page_title: Total contact casting
section_title: History of clinical use
hierarchical_section_title: Total contact casting / History of clinical use
caption_attribution_description: Diagramme showing how diabetic foot ulcers are caused by pressure, shear and repetitive stresses
context_page_description: Total contact casting is a specially designed cast designed to take weight off of the foot in patients with diabetic foot ulcers. Reducing pressure on the wound by taking weight off the foot has proven to be very effective in DFU treatment. DFUs are a major factor leading to lower leg amputations among the diabetic population in the US with 85% of amputations in diabetics being preceded by a DFU. Furthermore, the 5 year post-amputation mortality rate among diabetics is estimated at around 45% for those suffering from neuropathic DFUs.
  TCC has been used for off-loading DFUs in the US since the mid-1960s and is regarded by many practitioners as the “reference standard” for off-loading the bottom surface of the foot.
  TCC involves encasing the patient’s complete foot, including toes, and the lower leg in a specialist cast that redistributes weight and pressure in the lower leg and foot during everyday movements. This redistributes pressure from the foot into the leg, which is more able to bear weight, to protect the wound, letting it regenerate tissue and heal.
context_section_description: The use of TCC for foot ulcers resulting from leprosy (Hansen's disease) was reported by Joseph Khan in India in the 1930s. Research conducted by Paul W. Brand, MD, in the 1940s and 50s, also in India, demonstrated that the wounds in the feet were caused by nerve damage (neuropathy) rather than infection, as previously thought. In his use of TCC to eliminate weight and pressure on the ulcers, he observed the healing of ulcers that had been present for a long time. These seminal observations resulted in the development of treatments to manage neuropathic foot ulcers, which are useful for patients with diabetes.
  In 1965, TCC was introduced to the United States by Dr. Brand, then at the National Hansen’s Disease Center in Carville, Louisiana. The goal of TCC was to distribute weight over the entire foot and lower leg. Over time, the staff at Carver Hospital refined the method to reduce the development of other wounds that occur in part because of the initial problem with the foot (secondary ulceration).
  Materials have changed over the years, from an unmodified plaster of Paris, to formulations containing fiberglass. However, plaster of Paris casts take too long to fully dry and limits patient mobility for up to 74 hours — if the patient walks on the cast during this time, the shape will change, and the cast will not protect the foot and wound correctly. Fiberglass casts were introduced in the 1980 or '90s. The curing time of a fiberglass cast is far shorter than plaster of Paris, letting the patient walk with an outer boot within an hour of application. Because casts made of fiberglass have lower breakdown rate and do not impede patient mobility, this material has become the choice for TCC.
  In 2003, the first TCC casting system that contained all the materials in one package (MedE-Kast® Total Contact Casting System) was developed. This innovation helped standardize the application of TCC. Other advancements have been made to make casting easier to learn, easier to apply and less time consuming.
  In 2008, the TCC-EZ® Total Contact Casting system became available. In addition to the established benefits of traditional TCC, TCC-EZ® also provided an easy to apply casting sock. The one-piece, roll-on, woven design simplified the application process. This cast can be put on in less than 10 minutes. The ease of use of TCC EZ® has been a driver in the growth of TCC use and has helped increase the accessibility and administration of effective off-loading.
  However, despite the availability of specialist kits, there still exists a large “gap in practice” between the accepted gold standard of care and the number of patients currently treated with this standard of care. The US Wound Registry (USWR) data from 2007-2013 shows that, of 11, 784 patients treated for DFUs, only 16% received TCC.
caption: Figure 1 — DFUs caused by pressure, shear and repetitive stresses
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