Total Contact Casting as the Gold Standard for Offloading Diabetic Foot Ulcers

Total contact casting is the primary treatment for offloading plantar neuropathic foot ulcers. Case Study 1: 38-year-old diabetic male with neuropathy presented with a large plantar ulcer on his right foot. MRI showed osteomyelitis. He was started on antibiotics, had bone debrided, a total contact cast applied, and hyperbaric oxygen therapy initiated. Labs were ordered including HbA1C. Diabetic teaching was initiated. A new cast was applied weekly. The total contact cast remained 2-3 weeks beyond healing to ensure skin tensile strength. The patient was evaluated for diabetic shoes with custom inserts. Correct break-in period was discussed to prevent friction or breakdown, especially with an insensate foot. The wound was completely healed after 4 months of treatment. Case Study 2: 62-year-old morbidly obese, diabetic with osteomylitis and amputation of his right great toe came to clinic with chronic ulcer to his plantar surface of his right foot. The ulcer was associated with a moderate rocket-bottom Charcot deformity. The ulcer was unresponsive to previous treatments. Laboratory data and radiology reports were obtained. A contact cast was applied and the patient was instructed in partial weight-bearing ambulation. The cast was reapplied at weekly intervals, and the wound was fully closed in 3 months. Case Study 3: 60-year-old man admitted to wound clinic with an ulcer to the lateral aspect of the left foot. He has a cardiac history, diabetes, and chronic renal insufficiency. His HbA1c was 10.4, Vitamin D level 11.6 and Albumin 4.9. A total contact cast was reapplied weekly with serial debridement, silver foam dressings and compression. Lifestyle management was also consulted. This wound healed completely after 4 months of treatment. In conclusion, with skilled application and careful follow-up of the wound, total contact casting is easy, cost-effective, and results in excellent healing.