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How to Apply and Remove a Total Contact Cast

How to Apply and Remove a Total Contact Cast

How to Apply and Remove a Total Contact Cast


This topic provides practical guidance with step-by-step videos on how to apply total contact cast (TCC), considered gold standard for offloading of diabetic foot ulcers. For a comprehensive overview on offloading from the clinical, coverage and reimbursement perspective, see " Offloading Devices". For guidance on selection of offloading devices see " How to Select Offloading Devices". For evidence and recommendations on offloading for diabetic foot ulcer, see section 'Offloading' in topic "Diabetic Foot Ulcer - Treatment".

    Videos



Video 1. Application of a total contact cast (TCC) for offloading of a diabetic foot ulcer, patient in seated position

Video 2. Removal of total contact cast (TCC)  for offloading of a diabetic foot ulcer.

Video 3. Application of a total contact cast (TCC) for offloading of a diabetic foot ulcer, patient in prone position

Video 4. Removal of total contact cast (TCC)  for offloading of a diabetic foot ulcer, from another angle 


TCC is an evidence-based supported recommendation for management of diabetic foot ulcers (see section ' Offloading' in "Diabetic Foot Ulcer - Treatment"). [1] [2] [3] [4] [5] Nevertheless, treatment-associated morbidity when using TCC may be present in up to 42% of patients. [6]

According to a retrospective study involving 381 patients with diabetic foot ulcers (DFU), 42% of patients (159 patients) presented with at least one of the complications below. [6]  Complications are more likely in patients who have poor glycemic control (1.27 times greater) and are morbidly obese (1.55 times greater). [6]

  • Development of a new ulcer or wound over a bony prominence (1 4.17% or patients)
  • New or increasing odor or drainage
  • Wound infection,
  • Gangrene
  • Newly identified osteomyelitis
  • Pain or discomfort necessitating cast change or removal, including  [7]:
    •  B ack and hip pain caused by alteration in gait due to the difference in height between the casted leg and footwear of the opposite leg or the weight of the TCC on one side
    •  Abrasions on the opposing leg caused by the TCC, especially if the patient is an active sleeper

If any of the above complications arise, discontinue TCC and consider other methods of offloading (e.g. refer to non-removable knee high offloading device in section 'Offloading' in "Diabetic Foot Ulcer - Treatment" and in topic " How to Select Offloading Devices"). 

  • Because the ulcer cannot be checked regularly, non-removable offloading devices such as TCCs are contraindicated in patients with mild infection associated with mild PAD, in patients with severely infected and/or severely ischemic DFUs or in patients with heavily exudative ulcers. [8] However, if a patient has either a mild PAD or a mild infection under control with antibiotics, this patient may still be a candidate for non-removable knee-high devices. [8]
  • For details on diabetic foot infection, osteomyelitis and gangrene, see topics " Diabetic Foot Ulcer Associated with Ischemia - Management" and  "Diabetic Foot Ulcer Associated with infection - Management". 
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    NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.


    1. Bus SA, van Deursen RW, Armstrong DG, Lewis JE, Caravaggi CF, Cavanagh PR, International Working Group on the Diabetic Foot. et al. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes/metabolism research and reviews. 2016;volume 32 Suppl 1():99-118.
    2. de Oliveira AL, Moore Z et al. Treatment of the diabetic foot by offloading: a systematic review. Journal of wound care. 2015;volume 24(12):560, 562-70.
    3. Lewis, Jane; Lipp, Allyson et al. Pressure-relieving interventions for treating diabetic foot ulcers. Cochrane Database of Systematic Reviews. 2013;.
    4. Morona JK, Buckley ES, Jones S, Reddin EA, Merlin TL et al. Comparison of the clinical effectiveness of different off-loading devices for the treatment of neuropathic foot ulcers in patients with diabetes: a systematic review and meta-analysis. Diabetes/metabolism research and reviews. 2013;volume 29(3):183-93.
    5. Elraiyah T, Prutsky G, Domecq JP, Tsapas A, Nabhan M, Frykberg RG, Firwana B, Hasan R, Prokop LJ, Murad MH et al. A systematic review and meta-analysis of off-loading methods for diabetic foot ulcers. Journal of vascular surgery. 2016;volume 63(2 Suppl):59S-68S.e1-2.
    6. Riopelle A, LeDuc R, Wesolowski M, Schiff AP, Pinzur MS et al. Risk of Complications With the Total Contact Cast in Diabetic Foot Disorders. Foot & ankle specialist. 2021;volume 14(1):25-31.
    7. Melodie Blakely. A Practical Guide to Total Contact Casting: A Risk vs. Benefit Approach Today's Wound Clinic . 2010;.
    Topic 1723 Version 2.0


    This topic provides guidance on selection of Offloading Devices with an interactive framework