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diabetic foot ulcer, off-loading, electronic health records



  1. Fife, Caroline E. MD
  2. Carter, Marissa J. PhD
  3. Walker, David CHT
  4. Thomson, Brett MS
  5. Eckert, Kristen A. MPhil


OBJECTIVE: To evaluate the practice of off-loading diabetic foot ulcers (DFUs) using real-world data from a large wound registry to better identify and understand the gap between evidence and practice.


DESIGN: Retrospective, deidentified data were extracted from the US Wound Registry based on patient/wound characteristics, procedures performed, and at which clinic the DFU was treated.


SETTING: 96 clinics (23 from the United States and Puerto Rico)


PATIENTS: 11,784 patients; 25,114 DFUs


MAIN OUTCOME MEASURES: Healed/not healed, amputated, percent off-loading, percent use of total contact casting (TCC), infection rate


MAIN RESULTS: Off-loading was documented in only 2.2% of 221,192 visits from January 2, 2007, to January 6, 2013. The most common off-loading option was the postoperative shoe (36.8%) and TCC (16.0%). There were significantly more amputations within 1 year for non-TCC-treated DFUs compared with TCC-treated DFUs (5.2% vs 2.2%; P = .001). The proportion of healed wounds was slightly higher for TCC-treated DFUs versus non-TCC-treated DFUs (39.4% vs 37.2%). Infection rates were significantly higher for non-TCC-treated DFUs compared with TCC-treated DFUs (2.6 vs 1.6; P = 2.1 x 10-10). Only 59 clinics used TCC (61%); 57% of those clinics used traditional TCC, followed by TCC-EZ (36%). Among clinics using any type of TCC, 96.3% of the DFUs that did not receive TCC were "TCC-eligible" ulcers. Among clinics using "traditional" TCC systems, 1.4% of DFUs were treated with TCC, whereas clinics using TCC-EZ provided TCC to 6.2% of DFUs.


CONCLUSION: Total contact casting is vastly underutilized in DFU wound care settings, suggesting that there is a gap in practice for adequate off-loading. New, easier-to-apply TCC kits, such as the TCC-EZ, may increase the frequency with which this ideal form of adequate off-loading is utilized.