Current Pedorthics | September-October 2014 | Vol.46, Issue 5 | Page 27

Transitioning from Open
Wound to Final Footwear
Offloading the Diabetic Foot - Part 2
BY DR. JAMES B. MCGUIRE, DPM, PT, C. PED.
ORIGINALLY PUBLISHED: © PODIATRY TODAY, JUNE 2012; PERMISSION TO REPRINT BY AUTHOR.

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ound Management Devices. The total contact cast or TCC has for many years
been considered the gold standard for off-loading a diabetic foot wound,
with healing rates as high as 90%.20-22 Despite this the International Working
Group on the Diabetic Foot and several other studies have concluded that
relatively few practitioners use this modality on a routine basis.23,24 There are
many reasons for this that include: entrenched practice habits, fears and prejudices about the
TCC, inadequate training, bad experiences with the device, and financial and reimbursement
issues.
Based on strict criteria for the use of the TCC, a number of
patients should not be treated with casting. They include patients
with documented PAD, an ankle brachial index of less than 0.7,
or an active infection.25 Other contraindications include cast
claustrophobia, known non-adherence, fluctuating leg edema,
active skin disease, a sinus tract with deep extension into the foot,
or when the clinical staff has inadequate training and confidence
to administer the treatment. In numerous conversations with
clinicians I believe the single most common reason for this
hesitancy is a documented lack of compliance noted in diabetic
neuropathic wound patients. It is very difficult to trust a patient,
who has a demonstrated history of poor judgments with regard to
their care, with the responsibility of wearing and adhering to the
restrictions imposed by the TCC. In those cases, other treatment
modalities can and should be used.

molded footwear. Most practitioners choose between these
devices based on their individual experience with a particular
modality, clinical availability, patient preference, or even insurance
reimbursement.2,27 The most commonly employed device is the
surgical shoe with or without internal shoe modifications despite
relatively poor evidence for healing when compared to the TCC
or the iTCC. For this reason I have chosen to limit the shoe
based devices to the Transition period between healing and final
footwear. In addition to the TCC, the iTCC, Football dressing,
and Felted Foam techniques have been the only methods which
when employed have consistently produced healing rates in the
high 80%s and can reasonably be expected to effectively offload
and heal wounds within a 12 week period. 28,29,30,31

Most practitioners treating diabetic wounds, because of the
complications mentioned, in addition to the time and complexity
of application and the cost of materials for the device, have chosen
to employ a number of alternative devices.1,2,26 These include the
removable cast walker (RCW), the non-removable cast walker
or instant TCC (iTCC), the molded or double upright ankle
foot orthosis with or without a patellar tendon-bearing addition,
Charcot restraint orthopedic walkers (CROWs), a modified
Carville healing sandal or shoe, the felted foam technique, the
football dressing, and commercial off-loading shoes, such as the
half or wedge shoes, a post-operative shoe, and depth or custom-

If the clinician is not comfortable with the application of the
TCC, or if the patient has one or more of the established
contraindications to its use, prefabricated removable cast walkers
(RCWs) and non-removable cast walkers or the iTCC have been
shown to be comparable to the TCC in their ability to off-load
the diabetic foot and close wounds in a similar time frame.28,29
Armstrong, and his colleagues have been the pioneers in the use
of the iTCC. Lavery, Pollo, and Lawless have studied pressure
redistribution in commercially produced removable diabetic
walkers and found them to be comparable to the TCC and
superior to other off-loading devices in their ability to reduce

Instant Total Contact Cast

Current Pedorthics

September/October

2014

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