Clinical Problem: In our practice setting, diabetic foot ulcers (DFUs) were not closing to our satisfaction. After becoming a certified diabetic wound specialist, it was apparent that improved off-loading could improve outcomes. A thorough literature review was performed. Literature showed the Total Contact Cast (TCC) as the gold standard of care,” but it had many contraindications and was not practical in most settings. Articles also reported that a TCC modification, called the instant Total Contact Cast (iTCC), which could be used in most settings, eliminated the TCC contraindications, but still had limitations. A key limitation identified in the literature was periwound maceration. The goal was to maximize DFU healing through development of a practical off-loading approach that eliminated all contraindications and problems.
Phase 1: We implemented the iTCC approach as reported in clinical literature. The iTCC was found to provide improved results, but our experience confirmed the maceration problems reported in literature.
Phase 2: We evaluated alternative dressings for the purpose of reducing periwound maceration, rather than increasing dressing change frequencies.
Phase 3: We developed a “best practice” protocol for the team to test after discovering the dressing approach which overcame maceration issues.
Phase 4: We validated the approach in complex DFU patients. Home health nurses applied the iTCC and polymeric membrane dressing (PMD) 2-3 times a week, depending on exudate amounts, until closure. Digital photographs were taken and analyzed using digital planimetry software.
Patient Outcomes: The iTCC, combined with PMD, totaled approximately 4% of the TCC cost and resulted in 100% wound closure at 7.9 weeks compared to 80-100% wound closure at 7 to 12 weeks as reported in the literature with the TCC. This new approach eliminated periwound maceration, contraindications, and problems.
Conclusion: This organization’s iTCC approach, combined with PMD, provides improved healing outcomes, while significantly reducing costs.
1. Armstrong D. Removable cast walkers: more successful when rendered nonremovable. Diabetic Microvascular Complications Today. May/June 2005;21-23.
2. Armstrong D, Lavery L, Wu S, Boulton A. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot ulcers: a randomized controlled trial. Diabetes Care. March 2005;28(3):551-554.