A comparison of Traditional Total Contact Casting and the TCC-EZ® device
Marie Stirling, a Specialist Diabetes Podiatrist at Dr Gray’s Hospital in Elgin, was the proud winner of the Cosyfeet Podiatry Award 2016. She used her £1000 award money to fund a pilot study examining the practical considerations of selecting a TCC method to use in clinic. She was motivated by a desire to inform decision-making by NHS Grampian about the use and methods of TCC, thereby achieving the best possible outcomes for patients who require greater offloading than the removable devices which are readily available.
Both traditional TCC and the TCC-EZ® device are known to provide highly effective offloading to promote healing. Marie’s pilot study examined other factors including clinician training, clinician time, cost, application and patient experience. Her findings are reported here.
Diabetic foot ulceration is the most common cause of amputation in the UK, with over 169 amputations carried out per week.1 Individuals with a diabetic foot ulcer (DFU) have an increased risk of premature death, myocardial infarction and fatal stroke,2 therefore it is a serious and costly complication of diabetes, which must be managed effectively.3
Total Contact Casting (TCC) is the recommended ‘gold standard’ treatment to off-load DFUs.4,5 Patients with unilateral plantar ulcers treated by a TCC, can have their healing time reduced to a mean of 6 weeks.6 The cast redistributes peak plantar pressure to the cast wall, reduces shear and restricts ankle motion, provides optimal off-loading,7 and being irremovable by the patient, it ensures constant use.8
TCC it is underutilised due to a variety of factors such as the fear of causing complications, and the perceived complex application process.9 Evidence from literature, however, cites TCC as a safe and effective method when applied to appropriate patients within a multi-disciplinary setting.10 It is essential that practitioners applying a cast are fully trained and experienced.11
Traditional Total Contact Cast
The TCC has been established since the 1960s as a treatment for off-loading plantar ulceration.12 Over the years, materials have improved significantly, but the basic principles of treatment still apply.
A layer of stockinette is applied from the foot to above the knee, felt covers the bony prominences, wadding bandage is applied interdigitally, and extends to the foot and leg. The casting material (e.g. Delta-Cast® Conformable) is then applied to the foot, extending to below the knee, with the ankle maintained at 90 degrees. Finally, a plaster sandal is fitted.