Are DPMs Underusing The TCC To Offload Diabetic Foot Ulcers?

David G. Armstrong DPM MD PhD

Despite the evidence supporting the efficacy of total contact casts (TCC) to offload diabetic foot ulcers, podiatric physicians may not be putting this evidence into practice, according to a recent study.

The study, published in Advances in Skin and Wound Care, focused on 25,114 diabetic foot ulcers in 11,784 patients.1 The authors documented offloading in just 2.2 percent of 221,192 visits in a six-year period. They found the most common offloading options were the postoperative shoe (36.8 percent) and TCC (16 percent). At the one-year mark, the study notes 2.2 percent of patients who wore TCCs experienced amputations, in comparison to 5.2 patients who did not wear TCCs. In those who wore TCCs, 39.4 percent of patients had healed wounds while 37.2 percent of patients who did not wear TCCs experienced wound healing, with the authors adding that infection rates were significantly higher in those not wearing TCCs.

Furthermore, the authors note only 61 percent of clinics in the study used total contact casts, with 57 percent of those clinics using a traditional TCC, followed by 36 percent using the TCC-EZ (Derma Sciences).1 They concluded that wound care settings “vastly underutilize” TCCs, saying easy-to-apply devices like the TCC-EZ may lead to an increase in use for total contact casts.

The data from this most recent study confirm the adage that we have again and again experienced in practice: It is not what one puts on a wound that heals it, but what one takes off.

In 2008, we published a manuscript showing that, among some 900 diabetic foot specialty centers in the USA, fewer than 2 percent used the "gold standard" total contact cast as the primary means of offloading.2 The current study suggests the very same issue.

Why? I think that most clinicians still shy away from covering up an open wound with an irremovable device for a week in a neuropathic patient. Additionally, even though the application of TCCs has become much easier over the past few years with the development of kits, it is far easier for the clinician to think of other reasons not to take the extra time to use these.

Further, more and more of our patients are more and more complicated than ever before. When we first started studying offloading, most patients were neuropathic. Now, in the US and European Union, most also have an element of ischemia. While this is no longer a contraindication to application of a TCC except in primarily ischemic patients, it is enough to give the clinician pause.

Total contact casting is our absolute go-to tool for primarily neuropathic patients. However, with 12,900 annual patient visits between our Toe and Flow teams, we find ourselves in the above situation at our SALSA unit each and every day. The key is to merge the data that we see in study after study with the realities that we see in patient after patient. These lead us to an inescapable (and irremovable) conclusion that we have to keep trying to be and do better.


1. Fife CE, Carter MJ, Walker D, et al. Diabetic foot ulcer off-loading: the gap between evidence and practice. Data from the US Wound Registry. Adv Skin Wound Care. 2014; 27(7):310-16.

2. Wu SC, Jensen SL, Weber AK, et al. Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes Care. 2008; 31(11):2118-9.

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