The total contact cast: controversy in offloading the diabetic foot
Total contact casting has long been considered the gold standard for offloading the diabetic foot. However, it remains underutilised with less than 2% of clinicians reportedly using it for the treatment of the majority of diabetic foot ulcers. Proper TCC application with avoidance of iatrogenic lesions requires skilled cast technicians, trained in casting the insensate foot, and is an expensive and time-consuming process. Additionally the TCC is contraindicated in patients with infection or critical ischaemia and must be used with caution in elderly patients, those with visual or equilibrium problems, those with a contralateral foot ulcer or with varicose veins.
There is minimal robust evidence for the use of the TCC over other offloading modalities such as the removable cast walker and the instant total contact cast. However there is also minimal evidence for iatrogenic lesions caused by TCC. Additionally, the superior offloading properties and expedited healing rates of the TCC are demonstrated in a number of smaller studies. In conclusion there is a lack of consensus on the best device to offload DFU. However offloading is undoubtedly paramount to successful and timely healing. More research with larger samples sizes is required to support the TCC as the gold standard off loading device.
Diabetic foot ulceration (DFU) represents a major medical, social and economic problem globally. While more than 5% of diabetic patients have a history of foot ulceration, the cumulative lifetime incidence may be as high as 15% (Fig 1).1
Diabetic foot ulceration. The cumulative lifetime incidence may be as high as 15%
Retrospective and prospective studies have shown that elevated plantar pressure is a cause of the development of plantar ulcers in diabetic patients,2,3 and that ulceration is often a precursor of lower extremity amputation.4 The central goal of any treatment plan designed to heal plantar ulcers, is effective reduction of pressure (offloading).5 In the sensate foot, for example in a patient with rheumatoid arthritis, offloading pressure at painful regions of the foot is both driven and evaluated by the patient’s pain.6 However, up to 50% of patients with diabetes will eventually develop neuropathy and loss of protective sensation.7 Sensory neuropathy, coupled with deformity secondary to autonomic and motor neuropathy, makes offloading the diabetic foot a considerable challenge.8
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