Back To Basics: How To Ensure Effective Offloading With Total Contact Casting

I recently had the opportunity to speak at a dinner meeting to a group of wound care clinicians. During a question and answer session, the topic of discussion drifted toward the use of total contact casting (TCC). I asked the meeting participants to indicate, with a show a hands, how many of them were using this modality regularly in their practice. I was shocked to see that the number was less than 10 percent.

Numerous authors have described the underlying pathology in the development of lower extremity ulcerations. Perhaps one of the greatest difficulties in managing complex lower extremity ulcerations is offloading the wound site effectively. A review of the literature demonstrates that TCC is the “gold standard” for offloading non-infected, non-ischemic plantar foot ulcerations.1,2

There are several mechanisms that combine to provide the reduction of peak plantar pressures via the use of TCC. Studies have established that the use of TCC decreases altered gait mechanics with shortened stride length and an overall reduction of walking velocity, both of which contribute to the reduction of plantar pressures.3 Furthermore, given the “cone effect” provided by the physical structure of the patient’s leg (an inverted cone), the TCC (a conical receptacle) also allows more even distribution of the patient’s weight.

Despite the numerous studies that demonstrate the efficacy of TCC for healing plantar neuropathic ulcers, there seems to be a trend away from utilizing this powerful modality in the management of lower extremity ulcerations. For whatever reasons, clinicians do not seem to be casting as much as they used to do. A steep learning curve, application time and reimbursement issues are all reasons why clinicians involved in lower extremity wound care no longer perform TCC.

Granted, there was some truth to these concerns in the past. In recent years, however, numerous TCC kits have become available to make it easier and faster to apply TCC in the clinic or office. Armstrong and colleagues demonstrated the efficacy of what they described as instant total contact casting (iTCC) using a removal cast walking boot (RCW) wrapped with fiberglass to improve patient adherence for the management of lower extremity ulcerations.4 They demonstrated a wound healing success rate similar to the control arm of patients in TCC and the application time and cost were significantly less than the time and cost for traditional TCC.

Ultimately, for the clinician involved in the management of lower extremity wounds, there are a number of options available to provide a cost-effective and time-efficient TCC. In my own practice, I have utilized both an iTCC as well as several of the currently available TCC kits, such as the EZ-TCC (MedEfficiency). While there is a slight learning curve, I have found that with my clinical assistant, I can apply a TCC in less than five minutes. Usually I apply the cast while I am giving the patient my spiel on the “red flags” of TCC usage (i.e., the signs and symptoms he or she might notice that would prompt the patient to present to the office prior to the scheduled appointment).

When I am first utilizing TCC on patients, I bring them back to the clinic within approximately three days to evaluate for any potential pre-ulcerative lesions and to confirm that patients tolerated the cast appropriately. Assuming no issues, I reapply the cast and transition to weekly cast changes.

Fourteen Steps To Applying A Total Contact Cast From Scratch

Listed below is a primer on how to apply a TCC using materials available in the clinic.

1. Apply a foam dressing to the ulcer area and secure the dressing with paper tape. If the sterile package appears to be compromised, do not use it.
2. Place the stockinette over the foot, extending to the knee. Pull the stockinette forward to cover the toes and fold approximately 2 to 4 inches over the dorsum of the foot. Trim the excess and secure it with plastic tape.
3. Place a strip of felt along the anterior crest of the tibia with flaps covering the malleoli.
4. Fold adhesive foam lengthwise to cover the toes completely, with the top and bottom sticking to the stockinet. Trim the excess from each side.
5. Place the patient in a prone position with the leg flexed at the knee. Apply Webril around the leg, overlapping slightly at the shin area.
6. Maintain the foot in a neutral position with the ankle as close to 90 degrees as possible. Be sure not to crimp materials in toes or heel/ankle areas during application.
7. Using a 4-inch roll of plaster, briefly wet the material. Wrap the foot and leg from distal to proximal. One should make all “tucks” or folds of excess plaster over the padded areas only.
8. Wet a 3-inch roll of fiberglass and apply it in the same fashion. Wrap the foot and leg from distal to proximal. Make all tucks or folds of excess plaster over the padded areas only.
9. Fabricate a posterior splint from 4-inch fiberglass without wetting the material, extending from the toes to the most proximal part of casting material. Place the splint so any excess material hangs over the width of the foot medially and one can roll this inward to fill any void in the arch area.
10. Place 1/4-inch plywood on the bottom of the foot with a walking heel.
11. Fashion another posterior splint with 3-inch fiberglass without wetting it and cut it in the appropriate place for the walking heel to show through.
12. Apply a final layer of wet 4-inch roll of fiberglass as in step 8 to finish the cast.
13. Do not allow weightbearing for 15 minutes or until the cast has cooled and hardened.
14. Provide the patient with an instruction sheet and an emergency removal instruction card. Instruct the patient to carry the card in case of an emergency.

A Word About TCC Billing

The application of a TCC is identified by Current Procedure Terminology (CPT®) code CPT 29445 [application of a rigid total contact cast, half leg, adult]. Physicians and other qualified healthcare professionals utilize CPT 29445 to bill for this service. All payers use CPT codes for physician services provided in hospitals, clinics and other settings, including the physician’s office.

Unlike with most CPT codes, the American Medical Association has not included the cost of casting materials in the practice expense relative value unit (PE-RVU) calculation used by Medicare and other payers to establish a payment fee for applying TCC. Therefore, in a physician’s office where the physician incurs the expense of the casting supplies, the supplies are always separately billable, whether it is the first or subsequent cast application. Physicians use the appropriate Healthcare Common Procedural Coding System (HCPCS) codes for casting supplies [Q4001-Q4051] when reporting their service for the TCC application on billing claims.

I would encourage each of you to revisit this modality as an effective tool in your armamentarium for the management of complicated, difficult to offload plantar ulcerations. It is easier and quicker than you think.

References

1. Mueller MJ, Diamond JE, Sinacore DR, et al. Total contact casting in treatment of diabetic plantar ulcers. Diabetes Care. 1989; 12(6):384–388.

2. Armstrong DG, Nguyen HC, Lavery LA, et al. Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care. 2001; 24(8):1019–1022.

3. Brand PW. Management of the Diabetic Foot, Williams and Wilkens, 1987, p.15.

4. Armstrong DG, Short B, Espensen EH, Abu-Rumman PL, Nixon BP, Boulton AJ. Technique for fabrication of an "instant total-contact cast" for treatment of neuropathic diabetic foot ulcers. J Am Podiatr Med Assoc. 2002; 92(7):405-8.