Total Contact Casting in Diabetic Foot Ulcer Management: Insights from the 2019 IWGDF Offloading Guideline

Published by M-Med | Educational content for wound care professionals

The International Working Group on the Diabetic Foot (IWGDF) released an updated guideline in 2019 emphasizing the critical role of offloading in the treatment of diabetic foot ulcers (DFUs). Central to these recommendations is the use of total contact casting as a primary intervention for neuropathic plantar forefoot or midfoot ulcers.

Key Recommendations

For individuals with diabetes presenting with a neuropathic plantar forefoot or midfoot ulcer, the guideline strongly recommends the use of a non-removable knee-high offloading device, such as a total contact cast or a non-removable walker, to promote ulcer healing.

The choice between a total contact cast and a non-removable knee-high walker should be based on factors including resource availability, technician expertise, patient preferences, and the extent of foot deformity.

If non-removable knee-high devices are contraindicated or not tolerated, the guideline suggests considering removable knee-high offloading devices as a second-choice treatment, with removable ankle-high devices as a third option.

Rationale for Total Contact Casting

Total contact casting involves the use of a custom-made, knee-high, non-removable cast designed to redistribute pressure away from the ulcer site, reduce shear forces, and enforce adherence by preventing easy removal. Evidence indicates that non-removable offloading devices like total contact casts offer superior healing outcomes compared to removable devices, with studies showing faster healing times and higher healing rates.

Considerations and Contraindications

While total contact casting is effective, its use requires careful patient selection. Contraindications include severe peripheral arterial disease, infection, extensive necrosis, and heavily exuding wounds that require frequent dressing changes. Additionally, total contact casts may not be suitable for patients with balance issues or those at high risk of falls.

Implementation Challenges

Despite being considered the gold standard for offloading neuropathic DFUs, total contact casting is underutilized in clinical practice. Barriers include the need for specialized training, time-consuming application processes, and concerns about patient tolerance. Addressing these challenges through clinician education and resource allocation is essential for broader adoption.