Why Total Contact Casting Is Still The Gold Standard For Offloading DFUs
An extraordinary new review offers a treasure trove of information on offloading for diabetic foot ulcers (DFUs) and found that the total contact cast (TCC) is still the most effective offloading device.1
The review focused on 13 randomized controlled trials.1 The authors found that although ulcer healing was enhanced with total contact casting, irremovable cast walkers and removable cast walkers (RCWs), TCCs and irremovable cast walkers were more effective for ulcer healing. The study adds that patients with diabetic foot ulcers in the study preferred TCCs over removable cast walkers due to perceived increased wound healing, although the study notes concerns of cost, comfort and convenience for patients.
This health technology assessment series is one of the first times a government body has consistently evaluated the problem of offloading. I think some of the analysis is pretty novel, particularly looking at cost and resources, which we have not been able to look at in a systematic way in the past. Our group and others over many years have long extolled the virtues of using TCC for the diabetic foot. It has long been considered a gold standard device although people don’t use this device very much. We have found that fewer than 2 percent of clinicians use this device as their primary means of offloading DFUs.2 That has increased somewhat over the last decade but is probably still in the low double digits.
Why is this? I think there is an inherent fear of applying a cast to someone who is neuropathic. While most of the data suggests that this fear is irrational, it is still a fear nonetheless.3 There are also issues of effective reimbursement although that has changed in some health plans as well.
However, if people are not going to use a TCC, we have offered some alternatives as well. In 2002, we introduced the idea of an instant TCC, where one will take a RCW and simply make it irremovable by wrapping it in plastic or Coban.4 A couple of randomized controlled trials suggested that this irremovability seemed to be promising and the data have consistently guided us along this path.5,6 The most recent 2015 International Working Group on the Diabetic Foot guidelines were modified to include irremovable offloading rather than simply TCC.7
For my friends and colleagues, I believe it is a good idea to challenge all of our preconceived notions as well as our preconceived patterns of practice. This is one area where most of us can improve on a day-to-day basis. It could make a big difference not only in our practice, but for the patients whom we serve as well.
References
1. Health Quality Ontario. Fibreglass total contact casting, removable cast walkers, and irremovable cast walkers to treat diabetic neuropathic foot ulcers: a health technology assessment. Ont Health Technol Assess Ser. 2017; 17(12):1–124.
2. Wu SC, Jensen JL, Weber AK, et al. Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes Care. 2008;31(11):2118-2119.
3. Guyton GP. An analysis of iatrogenic complications from the total contact cast. Foot Ankle Int. 2005; 26(11):903-7.
4. Armstrong DG, Short B, Espensen EH, Abu-Rumman PL, Nixon BP, Boulton AJ. Technique for fabrication of an "instant total-contact cast" for treatment of neuropathic diabetic foot ulcers. J Am Podiatr Med Assoc. 2002;92(7):405-8.
5. Armstrong DG, Lavery LA, Wu S, Boulton AJ. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. Diabetes Care. 2005 Mar;28(3):551-4.
6. Najafi B, Grewal GS, Bharara M, Menzies R, Talal TK, Armstrong DG. Can't stand the pressure: the association between unprotected standing, walking, and wound healing in people with diabetes. J Diabetes Sci Technol. 2017 Jul;11(4):657-667.
7. Bakker K, Apelqvist J, Lipsky BA, et al. The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:2-6.
