Abstract
Still the gold standard, the total contact cast (TCC) has been the consensus
initial off-loading device for plantar diabetic foot ulcerations. This casting method,
which recommends minimal padding to allow the cast to conform to the contours of
the foot and leg, was introduced by Paul Brand at the Hansen’s Disease Center for
the treatment of neuropathic plantar ulcers in patients with leprosy (43). Anatomic
molding of casting material against the foot and leg has been shown to increase surface area of contact effectively reducing the focal reactive ground forces (both
vertical and shear) at the ulcer site. The mechanism of unloading is attributed to
increased proportion of plantar load transferred to the rearfoot, one-third of total
load received by the cast walls, and metatarsal off-loading by cavity of soft foam
in the forefoot (44). Various studies have demonstrated consistent reduction in plantar pressures and subsequent decrease in healing times with the TCC. Approximately
86% reduction in forefoot pressures was shown in a TCC compared to a cast shoe
(44). In a randomized prospective clinical trial, the percentage of diabetic ulcer
healing in patients over a 12week period was 89.5% for the TCC followed by the
removable cast walker (RCW) and half-shoe which were shown to be 65.0% and
58.3%, respectively. Accordingly, the average healing time in the TCC, RCW and
half-shoe was 33.5, 50.4, and 61.0 days, respectively (45). Success of the TCC in this
study was not only attributed to the off-loading capacity but also a significant
reduction in the patients’ weightbearing activity compared to a below-ankle device.
1. STUDY SHOWING DECREASE IN PRESSURE