Clinical and Economic Benefits of Healing Diabetic Foot Ulcers With a Rigid Total Contact Cast
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Index: WOUNDS. 2012;24(6):152–159.
Abstract: A total contact cast (TCC) is considered the gold standard for healing diabetic foot ulcers (DFU). Numerous studies have demonstrated the excellent healing success of a TCC; however, its adoption in routine clinical use does not match its success rate. This lack of implementation is due to several factors: Medicare’s payment structure, lack of clinical training, and a variety of patient factors. These factors have reduced clinicians’ use of TCC to approximately 25% of DFU. The aim of this review was to analyze and demonstrate common scenarios for outpatient wound centers where a TCC may be beneficial to both patients and hospital systems, and to expand its usage to more closely reflect its healing success rate.
The rising incidence and prevalence of diabetes in the United States has resulted in a synonymous escalation of nonhealing diabetic foot ulcers (DFU).1 Patients with these foot ulcers have flooded urgent care centers, primary care offices, podiatric services, inpatient wards, emergency rooms, and ultimately, wound care centers. Such occurrences have resulted in a boom of advance modalities to help heal these ulcers and prevent amputations. These modalities include bioengineered skin substitutes, platelet derived growth factors, negative pressure therapy, hyperbaric oxygen, advanced wound dressings, ultrasonic debridement tools, “superbug” busting antibiotics, and stem cell therapy.2–4
The challenges in healing DFU have fostered the use of advanced modalities. Concerns with diminishing reimbursement in procedural services, by both providers and hospital systems struggling to fight disease and maintain financial viability, have promulgated the use of such expensive modalities.5 Studies supporting the healing potential of advanced modalities over standard saline moistened dressings have further created a tailspin of doctrine termed “standard of care” that advanced (as well as expensive) modalities are preferable to treat DFU that have failed to heal.
Furthermore, studies touting DFU healing rates with various modalities have used variable offloading tools that do not provide consistent optimal pressure relief. Ideal offloading is obtained through minimal pressure on the diabetic ulcer. To date, a rigid total contact cast (TCC) has demonstrated the lowest peak plantar pressure on an ambulatory patient (Figure 1).6
A 2005 nationwide (United States) survey of 895 private practices treating DFU indicated that shoe modifications were used in 41.2% of cases for offloading, despite the lack of evidence supporting its use.7 Total contact casting was utilized in more than 40% of clinics; however, only 1.7% of the centers used the TCC as treatment for the majority of DFU in their care (Figure 2).7 If the TCC were used as standardized pressure relief in various clinical trials, then further validity could be given to the efficacy of bioengineered dressings, regenerative matrices, negative pressure therapies, and other advanced modalities.
Traditional DFU healing protocols include risk factor modification, offloading, debridement, and a protective dressing. A common failure in this pathway is the offloading method.