Tag: TCC

Treating Hard-to-Heal Wounds

An Evidence-Based Approach for DFU and Chronic Wounds

 

This is a brief summary of a presentation given at the annual conference of Wounds Canada, in Mississauga, Ontario, on November 16th, 2017. It has been produced with the financial support of Integra Life Sciences. The presenter was Robert Fridman, DPM FACFAS CWSP, a fellowship-trained podiatric surgeon at the Department of Orthopaedic Surgery at New York-Presbyterian Columbia University Medical Center and the Department of Surgery at New York-Presbyterian Weill-Cornell Medical Center.

 

Normal Wound Healing
For health-care professionals, standard wound management consists of preparing the wound bed to support the healing process. When treating diabetic foot ulcers (DFUs), health-care professionals must work toward controlling infection, correcting ischemia, optimizing nutrition, correcting hyperglycemia and offloading of the wound.

 

Offloading
Offloading is one of the cornerstones of effective management of a diabetic foot ulcer, as it helps to minimize repetitive trauma to the area. Total contact casting (TCC) has been established as the gold standard to achieve offloading while enabling patients to ambulate. TCC enables pressure to be transmitted to the cast wall or rearfoot, resulting in decreased forefoot pressure. The device also reduces gait speed and shortens stride length, resulting in reduction of pressure. Ankle movement and the propulsive phase of gait are reduced, resulting in a reduction in vertical loading forces (see Figure 1). Ninety percent of DFUs have been shown to heal within six weeks when treated with a TCC … read more

$70,000 Amputation or $250 Offloading Procedure

Please choose one

Easy choice right? Not for the Government of Ontario Canada. The vast majority of the 2,000 amputations that occur per year in that country would be preventable with common offloading practices (total contact casting*). Doris Grinspun, CEO of the Registered Nurses’ Association of Ontario was assured three years ago by government ‘premieres’ that they would begin to cover such procedures … that’s three years or 6,000 legs or $420,000,000 ago. “We’re willing to pay for the amputations but we’re not willing to pay for the prevention,” offered Grinspun.

Cost and human suffering aside, mortality rates jump significantly after an amputation especially in older patients, diabetes further increases mortality rates. In one rather grim study** 390 patients that had undergone lower extremity amputations were reviewed, of the patients with diabetes “the median time to death was 27.2 months“.

So if you are suffering from diabetic neuropathy and experience a diabetic foot ulcer and happen to be living in Ontario Canada you need to get your affairs in order. But there is hope as The Ontario Health Technology Advisory Committee is currently assessing total contact casting to treat foot ulcers, check back in three years.
original article

*total contact casting is considered “The Gold Standard of off-loading”. A comparison of the three major off-loading methods (total-contact casts (TCCs), removable cast walkers (RCWs), and half-shoes) reinforces this point. The proportions of healing for patients treated with TCC, RCW, and half-shoe were 89.5, 65.0, and 58.3%, respectively. A significantly higher proportion of patients were healed by 12 weeks in the TCC group when compared with the two other modalities.

**Mortality and Hospitalization in Patients After Amputation
http://care.diabetesjournals.org/content/29/10/2252.full 

Off-Loading the Diabetic Foot Wound
A randomized clinical trial
http://care.diabetesjournals.org/content/24/6/1019.long

How To Ensure Effective Offloading With Total Contact Casting

I recently had the opportunity to speak at a dinner meeting to a group of wound care clinicians. During a question and answer session, the topic of discussion drifted toward the use of total contact casting (TCC). I asked the meeting participants to indicate, with a show a hands, how many of them were using this modality regularly in their practice. I was shocked to see that the number was less than 10 percent.

 

Numerous authors have described the underlying pathology in the development of lower extremity ulcerations. Perhaps one of the greatest difficulties in managing complex lower extremity ulcerations is offloading the wound site effectively. A review of the literature demonstrates that TCC is the “gold standard” for offloading non-infected, non-ischemic plantar foot ulcerations.1,2

 

There are several mechanisms that combine to provide the reduction of peak plantar pressures via the use of TCC. Studies have established that the use of TCC decreases altered gait mechanics with shortened stride length and an overall reduction of walking velocity, both of which contribute to the reduction of plantar pressures.3 Furthermore, given the “cone effect” provided by the physical structure of the patient’s leg (an inverted cone), the TCC (a conical receptacle) also allows more even distribution of the patient’s weight read more

Total Contact Cast Use in Patients With Peripheral Arterial Disease

As the majority of diabetic foot ulcerations (DFUs) occur on the plantar foot, excessive pressure is a major contributing factor to delayed healing. The gold standard for offloading is the total contact cast (TCC); yet, TCC use is contraindicated in patients with ischemia. Lower extremity ischemia typically presents in the more severe end stages of peripheral arterial disease (PAD). As PAD exists on a severity spectrum from mild to severe, designation of a clear cutoff where TCC use is an absolute contraindication would assist those who treat DFUs on a daily basis. Objective. The aim of this study is to determine if a potential cutoff value for PAD where TCC use would be an absolute contraindication could be ascertained from a retrospective case series and a systematic literature review of patients with PAD in which treatment included TCC use … read more

Diabetic Foot Ulcer Off-loading: The Gap Between Evidence and …

 

Diabetic Foot Ulcer Off-loading: The Gap Between Evidence and Practice. Data from the US Wound Registry

 

Off-loading was documented in only 2.2% of 221,192 visits from January 2, 2007, to January 6, 2013. The most common off-loading option was the postoperative shoe (36.8%) and TCC (16.0%). There were significantly more amputations within 1 year for non-TCC–treated DFUs compared with TCC-treated DFUs (5.2% vs 2.2%; P = .001). The proportion of healed wounds was slightly higher for TCC-treated DFUs versus non-TCC–treated DFUs (39.4% vs 37.2%). Infection rates were significantly higher for non-TCC–treated DFUs compared with TCC-treated DFUs (2.6 vs 1.6; P = 2.1 × 10−10). Only 59 clinics used TCC (61%) … read more

Reexamining The Gold Standard For Offloading Of DFUs

Although the total contact cast can be effective for offloading diabetic foot ulcers, it is not in wide usage. These authors assert the gold standard for offloading lies in the non-removability of the device and offer a closer look at the merits of transitional offloading.

 

According to the American Diabetes Association, there are approximately 29.1 million Americans, or 9.3 percent of the population, who suffer from diabetes.1 Twenty-one million of these people have already been diagnosed with the disease and 8.1 million remain undiagnosed.

 

This number, although large, pales in comparison with the 86 million Americans who have been classified as “pre-diabetic” and who are at risk of having diabetes in the near future.1 Each year, 1.7 million Americans 20 years of age or older add to this number. This amounts to 4,660 people per day or one new patient with diabetes every 19 seconds. A full 25.9 percent of Americans age 65 or older suffer from diabetes and its complications. Almost twice as many American Indians (15.9 percent) and African-Americans (13.2 percent) develop the disease as Caucasians (7.6 percent) with Hispanics close behind (12.8 percent). Asian-Americans are not spared as 9 percent of this population will develop the disease and its many complications.

 

Glycosylation affects all organ systems and leads to complications such as dyslipidemia with an increased incidence of hypertension, and systemic vascular disease. It also leads to the development of a progressive ascending peripheral neuropathy with a loss of sensation and sweat gland function. This in turn leads to ulceration and, in some cases, amputation when infection of the wounds goes unchecked by an immune system that is also compromised by the process …
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How to apply a Total Contact Cast


This video demonstrates the application of the 901MF-WH Total Contact Casting Kit. Instructional dialog extends the length of the application considerably, actual application time of the Total Contact Casting Kit once comfortable with the process is approximately 5 minutes. For more information on the total contact casting kits being used visit: http://m-medusa.com