. Our clinicians focus on a holistic approach that includes identification of causative factors, vascular management, infection management and prevention, pressure relief (the VIPs),¹¹ surgical and sharp debridement, medications, compression, and offloading, along with adjunctive therapies and education. We regularly use TCC-EZ® Total Contact Casting System (Derma Sciences, Inc, Princeton, NJ) as first-line therapy for DFUs. TCC-EZ® works by creating a Healing Chamber™ for active healing, which helps establish a positive macroenvironment and microenvironment of the wound by reducing inflammation and increasing granulation tissue development while providing pressure relief. The following case study exemplifies TCC-EZ’s® potential to support DFU healing or protocol of care.

  Case study. A 62-year-old male smoker with multiple comorbidities (congestive heart failure, myocardial infarction, hypertension, chronic obstructive pulmonary disease, cancer of the gallbladder, diabetes, gout, and cirrhosis) was treated for a DFU on his right plantar foot that had been present for 8 months. Previous treatments included hyperbaric oxygen, offloading with a wedge shoe, silver alginate dressings, collagen foam, debridement, and cellular-based and tissue-based products. Little or no progress following 8 months of advanced wound care treatments was noted. The wound was progressing at 3 weeks and 6 weeks after initiating TCC-EZ® and providing debridement and a foam dressing, the wound decreased in size from 0.5 cm x 0.5 cm x 0.7 cm (see Figure 1a) to 0.1 cm x 0.1 cm x 0.1 cm (see Figure 1b); 47 days after TCC-EZ® was initiated, the wound healed (see Figure 1c). The chronic wound cycle was broken, the wound progressed to closure, and potential serious complications were avoided.

  Using TCC-EZ® in our clinic has helped patients with DFUs break the chronic wound cycle, promoting quick closure and thus minimizing the risk for complications while improving patients’ quality of life.

  Our clinical experience supports evidence showing when offloading with TCC-EZ® is integrated into the patient encounter process and provided at each visit, the likelihood of DFU healing increases and the chance of complications decreases.¹¹ For more complex wounds, the consensus statement¹¹ also notes advanced therapies are unlikely to improve wound-healing outcomes unless effective offloading is obtained.

  As you will see in next month’s column, offloading with TCC-EZ®, combined with advanced therapies such as AMNIOEXCEL® Amniotic Allograft Membrane (Derma Sciences, Inc), can help achieve optimal outcomes for more difficult wounds or high-risk patients.

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. National Diabetes Data Group. Diabetes in America, Vol. 2. Bethesda, MD: National Institutes of Health;1995.

2. Centers for Disease Control and Prevention. National Diabetes Fact Sheet 2011. Available at: www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Accessed March 19, 2013.

3. Chadwick P, Edmonds M, McCardle J, Armstrong D. International best practice guidelines: wound management in diabetic foot ulcers. Wounds International. 2013. Available at: www.woundsinternational.com. Accessed March 19, 2015.

4. Steed DL Attinger C, Colaizzi T, Crossland M, Franz M, Harkless L, et al. Guidelines for the treatment of diabetic ulcers. Wound Repair Regen. 2006;14(6):680–692.

5. Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Off-loading the diabetic foot wound. Diabetes Care. 2001;24(6):1019–1022.

6. Armstrong DG, Lavery LA, Wu S, Boulton AJ. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds. Diabetes Care. 2005;28(3):551–554.

7. Katz IA Harlan A, Miranda-Palma B, Prieto-Sanchez L, Armstrong DG, Bowker JH, et al. 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.

8. Piaggesi A, Macchiarini S, Rizzo L, Palumbo F, Tedeschi A, Nobili LA. An off-the-shelf instant contact casting device for the management of diabetic foot ulcers. Diabetes Care. 2007;30(3):586–590.

9. Lavery AL, Higgins KR, La Fontaine J, Zamorano RG, Constantinides GP, Kim PJ. Randomised clinical trial to compare total contact casts, healing sandals and a shear-reducing removable boot to heal diabetic foot ulcers. Int Wound J. 2014 [epub ahead of print, DOI: 10.1111/iwj.12213].

10. Mueller NJ, Diamond JE, Sinacore DR, Delitto A, Blair VP 3rd, Drury DA. Total contact casting in treatment of diabetic plantar ulcers; controlled clinical trial. Diabetes Care. 1989;12(6):384–388.

11. Snyder RJ, Kirsner RS, Warriner RA 3rd, Lavery LA, Hanft JR, Sheehan P. Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Ostomy Wound Manage. 2010;56(4 suppl):S1–S24.

12. Fife CE, Carter MJ, Walker D, Thomson 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.