By Tedman L. Tan and James McGuire DPM, PT, CPed, FAPWHc

The management of diabetic foot ulcers is becoming an increasingly significant concern with the growing population of patients with diabetes in the United States. Most amputations involving the lower extremity in patients with diabetes are preceded by foot ulcers, and in turn, lower extremity amputations are associated with a high 5-year mortality rate at around 45% among individuals with diabetes.¹ Therefore, diabetic foot ulcers require special attention due to the possible life-threatening complications associated with such wounds.

The Evidence Supporting Offloading for Treatment of Diabetic Foot Ulcers

Pressure offloading of the ulcerations is an essential component in the management towards healing of these wounds. Even considering proper vascular management, infection control, and adequate serial debridement, healing of diabetic foot ulcerations will be unlikely without adequate reduction of pressure.² Total contact casting (TCC) is considered the “gold-standard” modality in the offloading of non-infected, non-ischemic neuropathic plantar ulcerations. It involves molded and padded layers applied in intimate contact with the foot and leg to limit the motion of the foot on the ankle joint. This eliminates the propulsive phase of gait and shortens stride length, leading to a significant reduction in plantar pressures.

In a study conducted by Armstrong et al, TCC produced better healing outcomes compared to other offloading modalities, with a proportional wound healing rate of 89.5% compared to 65.0% with removable cast walkers and 58.3% with half-shoes.³ The advantage of TCC over other offloading devices is the improved patient compliance and adherence to the offloading regimen attributed to its non-removable nature.

Addressing Patient Compliance with Total Contact Casting

Despite substantial evidence with the efficacy of TCC in the management of diabetic foot ulcers through offloading, TCC is being underutilized as a treatment modality for patients among wound care clinics. Fife et al investigated the use of TCC for offloading diabetic foot ulcerations in 96 outpatient wound care centers across the United States and Puerto Rico and found that 96.4% of patients with wounds described to be eligible for treatment with TCC did not receive such treatment.⁴ The limited use of TCC in wound care settings for patients with ulcerations that may benefit from this option can be explained by the difficult and time-consuming process of its application and proper training for its appropriate use.

TCC-EZ® Total Contact Cast System by Derma Sciences, Inc. is a more efficient offloading system that is designed to overcome the barriers that discourage health care providers from using traditional TCC with its more complex method of application. It is composed of a lightweight one layer cast sock that is easy to apply using a quick 3-step prep/roll/apply process. The first step involves the application of foam dressing, stockinette, felt padding, and a protective sleeve to the foot and leg. After the prep step, the TCC-EZ cast sock would then be soaked in water for 5 seconds and rolled over onto the leg. The final step is the application of the outer boot included in the kit after the cast has been allowed to dry for 10-15 minutes.⁵

The easy roll-on application of the TCC-EZ cast is much simpler, easier to learn, and has a significantly faster application time compared to traditional TCC. A case study done by Jensen et al comparing application time between the TCC-EZ cast and traditional TCC in 100 patients showed an average of 75 seconds to roll on the TCC-EZ cast, which required considerably less time compared to an average cast application time of 452 seconds with traditional TCC.⁶ The average time for the whole prep, roll, and drying process was 21 minutes. Faster application times and the easy roll-on process of the TCC-EZ cast requires a minimal learning curve for proper application, essentially overcoming the complexity associated with TCC. Furthermore, the study conducted by Jensen et al showed no cases of serious complications associated with application error among all 100 patients that were treated with the TCC-EZ.⁶

With the simple design of the TCC-EZ, offloading pressure from diabetic foot ulcerations is a much easier process with the added advantage of efficacy and reliability. Such devices are a step forward in the healing of wounds in patients with diabetes and in the decrease in the rate of associated lower extremity amputations among patients with diabetes. Practitioners involved with the management of these wounds would hopefully be more encouraged in tackling the offloading component in the treatment of wounds in this population.

To learn more about this company and product visit http://www.woundsource.com/company/derma-sciences-inc

References
1. Jaakola E, Weber A. (2014). Current Concepts In Total Contact Casting For DFUs. Podiatry Today. 2014;27(4). http://www.podiatrytoday.com/current-concepts-total-contact-casting-dfus. Published March 20, 2014. Accessed December 2, 2014.
2. Cavanagh PR, Owings TM. Nonsurgical strategies for healing and preventing recurrence of diabetic foot ulcers. Foot Ankle Clin. 2006;11:735-43.
3. Armstrong DG, Nguyen HC, Lavery LA, van Schie CHM, Boulton AJM, Harkless LB. Off-loading the diabetic foot wound. Diabetes Care. 2001;24(6):1019-22. doi: 10.2337/diacare.24.6.1019
4. Fife CE, Carter MJ, Walker D, Thomson B, Eckert KA. 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. doi: 10.1097/01.ASW.0000450831.65667.89.
5. Derma Sciences. TCC Evidence. Derma Sciences. http://www.dermasciences.com/tcc-evidence. Accessed December 2, 2014.
6. Jensen J, Jaakola E, Gillin B, Riley EK. TCC-EZ® - Total Contact Casting System Overcoming the Barriers to Utilizing a Proven Gold Standard Treatment. DFCon, March 2008, Los Angeles, USA, Poster.

About the Authors:
Tedman L. Tan is a DPM candidate at Temple University School of Podiatric Medicine. He received his BS in Biology from Richard Stockton College of New Jersey.

Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.