Current Concepts In Total Contact Casting For DFUs

Eric Jaakola, DPM, and Anna Weber, DPM

The diabetic population in the United States has grown to over 26 million people and 10 to 15 percent of this population will develop a diabetic foot ulceration (DFU).1,2 That would equal 2.6 to 3.9 million diabetic foot ulcerations in this country. Diabetic foot ulcerations precede 85 percent of all non-traumatic lower extremity amputations and it is known that patients with diabetes who have an amputation of the lower extremity will have a mortality rate of 45 percent in the next three to five years.3,4

   Therefore, a diabetic foot ulceration is a life-threatening condition that carries a mortality rate that is actually greater than prostate and breast cancer combined.5 Accordingly, we as podiatrists need to take even the smallest diabetic foot ulceration very seriously.

   Sheehan, Snyder and their respective colleagues have produced studies that indicate that if a DFU has not shown significant progress within four weeks and one week respectively of treatment, that the chance of the wound healing within 12 weeks is less than 10 percent.6,7 Additionally, Lavery and coworkers have shown that a DFU open for greater than 30 days has a 4.7 times greater risk of infection.8

   In 1999, Margolis and colleagues reviewed 10 different DFU studies and extracted the control groups using standard “good” wound care, and evaluated the healing times.9 “Good” wound care included offloading, debridement, and a placebo gel or moistened saline gauze. Mean healing rates among the 10 studies revealed a meager 24.2 percent at 12 weeks and only 30.9 percent at 20 weeks.

   We now practice in an age when evidence-based medicine is not just a catchphrase but dictates a necessary protocol for the many facets of medicine in our ever evolving litigious society. There are hundreds of topical wound dressings and treatments that claim superior wound healing. However, only three have met the rigorous FDA Premarket Approval, proving that they can reduce the time to healing of a diabetic foot ulcer. Of the three modalities to gain pre-market approval, the best healing rate was 56 percent of patients healed at three months.10

   At this point, there is not a study that correlates the length of time a diabetic foot ulceration is open with the rate of amputation. It would seem obvious, however, that the longer a wound is present, the greater chance of infection and amputation.

   Total contact casting (TCC) has long been referred to as the “gold standard” for treating non-infected, neuropathic foot ulcerations. This is for good reason. There are currently seven randomized, controlled trials that have validated the TCC’s efficacy as well as a meta-analysis with 498 patients that noted healing rates of 88 percent in a mean of 43 days.11-21 Of the seven randomized, controlled studies, the healing rates range from 34 to 58 days with 50 to 100 percent healed.

   One of the studies by Armstrong and colleagues involved 63 patients with non-infected neuropathic plantar foot ulcers and compared the TCC with a removable cast walker (RCW) and a half shoe.11 All patients had follow-up for 12 weeks and weekly visits for wound care and debridement. The ulcer healing rate for the TCC patients was 89.5 percent in comparison to 65 percent for patients treated with a removable cast walker and 58.3 percent for patients treated with a half shoe.

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