This document summarizes evidence comparing the effectiveness of removable cast walkers (RCW) to total contact casts (TCC) for treating diabetic foot ulcers. It finds that RCWs can achieve similar healing outcomes to TCCs when made non-removable, reducing healing times and complication rates. While TCC application requires more expertise, RCWs are easier for patients to don and doff and have lower costs. The document recommends RCWs as an effective alternative to TCCs when used on a full-time basis.

1. Comparison ofRemovable Cast Walkers to the Total Contact Cast for the Treatment of Diabetic Foot UlcersCritically Appraised Topic (CAT) SummaryLinda LaaksoB.Sc.,C.O.(c)www.customorthotic.ca

2. Diabetic Foot Ulcers (DFU)2.3 million Canadians have diabetes today*15% will develop a diabetic foot ulcer*85% of all amputations are the result of a non-healing ulcer**National Diabetes Surveillance System: Diabetes in Canada 2009

3. Contributing Factors to DFUAdapted from Lusardi and Neilson, page 544.

4. Treatment of Plantar DFURemoval of PressureGold Standard: Total Contact Cast (TCC)Redistribute pressureProtects healing tissueDisadvantagesSpecialized applicationCannot check wound

5. Alternatives for ulcer offloadingCustom ShoesFoot OrthosesCustom Brace (AFO)Removable cast walker (RCW)Surgical shoes/bootsRebound Air Walker removable cast walker image courtesy of Ossur Canada.

6. Is the removable cast walker (RCW) as effective as the total contact cast (TCC) in the treatment of the plantar diabetic foot ulcer?

7. Search Strategy

8. Selected Literature*Levels of evidence defined by Phillips et al. (1998).

9. Selected Literature

10. Summary of Best EvidenceKatz et al. (2005)Key Demographics

11. Summary of Best EvidenceKatz et al.Main FindingsComparison of TCC and iRCW had similar outcomes for:Proportion of people who had ulcers that healed

12. Median heal times

13. Complication ratesTime to don/doff: iRCW< TCCCost: iRCW< TCC

14. Implications for PracticeBest Practice Recommendations:-> Remove the pressureHow?Consensus suggests:Fulltime use provides better outcomesThe RCW when made irremovable has similar outcomes when compared to the TCC

15. ConsiderationsStrengthsStudies are consistent with each otherHigher level studies (1b)Studies are valid, reliable and relevantLimitationsStudies use small numbersStudies are not blinded

16. Next StepsLarger studies comparing TCC to RCWFurther study to compare RCW with and without custom insoleImplementation of results into clinical practice-> make the RCW irremovable when using

17. ReferencesArmstrong, D. G., Lavery, L. A., Wu, S., Boulton, A. J. M. (2005). Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds. Diabetes Care, 28(3), 551-554.Beuker, B. J., van Deursen, R. W., Price, P., Manning, E. A., van Baal, J. G., Harding, K. G. (2005). Plantar pressure in off-loading devices used in diabetic ulcer treatment. Wound Repair and Regeneration, 13, 537-542.Boninger, M. L., Leonard, J. A. (1996). Use of bivalve ankle foot orthosis in neuropathic foot and ankle lesions. Journal of Rehabilitation Research and Development, 33(1), 16-22.Botros, M., Goett, K., Parsons, L. Menzildzic, S., Morin, C., Smith, T. Hoar, A., Nesbeth, H., McGrath, S. (2010). Best Practice Recommendation for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers: Update 2010. Wound Care, 8(4), 6-40.Bus, S. A., van Deursen, R. W., Armstrong, D. G., Caravaggi, C., Hlavacek, P., Bakker, K., Cavanaugh, P. R. (2008). The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes/Metabolism Research and Reviews, 24(Suppl 1), S162-S180. DOI:10.1002/dmrr.850.Elftman, N. W. (2006). Orthotic management of the neuropathic limb. Physical Medicine and Rehabilitation Clinics of North America, 17, 115-157.