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The best way to off-load a diabetic foot ulcer

Three Part Question

In a [diabetic patient with peripheral neuropathy and a plantar foot ulcer] are [instant total contact casts (iTCCs) or traditional total contact casts (TCCs) better] at [reducing joint destruction?]

Clinical Scenario

A 45 year old male with diabetes, peripheral neuropathy and obesity presents to the emergncy department with a wound to the planter aspect of his left foot. On inspection you find an ulcer roughly 2cm x 2cm which does not appear to be infected. The man tells you it has been there for some time and is gradually enlarging, although it is not painful. You know that off-loading the pressure on the area should help it to heal and wonder what is the best way to do this.

Search Strategy

(exp diabetes mellitus OR diabetic neuropathies OR exp diabetic foot OR arthropathy) AND (total contact OR OR removable cast OR LIMIT to humans and English language
Medline from 1950 to June 2007 using the Ovid interface and Embase from 1996 to week 25 2007

Search Outcome

The search located 79 articles, 2 of which were relevant.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Katz IA et al
41 consecutive diabetic patients with chronic, non-ischaemic, neuropathic plantar foot ulcersRandomized clinical trialThe proportion of patients with ulcers that healed at 9less than or equivalent to) 12 weeksThe proportions of patients with ulcers that healed within 12 weeks in the iTCC and TCC groups were 945 AND 935 respectively (once patients lost to follow up were excluded)There is a small sample size and blinding couldnt be used
healing ratesHealing rates were statistically significant in the two groups
complication ratesComplication rates were statistically significant within the two groups
cast placement/removal timesThe i TCC took considerably less time to place and remove than the TCC with 39% and 36% reductions, respectively
costsThere was an overall lower cost associated with the use of the iTCC compared with the TCC
Piaggesi A et al
40 diabetic out-patients attending foot clinic randomized to TCC or iTCC treatment.A randomized prospective trialHealing rates at 12 weeksThere was no difference observed in healing rates at 12 weeks (95% in the TCC group and 85% in the iTCC group)This was a small trial and blinding was not possible
Number and severity of adverse eventsThere was no significant difference in the number of adverse events (6 in the TCC group compared to 4 in the iTCC group)
CostsThe iTCC was significantly less expensive than the TCC (a mean reduction of costs of 78%)
Applicability of the deviceThe iTCC was a 77 and 58% reduction in the time required for application and removal of the devices respectively (P=0.001)
Patient satisfactionPatient satisfaction was higher in the iTCC group (P=0.01)
Healing timeThere was no significant difference in healing time (6.5 in the TCC group compared to 6.7 in the iTCC group)


The evidence shows that iTCCs are as good at healing ulceration as TCCs are, with no additional adverse events. However, they are preferable to TCCs as they are easier to apply/remove, cheaper and better tolerated by the patient.

Clinical Bottom Line

iTCCs should be the off-loading methoed of choice for a diabetic patient with an ulcerated neuropathic foot; especially in the emergency department where TCCs are not available.


  1. Katz IA et al A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care 2005;28(3):555-559
  2. Piaggesi A et al An off-the-shelf contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast Diabetes Care 2007;30(3):586-90