Is Total Contact Casting Time Effective?

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By Brian McCurdy, Associate Editor

Is total contact casting (TCC) too time-consuming a modality to be used in treating plantar foot ulcerations? It’s a prevailing question that has thwarted wider use of the modality. However, a new study recently presented at the Symposium on Advanced Wound Care (SAWC) attempts to shed new light on the “time-effectiveness” of TCC. Study researchers concede there is a “relatively low use rate” of total contact casts for diabetic foot ulcers. Why? They say many do not use TCC because of the time involved in the process and frequent office visits. However, previous studies have shown that employing TCC has resulted in healing times of 38 to 60 days. Study co-author Jeffrey Jensen, DPM, calls TCC the “gold standard.” “(TCC) provides the patient and the clinician with a method of healing wounds quickly,” says Dr. Jensen, a Diplomate of the American Board of Podiatric Surgery and Associate Professor at the University of Colorado Health Sciences Center. “This increases the clinician’s credibility in the community and they will receive more referrals because they are getting desirable outcomes.” Addressing The Issue Of Time-Consuming Application Dr. Jensen and his co-authors tracked 50 patients for the study and timed the applications of casting. The total average time a patient spent in the office for cast application following wound debridement was 29 minutes, according to the study. For the average patient, set-up and drying time totaled 21 minutes and 29 seconds. Application time, or actual physician time with the patient, was seven minutes and 32 seconds. When using total contact casting, you can save time “by effectively utilizing and minimizing physician involvement, understanding the importance of appropriate application of the TCC and minimizing the number of visits to heal the wound,” the study concludes. Dr. Jensen says he and his colleagues at the University of Colorado Health Sciences Center and Diabetic Foot and Wound Center use about 750 casts a year, employing them in case rate scenarios for insurers like Pacificare. Weighing The Results “Patients like the (casts) because they heal quickly,” says Dr. Jensen. “In the absence of infection and with intact vascular status, there is no equivalent treatment.” Between 1993 and 1999, Dr. Jensen tracked 305 patients, whose average wound duration was 304 days before presenting to his clinic. He discovered the average healing time was 79 days for compliant patients and 135 days for non-compliant patients, based upon patients wearing their offloading device and presenting to the clinic on a weekly basis. According to Dr. Jensen, the overall average healing time was 89 days. While Dr. Jensen notes not all patients were healed utilizing total contact casts, the TCCs “contributed significantly” to healing and decreased healing times. Offloading is a key consideration to keep in mind and healing while ambulating is crucial, according to Dr. Jensen. “Patients cannot utilize crutches effectively and asking them to use crutches or wheelchairs is really setting them up to fail,” he says. “I have not had a great deal of success with the removable walking devices because, in my experience, they do not control shearing forces and often do not reduce plantar forces if the foot is moving within the device.” He also notes compliance issues. Will More DPMs Use Total Contact Casting? Dr. Jensen believes podiatrists will start using TCC more for several reasons. Patients using the casts heal and Dr. Jensen adds that managed care and Medicare “will gladly pay for” casting and its results. “Everybody wins,” he says. “That cannot be said for most wound care modalities or treatments.” Study co-author Eric Jaakola, DPM, has been working with TCCs for two years in his residency at the North Colorado Podiatric Surgical Residency. He hopes the study will encourage more DPMs to use the casts and advises his fellow residents about the casts. “It’s a choice I would make,” Dr. Jaakola says of using TCC. “I’ve seen quite a great deal of success with it.” While some patients are reluctant to accept the therapy due to the thought of wearing the cast, Dr. Jaakola says most accept it once they realize it is working. He says a selling point of the cast therapy is the lack of crutches and the patient’s ability to ambulate. Starting this summer, Dr. Jensen will be offering TCC workshops for clinicians.

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