Total contact casting

Total contact casting (TCC) is a specially designed cast designed to take weight off of the foot (off-loading) in patients with diabetic foot ulcers (DFUs). Reducing pressure on the wound by taking weight off the foot has proven to be very effective in DFU treatment. DFUs are a major factor leading to lower leg amputations among the diabetic population in the US with 85% of amputations in diabetics being preceded by a DFU. Furthermore, the 5 year post-amputation mortality rate among diabetics is estimated at around 45% for those suffering from neuropathic DFUs. Total contact casting (TCC) is a specially designed cast designed to take weight off of the foot (off-loading) in patients with diabetic foot ulcers (DFUs). Reducing pressure on the wound by taking weight off the foot has proven to be very effective in DFU treatment. DFUs are a major factor leading to lower leg amputations among the diabetic population in the US with 85% of amputations in diabetics being preceded by a DFU. Furthermore, the 5 year post-amputation mortality rate among diabetics is estimated at around 45% for those suffering from neuropathic DFUs. TCC has been used for off-loading DFUs in the US since the mid-1960s and is regarded by many practitioners as the “reference standard” for off-loading the bottom surface (sole) of the foot. TCC involves encasing the patient’s complete foot, including toes, and the lower leg in a specialist cast that redistributes weight and pressure in the lower leg and foot during everyday movements. This redistributes pressure from the foot into the leg, which is more able to bear weight, to protect the wound, letting it regenerate tissue and heal. TCC also keeps the ankle from rotating during walking, which prevents shearing and twisting forces that can further damage the wound. Effective off loading is a key treatment modality for DFUs, particularly those where there is damage to the nerves in the feet (peripheral neuropathy). Along with infection management and vascular assessment, TCC is vital aspect to effectively managing DFUs. TCC is the most effective and reliable method for off-loading DFUs. The use of TCC for foot ulcers resulting from leprosy (Hansen's disease) was reported by Joseph Khan in India in the 1930s. Research conducted by Paul W. Brand, MD, in the 1940s and 50s, also in India, demonstrated that the wounds in the feet were caused by nerve damage (neuropathy) rather than infection, as previously thought. In his use of TCC to eliminate weight and pressure on the ulcers, he observed the healing of ulcers that had been present for a long time. These seminal observations resulted in the development of treatments to manage neuropathic foot ulcers, which are useful for patients with diabetes. In 1965, TCC was introduced to the United States by Dr. Brand, then at the National Hansen’s Disease Center in Carville, Louisiana. The goal of TCC was to distribute weight over the entire foot and lower leg. Over time, the staff at Carver Hospital refined the method to reduce the development of other wounds that occur in part because of the initial problem with the foot (secondary ulceration). Materials have changed over the years, from an unmodified plaster of Paris, to formulations containing fiberglass. However, plaster of Paris casts take too long to fully dry and limits patient mobility for up to 74 hours — if the patient walks on the cast during this time, the shape will change, and the cast will not protect the foot and wound correctly. Fiberglass casts were introduced in the 1980 or '90s. The curing time of a fiberglass cast is far shorter than plaster of Paris, letting the patient walk with an outer boot within an hour of application. Because casts made of fiberglass have lower breakdown rate and do not impede patient mobility, this material has become the choice for TCC.