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]

Complications are more likely in patients who have poor glycemic control (1.27 times greater) and are morbidly obese (1.55 times greater).[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]:

• Development of a new ulcer or wound over a bony prominence (14.17% or patients)
• New or increasing odor or drainage
• Wound infection
• Gangrene
• Newly identified osteomyelitis
• Pain or discomfort necessitating cast change or removal, including  [7]:
•  Back 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".