Total contact casting: A forgotten art in the management of neuropathic foot ulcers

Manikumar Jogarao Chemboli; R Balaji Rao; Sivananda Pathri; Chandana Pathri; Varun Kumar Paka

doi:10.4103/jodp.jodp_14_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 5 | Issue : 3 | Page : 151-156

Total contact casting: A forgotten art in the management of neuropathic foot ulcers

Manikumar Jogarao Chemboli¹, R Balaji Rao¹, Sivananda Pathri¹, Chandana Pathri², Varun Kumar Paka³
¹ Department of Orthopaedics, King George Hospital, Visakhapatnam, India
² Under graduate, Andhra Medical College, Visakhapatnam, India
³ Department of Orthopaedics, NIMRA Institute of Medical Sciences, Vijayawada, Andhra Pradesh, India

Date of Submission	20-Feb-2022
Date of Decision	16-Mar-2022
Date of Acceptance	17-Mar-2022
Date of Web Publication	1-Sep-2022

Correspondence Address:
Sivananda Pathri
Department of Orthopaedics, King George Hospital, Visakhapatnam - 530 002, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_14_22

Abstract

Background: Neuropathic ulcers affect a patient's ambulation and are the leading cause of nontraumatic amputations. Offloading (reduction of pressure) is the key to success in managing these ulcers. Total contact casting (TCC) is considered as the gold standard of treatment for managing neuropathic foot ulcers (NFU). However, this method is less frequently used in the present-day ulcer management due to the lack of skill and laborious nature of work involved. Aim: This study aims to explore the merits and demerits of this technique and understand its relevance in modern times in managing NFUs. Patients and Methods: A total of 24 patients with NFU of different etiologies presented to outpatient unit between August 2018 and August 2020 were included in this prospective case series. All the patients were treated with TCCs applied at weekly intervals, until the ulcer healed completely. Results: Primary outcomes measured were number of casts required which reflected the time of healing in weeks. The mean number of castings required for each centimeter of ulcer healing was 2.310 cast time duration with a 91.66% percentage of success rate. Ulcers in all the patients healed on or before 16 weeks with a mean duration of healing of 58 days after commencement of treatment. Conclusion: It offers attractive healing rates in the management of NFUs and is associated with fewer manageable low-risk complications. Surgeons should incorporate this casting method as part of standard care of NFU to produce early healing and avoid major complications secondary to poor wound healing.

Keywords: Brodsky classification, neuropathic foot ulcer, offloading, total contact casting

How to cite this article:
Chemboli MJ, Rao R B, Pathri S, Pathri C, Paka VK. Total contact casting: A forgotten art in the management of neuropathic foot ulcers. J Orthop Dis Traumatol 2022;5:151-6

How to cite this URL:
Chemboli MJ, Rao R B, Pathri S, Pathri C, Paka VK. Total contact casting: A forgotten art in the management of neuropathic foot ulcers. J Orthop Dis Traumatol [serial online] 2022 [cited 2023 Jun 5];5:151-6. Available from: https://jodt.org/text.asp?2022/5/3/151/355237

Introduction

Neuropathic ulcers are a result of peripheral neuropathy, mostly due to diabetes mellitus. Other causes include B12 deficiency, Charcot-Marie-Tooth disease, demyelinating polyneuropathy, HIV, syphilis, Lyme's disease, alcoholism, autoimmune disorders. Plantar ulcers are caused due to repetitive trauma to an insensitive foot (Paul brand et al.), especially over the pressure points.

Diabetic peripheral neuropathy is the leading cause of neuropathic foot ulcers (NFUs). The prevalence of diabetic foot ulcers (DFUs) ranges from 4% to 27%.^[1],[2],[3] DFUs contribute to 20% of hospital admissions in patients with diabetes mellitus. Infection, gangrene, and amputation are the most feared of sequelae in the absence of timely intervention.^[4] These ulcers are believed to contribute to a significant proportion (50%–70%) of lower limb amputations.^[5]

Treatment of a neuropathic needs a multidisciplinary approach. It is imperative to follow five cardinal principles while managing these ulcers.

To attain either control or cure of local infection through culture-guided appropriate antibiotic courses as per local recommendations
Local ulcer care through debridement (surgical, enzymatic, biologic), vacuum-assisted closure, bone marrow-derived stem cell therapy, bioengineered skin equivalents, growth factor therapy, platelet-rich plasma therapy, hyperbaric oxygen therapy, etc.,
Relieve pressure over the ulcer region through various offloading techniques
Surgical correction of deformities (Tendo Achilles lengthening (TAL), tenotomy of toe extensors, metatarsal osteotomy or resection of metatarsal head, etc.,) to either attain ulcer healing or prevent its recurrence
Management of underlying causes such as diabetes mellitus and leprosy.

Apart from these, lifestyle modifications such as exercise, diet modification, cessation of smoking, control of blood pressure, blood levels of glucose, and cholesterol also have a role in the healing of neuropathic ulcers in general.

Studies have shown that these ulcers tend to occur over areas subjected to highest pressure over the plantar aspect of the foot. This forms the basis of the idea of reduction and redistribution of forces over the affected area of foot. This casting principle is the gold standard for treatment methods which imposes forced compliance. Various removable offloading devices such as walkers, half shoes, felted foams, and orthoses are also available for use.

A total contact cast is a rigid cast that extends from just below the tibial tuberosity to the toes, molded to the curves of the foot and leg to immobilize involved joints, soft tissue while ensuring protective ambulation.^[6] It offers higher healing rates with relatively shorter healing periods. It offers multiple modes of securing wound healing by offering protection against further trauma, immobilization necessary for healing of bone and soft tissue, offloading and redistribution of pressure. In spite of the cited advantages, it is a lost art and treated as an outdated technique in modern-day NFU management owing to the skill and laborious effort required for successful implementation.

Role of orthopedic surgeon in modern-day management of foot ulcers is unfortunately being confined to secondary complications such as osteomyelitis or pyoarthrosis. Contact casting method has taken a back step due to reliance on other modalities which are easy to implement in spite of the superiority of this casting method in deliveries promising results. This study is aimed at redefining the role of orthopedic surgeon in avoiding amputations secondary to ill-treated primary ulcers through early, timely intervention. This study is an attempt to verify and apply the principle offered by this technique and assess ulcer healing rates. Correlations such as duration of diabetes versus occurrence of ulcer and diameter of ulcer to duration of the cast are interpreted through this study.

Patients and Methods

Patients aged between 30 and 80 years presenting with NFUs of varying etiology presented outpatient unit of our institute between August 2018 and August 2020 were included in the study. Patients aged between 30 and 80 years with NFU of Wagner Grade 0, 1, 2 or Brodsky [Table 1] Grade A of ischemic classification and Grade 0, 1, 2 of depth classification were included in the study. Exclusion criteria were critical limb ischemia with ankle brachial index of <0.6, presence of infection higher than grade two of perfusion, extent, depth, infection and sensation (PEDIS) system, active infection, nonambulatory patients, and patients with wounds other than plantar aspect of foot.

Table 1: Brodsky classification of diabetic ulcers

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A detailed history regarding duration and type of diabetes, renal disease, ischemic heart disease along with ulcer duration and previous treatment for the same if any were recorded. General and systemic examinations were performed. A thorough initial clinical examination of the foot [Figure 1]a and [Figure 1]b to record details such as location, size, shape, dimensions, and presence of discharge was performed on all patients. Brodsky's classification of diabetic ulcers was used to categorize the ulcers. When more than one ulcer was present, the largest ulcer was considered as the index ulcer. Doppler ultrasound, Nerve velocity conduction study (NVCS), and complete hemogram were the routine investigations carried out on all patients. Anteroposterior and oblique views of the foot were obtained to exclude osteomyelitis and Charcoat joint. All the patients were explained in detail about the procedure and informed consent was taken before application of first cast. All the patients were treated on an outpatient basis.

Figure 1: Preoperative clinical assessment of plantar ulcer. (a) Metal ruler used to measure ulcer over heel region. (b) Measurement of second ulcer in the mid foot region which is the index ulcer in this patient

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Procedure

Preliminary debridement was carried out in some patients to remove necrotic tissue, callus, and foreign material. The leg was thoroughly cleaned and the wounds were covered with a sterile gauze pad. Cast padding was cut into small pieces and packed in between the toes so that they remain held in between them (interdigital padding). The cast padding was then snugly wound round the leg starting from the tip of the toes to the tibial tuberosity/level of the fibular head in two layers assuring at least.

Fifty percentage overlap between each turn. Extrapadding was provided over pressure points (toes, malleoli, medial aspect of the navicular, anterior shin, first and fifth metatarsal heads, and heel) and over any preexisting deformities. Padding should be minimal in the remaining areas as excessive padding will lead to increased motion once the padding is compressed due to relieved edema. A 6” orthopedic plaster of paris cast was applied over the cast padding molded to the shape of the limb to maintain maximum contact [Figure 2]a. Walking heel was added to none of the patients in the study.

Figure 2: Applied total contact cast and follow-up images of foot. (a) Total contact casting applied from the toes to the level of tibial tuberosity. (b) Clinical assessment of the ulcer over foot at 6-week follow-up

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At each weekly visit, dimensions of the ulcer were noted and the limb was examined for signs such as joint-related problems, breakdown of skin, and presence of new ulcers. Patients were not allowed to bear weight during the first two castings (2 weeks). Glycemic control was achieved in patients through endocrinologist supervision. Patients were on empirical antibiotic therapy (oral clindamycin 300 mg twice a day) for 1 week. Cast was changed at weekly intervals with one rest day in between change of cast to allow for personal assessment and care. This process of weekly application of cast was done until the ulcers healed completely [Figure 2]b. Healing was defined as the presence of intact skin on clinical examination and marked the end of cast treatment [Figure 3]a and [Figure 3]b. Patients were advised absolute nonweight bearing during the first two castings followed by protected weight bearing during the remaining period of castings. No Achilles tendon lengthening was performed in any of the patients. The application of cast was withdrawn when the size and depth of wound remained the same for four consecutive weeks, when the patient complained of severe discomfort or when infection was noticed. These features were included to define cast treatment failure. Patients were advised to use custom-made shoes to offload the pressure areas once the cast treatment was completed to prevent recurrence.

Figure 3: Sequence of healing with total contact cast. (a) Initial assessment of ulcer before the first cast application. (b) First cast applied in the outpatient unit. (c) Partially healed ulcer at 5 weeks of follow-up (d) endpoint of treatment marked by intact skin on clinical examination

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Main outcomes measured were time to heal and percentage of ulcers healed. Outcome assessors were treating surgeons who participated in the intervention, i.e., application of this cast. Student's t-test was used to analyze size and duration of ulcer, compare mean duration of diabetes and associated complications of diabetes. Data collections analysis was performed using IBM SPSS Statistics for Windows, Version 27.0. (Armonk, New York: IBM Corp. Released 2020).

Common complications mentioned in previous studies were appearance of new ulcers, joint-related problems, chafed skin, patient discomfort, infection, recurrence/pre ulcerous condition. Superficial infection was defined as that confined to skin and soft tissue without the presence of any systemic signs.

Results

A total of 24 patients enrolled for the study. Two were lost in follow-up and twenty-two of them completed the study. Seventeen (70.83%) of the patients were male and seven (29.16%) of them were female. The mean age of presentation was 53.6 ± 5.09 years. Seventy percent (17) of the patients had type 2 diabetes mellitus. The average duration of type 2 diabetes reported by patients was 27.43 months excluding nondiabetes. Seven of the patients included in the study were nondiabetic (two younger patients of posttraumatic tibial nerve injury etiology, two patients of Charcot's arthropathy, and three patients with Hansen's sequel). The mean ankle-brachial index was 0.872 ± 0.0208.

Out of the 24 patients, 9 were of Grade 1 of Wagner/Brodsky (depth) and 15 were of Grade 2 of Wagner/Brodsky (depth). All 24 were of Grade A classification of Brodsky ischemic classification. The mean healing time for ulcers of Wagner/Brodsky (depth) Grade 1 was 6.5 weeks and for Grade 2 was 11.5 weeks. The mean diameter of the ulcer was 3.59 ± 1.49 cm. The minimum and maximum number of casts required for complete healing were 6 and 16, respectively. Total number of casts required was 192 (183 in 22 patients) with a mean of 8.318 ± 2.714 casts per patient. Ulcers in 22 out of 24 patients healed on or before 16 weeks mean duration of healing of 58 ± 19 days of healing after commencement of treatment. This yielded a ratio of 2.310 casts per cm of ulcer diameter for healing of the ulcers. A linear relationship was observed on a graph [Figure 4] plotted with maximum diameter of the ulcer (x-axis) and numbers of casts required for healing (y-axis). No correlation could be established between the duration of diabetes and diameter of the ulcer at the time of presentation to the outpatient unit.

Figure 4: Graph plotted with ulcer size in cm versus number of casts required to reach endpoint of healing (n = 22 foot in 22 patients). R denoted the number of casts needed to achieve healing of 1 cm of ulcer area in the study

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Two patients lost in follow-up was considered as treatment failure. Cast treatment was terminated in one patient at 4 weeks postcommencement of treatment due to severe cast discomfort. Ulcers failed to heal in another patient lost in follow-up. He presented with persistence of wound size from 5^th week onward for 4 consecutive weeks leading to stoppage of treatment. Ulcer in this patient was complicated secondarily by osteomyelitis that required surgical intervention in the form of thorough debridement and excision of sequestrum. Treatment failure rate in the present study was 8.33% (2 out of 24 patients). Two patients developed dermal abrasions on the contralateral limb that resolved over time. One patient developed a new ulcer (iatrogenic ulcer) that healed along with exiting ulcers over time. Complication rate of the present study was 16.66% (four patients-two patients with dermal abrasions, one patient with new ulcer, one patient with nonhealing ulcer and osteomyelitis). Two patients in the present study developed dermal abrasions over contralateral limb which resolved over time. One patient developed new ulcer that healed over time along with the existing ulcers at the end of treatment. One patient with treatment failure developed osteomyelitis which was treated with debridement, curettage, and wound dressing along with appropriate antibiotic coverage. Recurrence rate in the present study was 4.16% (1 in 24 patients). In this patient, ulcer recurred 7 months posthealing due to nonadherence to posttreatment use of protective foot wear.

Discussion

Nabuurs-Franssen et al. described a critical triad of neuropathy, minor foot trauma, and foot deformity contributing to more than 63% of patient's foot ulcers followed by edema (37%) and ischemia (35%). Callus formation was associated with 30% of foot ulcers. Diabetic patients having a 30-fold higher lifetime risk of ending up with lower limb amputation compared to nondiabetic individuals.^[7] 70.83% of the patients in the current study were males which is lesser than that reported by Sahu et al. 2018 (77.4% males). Mean age of the present study was 53.6 ± 5.09 years which is below the reported mean of 67yrs by Franssen et al. and 60 years by Sahu et al. Incidence of diabetes in the present study was 70.83% which is similar to that reported in most of the studies on this subject till date.

Diabetic ulcer was classified by the Wagner system into 6 grades 0–5 based on the depth, presence of osteomyelitis, or gangrene. Increase in the stage of the ulcer correlated with poorer outcome, i.e., either prolonged healing time or amputation.^[8] The current study followed the Brodsky classification system that includes the same criteria as Wagner's classification but excludes the presence of gangrene on the foot or limb.

Offloading is necessary to treat NFU.^[9] This view is supported by most of the recent studies.^[10] This casting method offers effective loading off superior to any other similar device as mentioned by Armstrong and Stacpoole-Shea.^[11] Greenhagen and Wukich suggested load redistribution theory and load sharing theory to explain the principle of this technique.^[12] Leibner et al. concluded that the key mechanism of unloading seems in the shank portion of the cast.^[13]

Armstrong et al. actually measured the mean peak pressures under metatarsal heads of DFU patients with various modalities of offloading devices. They found total contact casting (TCC) to be the most effective with a mean pressure of 7 N/cm² which was the lowest of all devices tested. They also found that casts applied without walking heel fared better in terms of stability of gait akin to the presence of neuropathy.^[14] We did not use walking heels in any of the patients throughout the study.

Shaw et al. described that TCC works on the principle of load transfer from forefoot to behind.^[15] Walker and Helm reported that it is effective for both forefoot and hindfoot ulcers. However, they demonstrated that forefoot ulcers treated with this method heal faster than those at any other site on the foot.^[16] Healing rates of ulcer over forefoot in our study were better than those over other areas of foot.

Charles L. Saltzman et al. in their prospective cohort study concluded that early weight bearing in TCC though improves patient compliance but tends to retard the healing of plantar ulcers. We strongly advised patients not to bear weight for the first 2 weeks to avoid pistoning akin to the reduction of edema in the 1^st week. This casting principle provides a “forced compliance” in patients as it does not allow self-removal.

In a Cochrane database review, Jane Lewis and Allyson Lipp concluded that nonremovable pressure relieving casts along with TAL decreases recurrence rate by 75% at 7 months and 52% at 2 years.^[17] Triceps surae weakness is the main reason for this decrease in recurrence following TAL. We did not use any surgical lengthening of Achilles tendon to offload forefoot ulcers. Lengthening of the Achilles tendon causes calcaneal gait and increase in plantar pressure. Nishimoto et al. described in detail the technique of Achilles lengthening but warned that too much lengthening results in calcaneal gait and hindfoot overload.^[18] This casting technique was found to improve outcome even in the presence of moderate peripheral artery disease (PAD) and infection.^[19] We did not include any patients with PAD (mean brachial index <0.6) or infection (infection higher than Grade 2 of the PEDIS system) in the study.

Fife et al. studied the economic aspects of wound care and concluded that the casting method was the most economical method but it was not reimbursed.^[20] Our patients were given a free-of-cost treatment at a government facility; hence, we did not incur economics in the study. In a comparative study by Merli et al. 2018 between traditional dressing and TCC for DFUs, they observed better results with the TCC group with a mean healing period of 48 ± 7 days over the traditional dressing group with a mean healing time of 58 ± 9 days.

Advantages of total contact casting

It delivered higher healing percentages at a faster rate compared to standard care demonstrated in a randomized trial by Mueller et al.^[21] This is partly explained by its forced compliance nature. Armstrong et al. in their study showed that a removable device was worn by patients only for a total of 28% of their daily activities, with even the most compliant patients resorting to fewer than 60% in daily use.^[22] It aids in reducing the edema related to ulcer.^[21] Further, it allows for a superior reduction of pressure over removable devices like below knee/ankle/below ankle walkers.^[23]

A 5.5% of complication rate per cast has been predicted by Guyton et al. Charcoat arthropathy has a 1.5-fold higher estimated risk of complications compared to other etiologies. Dermal abrasion is the most commonly observed minor complication.^[24] Other reported complications of this method in the literature are fungal infection, maceration, impaired ambulation, and complications arising secondary to tightly applied cast. Complications associated with it are mainly due to patient noncompliance or previous undiagnosed osteomyelitis.^[25]

Patients should frequently check for signs of bleeding from the edges of casts for proper intervention. Use of a long sock or pillow during sleep avoids ulceration on the contralateral limb due to contact with cast material. Change in the gait pattern of the patient following this casting method does not seem to alter the risk of ulceration on the contralateral side.^[26] Frequent change of cast and padding of the bony prominences have been recommended as important factors for reducing the risk of iatrogenic complications. Prolonged treatment periods may end up causing muscle atrophy and decreased bone density.

Recent options have an adjuvant role in the management of NFU. Clinical data recommends the use of strategies aimed at preventing the disease and altering the effect of modifying agents on the disease.^[27]

TCC is an underutilized treatment option in the modern world. Wu SC et al. found out that only <2% of specialists in the US use of this technique for DFU management. A combination of higher success rate and low risk of major complications should render it as a gold standard of treatment for NFU management. Forced compliance reduced walking speed with shorter stride length^[27] result in less activity in patients treated with this method. Degree of exudation does influence the decision to use it. In such situations, creation of a window at a wound site offers the much-required exposure of wound site for proper wound care.

Conclusion

Diabetes mellitus remains the major cause of neuropathic foot ulceration. Loading off therapy with TCC technique is a useful treatment option and highly economic therapy for DFUs. Healing percentages delivered by TCC are impressive. Size of the ulcer has an impact on the duration of healing and number of casts required. Role of this principle in the management of ulcers is unparalleled by any of the modern-day options and treating surgeons need to reframe their strategies to include this casting method as part of their standard care of neuropathic ulcers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Richard JL, Schuldiner S. Épidémiologie du pied diabétique Epidemiology of diabetic foot problems. Rev. Med. Interne. 2008;29 Suppl 2:S222-30.
2.	Nather A, Bee CS, Huak CY, Chew JL, Lin CB, Neo S, et al. Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diabetes Complications 2008;22:77-82.
3.	Bakri FG, Allan AH, Khader YS, Younes NA, Ajlouni KM. Prevalence of diabetic foot ulcer and its associated risk factors among diabetic patients in Jordan. J Med J 2012;46:118-25.
4.	Snyder RJ, Hanft JR. Diabetic foot ulcers – Effects on QOL, costs, and mortality and the role of standard wound care and advanced-care therapies. Ostomy Wound Manage 2009;55:28-38.
5.	Leone S, Pascale R, Vitale M, Esposito S. Epidemiology of diabetic foot. Infez Med 2012;20 Suppl 1:8-13.
6.	Armstrong DG, Nguyen HC, Lavery LA, van Schie CH, Boulton AJ, Harkless LB. Off-loading the diabetic foot wound: A randomized clinical trial. Diabetes Care 2001;24:1019-22.
7.	Nabuurs-Franssen MH, Sleegers R, Huijberts MS, Wijnen W, Sanders AP, Walenkamp G, et al. Total contact casting of the diabetic foot in daily practice: a prospective follow-up study. Diabetes Care. 2005;28:243-7.
8.	Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: The Wagner and the University of Texas wound classification systems. Diabetes Care 2001;24:84-8.
9.	Armstrong DG, Lavery LA, Nixon BP, Boulton AJ. It's not what you put on, but what you take off: Techniques for debriding and off-loading the diabetic foot wound. Clin Infect Dis 2004;39 Suppl 2:S92-9.
10.	Cavanagh PR, Bus SA. Off-loading the diabetic foot for ulcer prevention and healing. J Vasc Surg 2010;52:37S-43S.
11.	Armstrong DG, Stacpoole-Shea S. Total contact casts and removable cast walkers. Mitigation of plantar heel pressure. J Am Podiatr Med Assoc 1999;89:50-3.
12.	Greenhagen RM, Wukich DK. Total contact casting for neuropathic ulcers: A lost art? J Dias Foot Compl 2009;1:85-93.
13.	Leibner ED, Brodsky JW, Pollo FE, Baum BS, Edmonds BW. Unloading mechanism in the total contact cast. Foot Ankle Int 2006;27:281-5.
14.	Armstrong DG, Isaac AL, Bevilacqua NJ, Wu SC. Offloading foot wounds in people with diabetes. Wounds 2014;26:13-20.
15.	Shaw JE, Hsi WL, Ulbrecht JS, Norkitis A, Becker MB, Cavanagh PR. The mechanism of plantar unloading in total contact casts: Implications for design and clinical use. Foot Ankle Int 1997;18:809-17.
16.	Walker SC, Helm PA, Pullium G. Total contact casting and chronic diabetic neuropathic foot ulcerations: Healing rates by wound location. Arch Phys Med Rehabil 1987;68:217-21.
17.	Mueller MJ, Sinacore DR, Hastings MK, Strube MJ, Johnson JE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. J Bone Joint Surg Am 2003;85:1436-45.
18.	Nishimoto GS, Attinger CE, Cooper PS. Lengthening the Achilles tendon for the treatment of diabetic plantar forefoot ulceration. Surg Clin North Am 2003;83:707-26.
19.	Bus SA, van Netten JJ, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, et al. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Diabetes Metab Res Rev 2016;32 Suppl 1:16-24.
20.	Fife CE, Carter MJ, Walker D. Why is it so hard to do the right thing in wound care? Wound Repair Regen 2010;18:154-8.
21.	Mueller MJ, Diamond JE, Sinacore DR, Delitto A, Blair VP 3^rd, Drury DA, et al. Total contact casting in treatment of diabetic plantar ulcers. Controlled clinical trial. Diabetes Care 1989;12:384-8.
22.	Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJ. Activity patterns of patients with diabetic foot ulceration: Patients with active ulceration may not adhere to a standard pressure off-loading regimen. Diabetes Care 2003;26:2595-7.
23.	Begg L, McLaughlin P, Vicaretti M, Fletcher J, Burns J. Total contact cast wall load in patients with a plantar forefoot ulcer and diabetes. J Foot Ankle Res 2016;9:2.
24.	Guyton GP. An analysis of iatrogenic complications from the total contact cast. Foot and ankle international. 2005;26:903-7.
25.	Myerson M, Papa J, Eaton K, Wilson K. The total-contact cast for management of neuropathic plantar ulceration of the foot. J Bone Joint Surg Am 1992;74:261-9.
26.	Hartsell HD, Brand RA, Saltzman CL. Total contact casting: Its effect on contralateral plantar foot pressure. Foot Ankle Int 2002;23:330-4.
27.	Wu SC, Jensen JL, Weber AK, Robinson DE, Armstrong DG. Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes care 2008;31:2118-9.