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Total contact casting (TCC) is a specially designed cast designed to take weight of the foot (off-loading) in patients with diabetic foot ulcers (DFUs). Reducing pressure on the wound by taking weight of the foot has proven to be very effective in DFU treatment. DFUs are a major factor leading to lower leg amputations among the diabetic population in the US with 85% of amputations in diabetics being preceded by a DFU.〔Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008, www.ahrq.gov.〕 Furthermore, the 5 year post-amputation mortality rate among diabetics is estimated at around 45% for those suffering from neuropathic DFUs.〔Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008, www.ahrq.gov.〕 TCC has been used for off-loading DFUs in the US since the mid-1960s and is regarded by many practitioners as the “reference standard” for off-loading the bottom surface (sole) of the foot.〔Armstrong, D.G., et al., It's not what you put on, but what you take off: techniques for debriding and off-loading the diabetic foot wound. Clin Infect Dis, 2004. 39 Suppl 2: p. S92–9. 〕 TCC involves encasing the patient’s complete foot, including toes, and the lower leg in a specialist cast that redistributes weight and pressure in the lower leg and foot during everyday movements. This redistributes pressure from the foot into the leg, which is more able to bear weight, to protect the wound, letting it regenerate tissue and heal.〔Raspovic, A. and K.B. Landorf, A survey of offloading practices for diabetes-related plantar neuropathic foot ulcers. J Foot Ankle Res, 2014. 7: p. 35. 〕 TCC also keeps the ankle from rotating during walking, which prevents shearing and twisting forces that can further damage the wound.〔Snyder, R.J., et al., The management of diabetic foot ulcers through optimal off-loading building consensus guidelines and practical recommendations to improve outcomes. J Am Podiatr Med Assoc, 2014. 104(6): p. 555–67. 〕 Effective off loading is a key treatment modality for DFUs, particularly those where there is damage to the nerves in the feet (peripheral neuropathy). Along with infection management and vascular assessment, TCC is vital aspect to effectively managing DFUs.〔Snyder, R.J., et al., The management of diabetic foot ulcers through optimal off-loading building consensus guidelines and practical recommendations to improve outcomes. J Am Podiatr Med Assoc, 2014. 104(6): p. 555–67.〕 TCC is the most effective and reliable method for off-loading DFUs.〔Armstrong, D.G., et al., Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care, 2001. 24(6): p. 1019–22. 〕〔Lavery, L.A., et al., Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations: a comparison of treatments. Diabetes Care, 1996. 19: p. 818–821.〕〔Lewis, J. and A. Lipp, Pressure-relieving interventions for treating diabetic foot ulcers. Cochrane Database Syst Rev, 2013. 1: p. Cd002302.〕 == History of clinical use == The use of TCC for foot ulcers resulting from leprosy (Hansen's disease) was reported by Joseph Khan in India in the 1930s.〔Birke, J.A. and C.A. Patout, The Contact Cast: An Update and Case Study Report. Wounds UK, 2000. 12(2).〕 Research conducted by Paul W. Brand, MD, in the 1940s and 50s, also in India, demonstrated that the wounds in the feet were caused by nerve damage (neuropathy) rather than infection, as previously thought. In his use of TCC to eliminate weight and pressure on the ulcers, he observed the healing of ulcers that had been present for a long time. These seminal observations resulted in the development of treatments to manage neuropathic foot ulcers, which are useful for patients with diabetes.〔Boulton, A.J., Diabetic foot--what can we learn from leprosy? Legacy of Dr Paul W. Brand. Diabetes Metab Res Rev, 2012. 28 Suppl 1: p. 3-7.〕 In 1965, TCC was introduced to the United States by Dr. Brand, then at the National Hansen’s Disease Center in Carville, Louisiana. The goal of TCC was to distribute weight over the entire foot and lower leg.〔Birke, J.A. and C.A. Patout, The Contact Cast: An Update and Case Study Report. Wounds UK, 2000. 12(2).〕 Over time, the staff at Carver Hospital refined the method to reduce the development of other wounds that occur in part because of the initial problem with the foot (secondary ulceration). Materials have changed over the years, from an unmodified plaster of Paris, to formulations containing fiberglass. However, plaster of Paris casts take too long to fully dry and limits patient mobility for up to 74 hours — if the patient walks on the cast during this time, the shape will change, and the cast will not protect the foot and wound correctly.〔Schmidt, V.E., J.H. Somerset, and R.E. Porter, Mechanical properties of orthopedic plaster bandages. J Biomech, 1973. 6(2): p. 173-85.〕 Fiberglass casts were introduced in the 1980 or '90s. The curing time of a fiberglass cast is far shorter than plaster of Paris, letting the patient walk with an outer boot within an hour of application. Because casts made of fiberglass have lower breakdown rate and do not impede patient mobility, this material has become the choice for TCC.〔Kowalski, K.L., J.D. Pitcher, Jr., and B. Bickley, Evaluation of fiberglass versus plaster of Paris for immobilization of fractures of the arm and leg. Mil Med, 2002. 167(8): p. 657-61.〕〔Greenhagen, R.M. and D.K. Wukich, Total contact casting for neuropathic ulcers: a lost art? J Diabetic Foot Complications, 2009. 1(4): p. 2-9.〕 In 2003, the first TCC casting system that contained all the materials in one package (MedE-Kast® Total Contact Casting System) was developed. This innovation helped standardize the application of TCC. Other advancements have been made to make casting easier to learn, easier to apply and less time consuming. In 2008, the TCC-EZ® Total Contact Casting system became available. In addition to the established benefits of traditional TCC, TCC-EZ® also provided an easy to apply casting sock. The one-piece, roll-on, woven design simplified the application process, which reduced the potential for causing additional tissue damage. This cast can be put on in less than 10 minutes (about a quarter of the time of previous methods), and its lightweight design is more comfortable for the patient.〔Jensen, J., et al., TCC-EZ® - Total Contact Casting System Overcoming the Barriers to Utilizing a Proven Gold Standard Treatment. DFCon, Los Angeles, USA, Poster., 2008.〕 The ease of use of TCC EZ® has been a driver in the growth of TCC use and has helped increase the accessibility and administration of effective off-loading.〔Fife C.E. et al., Diabetic foot ulcer off-loading: The gap between evidence and practice. Data from the US Wound Registry. Adv Skin Wound Care. 2014 Jul;27(7):310-6.〕 However, despite the availability of specialist kits, including kits that reduce application time to less than 10 min, there still exists a large “gap in practice” between the accepted gold standard of care and the number of patients currently treated with this standard of care. The US Wound Registry (USWR) data from 2007-2013 shows that, of 11, 784 patients treated for DFUs, only 16% received TCC.〔http://www.uswoundregistry.com/〕 抄文引用元・出典: フリー百科事典『 ウィキペディア（Wikipedia）』 ■ウィキペディアで「Total contact casting」の詳細全文を読む スポンサード リンク
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