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TCC - As good as some say?

Discussion in 'Diabetic Foot & Wound Management' started by Industry Guru, Nov 24, 2015.

  1. Industry Guru

    Industry Guru Member

    Members do not see these Ads. Sign Up.
    Everyone knows a TCC is purported to be the gold standard for offloading. But it seems those who tout this method tend to embellish it as "an end all, be all "of offloading.
    Currently a little over 2% of clinicians use this method. Why?

    Many clinicians tell me that time, cost, lack of a qualified cast tech, lack of patient compliance; all play a role in why they do not apply a TCC more frequently.

    What many don't seem to caution when speaking of a TCC is that a TCC can actually do more harm than good if not applied correctly and monitored as such.

    It seems that if more attention was paid to preventative treatment - offloading lesions and grade one uclers before they developed into more serious issues; would help immensely.
    A recent study indicated it costs approx. $3400.00 to treat and heal a Grade 1 ulcer. That cost balloons to $7000.00 when treating a Grade 3 and skyrockets to $27K for a Grade 4.

    Knowing that, should we not focus on early treatment and prevention? And if so, that would seem a TCC is vast overkill in many cases. Thoughts?
  2. Ben Lovett

    Ben Lovett Active Member

    Hi Industry Guru,

    I?d agree that prevention and early intervention are critical but I can?t agree that a TCC is overkill.

    As you point out there is indeed a gulf between evidence and practice when it comes to pressure management for diabetic foot ulcers (DFU). Indeed studies have now been undertaken to look into the reasons for this. http://www.ncbi.nlm.nih.gov/pubmed/24932951

    And the evidence supporting the efficacy of total contact casting (TCC) or irremovable CAM walkers over other interventions such as semi compressed felt padding, total contact (accommodative) orthoses, post op shoes etc has been consistent for over 20 years. Systematic review of this evidence( http://www.ncbi.nlm.nih.gov/pubmed/23440787 ) now forms the basis of a number of clinical guidelines.

    I think everyone would agree that prevention is better than cure and also that the sooner help is sort for the management of a DFU the better. However regardless of whether the ulcer is recent or established the important thing is to close it as quickly as possible. Offloading modalities that provide even pressure distribution across the plantar surface while immobilising the ankle significantly reduce time to healing for DFUs at any stage.

    I agree that an ineptly applied cast could simply generate further problems but there are well established alternatives such as TCC-EZ or a CAM walker rendered non removable. Ultimately though, if a practitioner doesn?t have the skills to manage the condition they are presented with then they should involve someone who does, which is why Multi Disciplinary Teams are so important in the management of DFUs as so many different skills are needed.

    So while I certainly agree that focus on early treatment and prevention is critical, the very presence of neuropathy makes this challenging. Potentially there is a lack of seriousness attached to DFUs by patient and practitioner alike due to the absence of pain and this goes some way towards explaining not only late presentation for medical help on the part of the patient but also the failure by the practitioner to then implement the most appropriate intervention. Imagine how much fuss a patient without neuropathy would kick up if they had a hole in the bottom of their foot with bits of bone and tendon sticking out.

    So the patient doesn?t realise the seriousness of a wound they can?t feel and often can?t see and doesn?t understand the path from local infection to bacteraemia and endocarditis. The podiatrist meanwhile doesn?t want to inconvenience their patient by putting them into a cast;
    ?but I?ve got a wedding / funeral to go to etc?.
    ?OK then we?ll put some padding on and you?ll still be able to wear your smart shoes?

    Perhaps one of the reasons that practice is lagging so far behind the evidence is simply an established culture of treating DFUs as common and mundane and an acceptance that they take 6 months or more to heal. For a more in depth analysis of barriers to use of TCCs there's this http://www.japmaonline.org/doi/abs/10.7547/8750-7315-104.6.555 by Rob Snyder and team.

    Very interested to know how many Pods are working in clinics where DFUs are routinely off loaded with TCC or non removable CAM walker from first presentation rather than when all else has failed?

  3. Industry Guru

    Industry Guru Member


    Good points certainly. I still maintain that if the industry really wants to cut down on complications due to ulcers they would make a huge push on education and prevention. Many times the clinician is pulled in too many directions in regards to spending adequate time with a patient and fullfilling their patient schedule for the day.
    Being brutally honest with a patient may help them see the light. Obviously you don't want to put fear into them that they "might lose their foot' if they don't comply with directions; but if thats what it takes, then thats what they need to hear.

    Patient education is the key. The new TCC kits on the market are made to offload but we all know companies build products to get a code, not so much to benefit the patient. Walkers are an option but then patients take them off when they get home. Finding a walker that offloads, eliminates shear and cannot be removed easily may be the golden ticket to really helping a vast majority of patients who find a TCC too limiting and for docs who can't or won't apply a TCC for various reasons. That said, I still convinced that a TCC is not the end all, be all solution.
    Thanks for your input. Have a great day.
  4. Admin2

    Admin2 Administrator Staff Member

  5. Ben Lovett

    Ben Lovett Active Member

    Agreed, but since less diabetes would probably be the only way to get less DFUs then maybe it should be all hands on deck to help with the current battle with the sugar industry...

    I think part of this approach is to raise the seriousness of DFUs in the psyche of diabetic patients and their health care professionals. It needs to become accepted that TCC or some form of ankle immobilising and non removable device is part of the standard first line intervention for most DFUs in the same way that it is for a fractured tibia.

    This is why they need to be rendered non removable, either through the application of a scotch cast wrap or through use of one of the many CAM walkers on the market that come with some kind of lock or seal. Again the evidence here is well established that CAM walkers rendered non removable are as effective as TCC while those that the patient can take off are not.

    Aircast XP walker or Vacoped both come with locking devices or you can wrap them in scotch cast.


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