Health Quality Ontario .
Ontario health technology assessment series. Date of publication 2017 Sep 21;volume 17(12):1-124.
1. Ont Health Technol Assess Ser. 2017 Sep 21;17(12):1-124. eCollection 2017.
Fibreglass Total Contact Casting, Removable Cast Walkers, and Irremovable Cast
Walkers to Treat Diabetic Neuropathic Foot Ulcers: A Health Technology
Assessment.
Health Quality Ontario.
Collaborators: Costa V, Tu HA, Wells D, Weir M, Holubowich C, Walter M.
BACKGROUND: Diabetic neuropathic foot ulcers are a risk factor for lower leg
amputation. Many experts recommend offloading with fibreglass total contact
casting, removable cast walkers, and irremovable cast walkers as a way to treat
these ulcers.
METHODS: We completed a health technology assessment, which included an
evaluation of clinical benefits and harms, value for money, and patient
preferences for offloading devices. We performed a systematic literature search
on August 17, 2016, to identify randomized controlled trials that compared
fibreglass total contact casting, removable cast walkers, and irremovable cast
walkers with other treatments (offloading or non-offloading) in patients with
diabetic neuropathic foot ulcers. We developed a decision-analytic model to
assess the cost-effectiveness of fibreglass total contact casting, removable cast
walkers, and irremovable cast walkers, and we conducted a 5-year budget impact
analysis. Finally, we interviewed people with diabetes who had lived experience
with foot ulcers, asking them about the different offloading devices and the
factors that influenced their treatment choices.
RESULTS: We identified 13 randomized controlled trials. The evidence suggests
that total contact casting, removable cast walkers, and irremovable cast walkers
are beneficial in the treatment of neuropathic, noninfected foot ulcers in
patients with diabetes but without severe peripheral arterial disease. Compared
to removable cast walkers, ulcer healing was improved with total contact casting
(moderate quality evidence; risk difference 0.17 [95% confidence interval
0.00-0.33]) and irremovable cast walkers (low quality evidence; risk difference
0.21 [95% confidence interval 0.01-0.40]). We found no difference in ulcer
healing between total contact casting and irremovable cast walkers (low quality
evidence; risk difference 0.02 [95% confidence interval -0.11-0.14]). The
economic analysis showed that total contact casting and irremovable cast walkers
were less expensive and led to more health outcome gains (e.g., ulcers healed and
quality-adjusted life-years) than removable cast walkers. Irremovable cast
walkers were as effective as total contact casting and were associated with lower
costs. The 5-year budget impact of funding total contact casting, removable cast
walkers, and irremovable cast walkers (device costs only at 100% access) would be
$17 to $20 million per year. The patients we interviewed felt that wound healing
was improved with total contact casting than with removable cast walkers, but
that removable cast walkers were more convenient and came with a lower cost
burden. They reported no experience or familiarity with irremovable cast walkers.
CONCLUSIONS: Ulcer healing improved with total contact casting, irremovable cast
walkers, and removable cast walkers, but total contact casting and irremovable
cast walkers had higher rates of ulcer healing than removable cast walkers.
Increased access to offloading devices could result in cost savings for the
health system because of fewer amputations. Patients with diabetic foot ulcers
reported a preference for total contact casting over removable cast walkers,
largely because they perceived wound healing to be improved with total contact
casting. However, cost, comfort, and convenience are concerns for patients.
PMCID: PMC5628703
PMID: 28989556 [Indexed for MEDLINE]
