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Offweighting: What Does The Evidence Show? Part 2: The Concensus
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In last week’s Practice Perfect, Offweighting - Part 1: The Options, we discussed some of the options for offweighting diabetic foot ulcers. I stated rigidly and unequivocally that the total contact cast (TCC) and the nonremovable cast walker (NRCW) are the best offweighting methods. I introduced two past studies that proved the TCC is most effective at reducing plantar pressures and healing DFUs.
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But I only listed two studies last week, right? Even if one is a prospective randomized controlled trial, maybe you need more convincing with other studies? In a joint publication of the APMA and the Society for Vascular Surgery, Cavanagh and Bus provided a review of the evidence3. For time’s sake take a look at the Figure 3 from their study below.
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In a total of 37 studies, it is clear that the proportion of healed ulcers is greatest in the TCC and RCW groups, time to healing is least with these same modalities, and the range of healing is less with TCC and RCW treatment3. Now, you may argue that cast shoe was similar to TCC in time to healing and healed ulcers, but they only included three studies versus 20 studies about TCC. Given our above information about plantar pressure reduction and clinically effectiveness, it’s fair to argue that the cast shoe would likely fare much more poorly in a greater number of studies.
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The proportion of healed ulcers is greatest when offloading is achieved with Total Contact Cast or a Non-Removable Cast Walker
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Now, maybe I’ve convinced you that TCC is the best offweighting method for diabetic plantar ulcers, but your next thought is, “I don’t have time in my busy practice to apply these casts on a weekly basis.” I would agree completely with that thought. I don’t have time either. Luckily, Dr Armstrong saved us from TCCs with the advent of what he calls the Instant Total Contact Cast (iTCC). This is simple and fast to apply. Treat the ulcer in your usual manner (debridement, moist wound care dressing) and apply a removable cast walker. Then apply a couple of layers of Coban or Webril around the leg portion of the RCW and cover only that part with two or three layers of cast tape, thus rendering the RCW nonremovable. This takes literally five minutes in my office.
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What’s so impressive about this modality is that it is as effective as the TCC in healing DFUs. Katz and associates performed a prospective, randomized, controlled study in which 41 patients were placed into either an iTCC or standard TCC. They found healing within 12 weeks occurred in 94% of patients with the iTCC and 93% with the TCC (when those lost to follow-up were excluded). Healing rates were similar between the two groups. They also found lower costs with the iTCC as well as decreased application and removal times4.
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I’ve incorporated the iTCC into my own practice (I used to do TCCs) with an improvement in all metrics (cost, time, and patient healing). It’s time to universally adopt this new paradigm. No foot with an ulcer should be allowed to remain in a shoe. Instead they should be iTCC’d.
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No foot with an ulcer should be allowed to remain in a shoe. Start using Non-Removable Cast Walkers now.
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