Diabetic Foot Ulcer Off-loading: The Gap Between Evidence and Practice. Data from the US Wound Registry

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-TCCYtreated 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-TCCYtreated DFUs (39.4% vs 37.2%). Infection rates were significantly higher for non-TCCYtreated 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.