Skip to main content
  • More from ADA
    • Diabetes
    • Clinical Diabetes
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care
  • Subscribe
  • Log in
  • My Cart
  • Follow ada on Twitter
  • RSS
  • Visit ada on Facebook
Diabetes Care

Advanced Search

Main menu

  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • Special Article Collections
    • ADA Standards of Medical Care
  • Browse
    • By Topic
    • Issue Archive
    • Saved Searches
    • Special Article Collections
    • ADA Standards of Medical Care
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
    • ADA Peer Review
  • More from ADA
    • Diabetes
    • Clinical Diabetes
    • Diabetes Spectrum
    • ADA Standards of Medical Care
    • ADA Scientific Sessions Abstracts
    • BMJ Open Diabetes Research & Care

User menu

  • Subscribe
  • Log in
  • My Cart

Search

  • Advanced search
Diabetes Care
  • Home
  • Current
    • Current Issue
    • Online Ahead of Print
    • Special Article Collections
    • ADA Standards of Medical Care
  • Browse
    • By Topic
    • Issue Archive
    • Saved Searches
    • Special Article Collections
    • ADA Standards of Medical Care
  • Info
    • About the Journal
    • About the Editors
    • ADA Journal Policies
    • Instructions for Authors
    • Guidance for Reviewers
  • Reprints/Reuse
  • Advertising
  • Subscriptions
    • Individual Subscriptions
    • Institutional Subscriptions and Site Licenses
    • Access Institutional Usage Reports
    • Purchase Single Issues
  • Alerts
    • E­mail Alerts
    • RSS Feeds
  • Podcasts
    • Diabetes Core Update
    • Special Podcast Series: Therapeutic Inertia
    • Special Podcast Series: Influenza Podcasts
    • Special Podcast Series: SGLT2 Inhibitors
    • Special Podcast Series: COVID-19
  • Submit
    • Submit a Manuscript
    • Journal Policies
    • Instructions for Authors
    • ADA Peer Review
Emerging Treatments and Technologies

An Off-the-Shelf Instant Contact Casting Device for the Management of Diabetic Foot Ulcers

A randomized prospective trial versus traditional fiberglass cast

  1. Alberto Piaggesi, MD,
  2. Silvia Macchiarini, DPM,
  3. Loredana Rizzo, MD,
  4. Francesca Palumbo, MD,
  5. Anna Tedeschi, MD,
  6. Laura Ambrosini Nobili, DPM,
  7. Elisa Leporati, DPM,
  8. Vincenzo Scire, DPM,
  9. Ilaria Teobaldi, DPM and
  10. Stefano Del Prato, MD, PHD
  1. From the Section of Diabetes and Metabolic Diseases, Department of Endocrinology and Metabolism, University of Pisa and Azienda Ospedaliera Pisana, Pisa, Italy
  1. Address correspondence and reprint requests to Alberto Piaggesi MD, Sezione Piede Diabetico-U.O., Malattie del Metabolismo e Diabetologia, Azienda Ospedaliera Universitaria Pisana, Via Paradisa 2-56124 Pisa, Italy. E-mail: piaggesi{at}immr.med.unipi.it
Diabetes Care 2007 Mar; 30(3): 586-590. https://doi.org/10.2337/dc06-1750
PreviousNext
  • Article
  • Figures & Tables
  • Info & Metrics
  • PDF
Loading

A randomized prospective trial versus traditional fiberglass cast

Abstract

OBJECTIVE—This study was designed to test the safety, effectiveness, and costs of off-loading with a novel, off-the-shelf irremovable device in the management of diabetic foot ulceration (DFU).

RESEARCH DESIGN AND METHODS—We prospectively evaluated off-loading of neuropathic plantar ulcers in 40 diabetic outpatients attending our diabetic foot clinic and compared healing rates at the 12-week follow-up, number and severity of adverse events, healing time, costs and applicability of the device, and patients’ satisfaction between those randomly assigned to total contact casting (TCC; group A) or to the Optima Diab walker (group B). Deep or infected ulcers were excluded.

RESULTS—No difference between groups A and B was observed in healing rates at 12 weeks (95 vs. 85%), healing time (6.5 ± 4.4 vs. 6.7 ± 3.4 weeks), and number of adverse events (six versus four). Treatment was significantly less expensive in group B, which showed a mean reduction of costs of 78% compared with group A (P < 0.001). Practicability was more favorable in group B, with a reduction of 77 and 58% of the time required for application and removal of the devices, respectively (P < 0.001). Patients’ satisfaction with the treatment was higher in group B (P < 0.01).

CONCLUSIONS—The Optima Diab walker is as safe and effective as TCC in the management of DFU, but its lower costs and better applicability may be of help in spreading the practice of off-loading among the centers that manage the diabetic foot.

  • DFU, diabetic foot ulceration
  • i-TCC, instant TCC
  • RCW, removable cast walker
  • TCC, total contact casting

Diabetic foot ulceration (DFU) is the most frequent form of ulcer in the foot in industrialized countries and the major determinant of lower-limb amputations in diabetic patients, since up to 85% of all major amputations in diabetes are preceded by an ulcer (1,2). The presence of active DFU has been reported in 4% of the general population, but it is estimated that up to 15% of people with diabetes will experience DFUs at least once in their lifetime (3,4).

The pathogenesis of DFU is well understood and is based on the effects of peripheral neuropathy upon the target organ, the foot, over a variable amount of time. The pressure resulting from normal daily activity gradually increases until it overwhelms the resistance of the skin and creates a lesion in the plantar surface of the foot that maintains itself with the continuity of load, eventually becoming complicated by infection and ischemia (5,6). The determinant role of foot loading in the genesis and maintenance of plantar ulcers in the neuropathic foot has been demonstrated beyond any reasonable doubt, and its interruption is the key to reversing the pathogenic chain and to starting the healing process (7–9).

Unfortunately, there are no easy ways to obtain effective off-loading of the foot. Patient compliance is generally poor because of the lack of symptoms due to sensory neuropathy, and they tend to wear off-loading devices very scarcely. Total contact casting (TCC), therefore, has been indicated as the gold standard for the management of neuropathic ulceration, mainly because it is nonremovable by the patients (10,11).

Nevertheless, management of these patients with TCC presents many problems. It is costly; it relies on the availability of a cast technician; it can raise safety issues, especially in elderly patients; and it requires time for application and removal (11,12). To address these issues, Armstrong et al. (13) proposed using a removable cast walker (RCW) rendered irremovable by the application of a single-layer fiberglass band so that the patient could not remove it, and they called it “instant” TCC (i-TCC) (13,14).

Following this philosophy, a new off-loading device (Optima Diab; Molliter, Civitanova Marche, Italy) has been designed to serve as an off-the-shelf i-TCC, and it was proposed for use in the management of DFU. Its characteristics include a rigid rocker sole with an innovative design, a modular insole composed of three layers of different stiffness that can be adapted according to the actual location of the ulcer, and a posterior rigid brace to block the ankle high up to the upper leg. The device can be rendered irremovable by securing it with a plastic lace that can be removed only by cutting it with a specific tool, thus rendering it nonremovable by the patients. We designed this study to compare its safety and effectiveness to TCC in the management of DFU in a group of diabetic outpatients.

RESEARCH DESIGN AND METHODS—

All the patients attending the diabetic foot clinic of the University of Pisa between April and October 2005 were screened for the following inclusion criteria: They should have type 1 or type 2 diabetes for a period of at least 5 years, they should have peripheral neuropathy as highlighted by insensitivity to a 10-g monofilament and by a vibration perception threshold measured at malleolus of at least 25 volts (15), and they should have a forefoot plantar ulcer for a period of at least 3 weeks with an area wider than 1 cm2 graded 1A or 2A according to Texas University classification (16). The exclusion criteria considered were peripheral vascular disease with an ankle-brachial pressure index <0.9; the presence of clinical signs of infection, including edema, erithema, increased local skin temperature, secretion, fever, and leukocytosis, confirmed by culture exams; previous ulcer in the same site in the last 6 months; probing to bone and/or radiographic signs of osteomyelitis; Charcot’s neuroarthropathy of the foot; bilateral ulceration; serum creatinine >2 mg/dl; any systemic pathology or therapy possibly interfering with the healing process; severe visual or motor impairment that could expose the patient to risk of accidents while participating in the study; and/or a life expectancy shorter than 1 year.

Patients released a written informed consent before enrolling in the study. The information given to patients included a description of both off-loading techniques. Participants were then randomly divided into two different groups with a computer-generated randomization list. Group A was off-loaded with a nonremovable fiberglass cast as is the standard approach in our clinic, and group B subjects were placed in the Optima Diab device according to the manufacturer’s instructions.

Besides the off-loading treatment, patients received specific instructions on how to manage the off-loading devices and the standard therapy of neuropathic ulceration performed in our clinic according to the international consensus on the diabetic foot (17). Ulcers were surgically debrided, eliminating all the nonviable tissue, as well as any sinus or undermined zone, and exposing the entire area of the lesion. The ulcers were then photographed and measured by means of Visitrak (Smith & Nephew, Hull, U.K.). Ulcers were dressed with paraffined gauze and covered with a single layer of sterile gauze before application of the off-loading devices.

Patients in group A were casted according to a technique previously described by Petre et al. (18). Positioning a layer of isolating foam (Allevyn adhesive; Smith & Nephew) in relation to the ulceration site, the lesion is better isolated from contact with the cast, paying attention to avoid friction or trauma with bony prominences by protecting them with extra layers of cotton-wool. The fiberglass material used for manufacturing each cast was produced by 3M (St. Paul, MN) and consisted of two Scotchcast longuettes (10 × 90 or 7.5 × 70 cm, depending on the size of the foot) to create the plantar support and block the ankle, and three Sofcast rolls (10.1 or 7.6 cm) to make the boot. Each cast was provided with one or two rubber heels (Lohmann, Neuwied, DE) to allow the patients to stand and walk.

Patients in group B were given the Optima Diab device, adapted according to the patient’s foot condition and secured to the patient’s leg with a plastic nonremovable lace, which was an integral part of the device (Fig. 1). The patients’ foot and leg were protected by a layer of cotton-wool to avoid friction with the device, and the three-layer insoles were modeled to accommodate the position of the ulcer site. All the casts were made by the same podologist, certified for this particular expertise (S.M.). The manufacturing time of each cast was measured at each visit, including the first one, and cost of treatment was calculated for both groups.

Cost for TCC was calculated based on the real cost paid by the hospital to buy all the necessary materials (fiberglass bandages, rubber heel, cotton-wool, etc.) from manufacturers, while cost of the Optima Diab device was calculated based on the cost at which the device is sold on the market. Costs were calculated for each TCC based on the actually consumed materials, which could vary in amount depending on the size of the foot and location of ulcer. All the costs were inclusive of 20% tax.

Patients of both groups were followed-up weekly for 12 weeks or up to complete reepithelialization of the lesions. At each checkup, patients in group A had their cast removed with an oscillating saw. Lesions were debrided, if necessary, measured, photographed, and dressed, and a new cast was then manufactured. Patients in group B underwent the same procedure except for the removal of the off-loading device, which was performed by cutting the nonremovable lace and then opening the device. This was then controlled and repositioned by replacing the nonremovable plastic laces. The time taken to remove the device also was measured, as well as the time to reposition it on the patients.

Any eventual adverse events were recorded, with special emphasis on possible infective complications or appearance of new lesions. At the end of the study, patients were requested to express their level of satisfaction with the treatment by means of a visual analogic scale ranging from 0 (no satisfaction at all) to 10 (maximum satisfaction), answering the question “how satisfied were you with your treatment?”

The primary end point was the rate of healing at 12 weeks (i.e., rate of patients with complete reepithelialization), while secondary end points were the number and severity of adverse events, mean healing time, time of application and removal of the devices, cost of treatment, and level of satisfaction expressed by patients.

The data, expressed as means ± SD, were analyzed according to the intention-to-treat model, with Student’s t test for normally distributed variables, the Kaplan-Meier analysis for survival data, and the χ2 tests for dichotomous variables, using commercially available software (StatView; SAS Institute, Cary, NC) running on a personal computer.

RESULTS—

A total of 43 patients were screened, but only 40 were actually randomized in the two study groups. Their characteristics are reported in Table 1. Of three patients who did not enter the study, one refused to release the informed consent and two were unable to attend the scheduled follow-up visits because of the distance of traveling to the clinic. There were no significant differences between the two groups as far as demographics and clinical data are concerned. The characteristics of patients are reported in Table 1. All patients of both groups completed the study and attended all control visits. In two cases in group A and three cases in group B, one control visit was delayed for 1 day because of patient-related causes.

No significant differences emerged between the groups with regard to treatment complications. In group A, five patients reported minor adverse events during the course of the study (one TCC partial rupture due to accidental trauma and four episodes of skin maceration in the perilesional area). In group B, one patient reported one single episode of transient paresthesia in the foot with no objective signs, two patients showed skin maceration, and one patient presented a superficial emathoma of the calf due to accidental trauma, without any skin injury. No new lesions were observed in any of the patients in either group during the study. None of the adverse events led to discontinuation of the study. One patient in group A and one in group B developed local signs of infection (perilesional erithema and edema), which led to the administration of oral antibiotics (1 g b.i.d. amoxicyllin-clavulanate) for 10 days. In both cases, the signs of infection were resolved in 1 week and did not recur, and patients continued the study. No significant differences in the healing rates were observed between the groups, since 95% of group A patients and 85% of group B patients healed within 12 weeks (χ2 1.569, P = 0.2104). In Fig. 2, the Kaplan-Meier plots show the survival curves of group A and group B patients with no differences between the two groups in terms of healing. The mean duration of healing time was 6.5 ± 4.4 weeks (range 2–14) in group A and 6.7 ± 3.4 weeks (2–17) in group B (P = 0.8745). Healing time correlated with the area of the lesion at baseline in both groups (P < 0.01), while it was not influenced by age, duration of diabetes, or A1C.

The time for placement of the off-loading devices significantly differed between group A and group B patients (15.1 ± 2.3 min [range 10.9–18.6] vs. 2.1 ± 0.7 min [1.9–2.6], respectively, P < 0.001) as did the time for their removal (2.1 ± 0.9 min [1.1–3.0] vs. 0.9 ± 0.4 min [0.5–1.0], respectively, P < 0.01). The cost of casting was 110.15 ± 4.38 euros (range 107.05–117.41) per cast, and the cost per patient was 727.29 ± 491.25 euros (214.11–1,827.84), while the cost of Optima Diab was 130 euros each, and the cost per patient was 162.5 ± 57.75 euros (130–260 euros, P < 0.001) since in five patients the device was replaced because of usage. Patients’ levels of satisfaction with the treatment, evaluated with the visual analogic scale, were significantly higher in the i-TCC group compared with the TCC group (8.45 ± 1.79 vs. 6.85 ± 2.39, respectively, P < 0.05).

CONCLUSIONS—

Our study confirms the effectiveness and the safety of nonremovable off-loading devices in the management of DFU, at the same level as TCC, and establishes their superiority over TCC in terms of practicability, cost, and patient acceptance.

Off-loading is an etiologic therapy of neuropathic diabetic foot ulcers. When correctly applied, it has been proven not only to interrupt the pathogenic chain that produces the ulceration but also to induce modifications in the histology of the ulcer, shifting it from a chronic inflammatory state to a much more evolutive condition (19,20).

The rate of success of off-loading strategies is strictly related to the nonremovability of the devices applied, as opposed to their peculiar characteristics. Previous studies emphasize how the rate of healing at 12 weeks is >80% in patients treated with irremovable devices, while it drops to <60% in patients treated with removable devices (21).

The nonremovability is effective in both maximizing the off-loading application time and minimizing the role of patient compliance, which is generally very poor. Ha Van et al. (22) demonstrated how the rate of patients completely adhering to an off-loading regimen may vary from 10% when it is removable to 98% when it is nonremovable. Armstrong et al. (23) demonstrated that patients wearing RCWs not only tended not to wear them but also increased their activity when they were not wearing them, thus reducing even further the benefit of off-loading.

Our study confirms the efficacy of an i-TCC off-loading regimen, since no differences in healing rates at 12-week follow-up emerged between TCC and Optima Diab. It also focuses more attention on the philosophy of complete, durable, and sustainable off-loading rather than on the strategy used to obtain it. The easier it is to pursue an off-loading strategy the more likely it is to be effective because of its actual application on patients. In this sense, TCC, although effective and safe, represents an option often difficult to pursue because it requires specific expertise, time, and many different materials to be assembled in a complex way, and, depending on how often it is changed, it is expensive (22).

A recent survey in European centers of excellence for diabetic foot, not yet published but quoted by Naaburs-Franssen et al. (24), shows how little the TCC is actually used in the management of DFU despite it being indicated as the gold standard for off-loading in the international guidelines for DFU management (17,24). The nonremovable device we used, although presenting good technical features (rigid rocker sole, posterior brace that blocks the ankle joint, composite multilayered insoles—all features that have been demonstrated to effectively reduce the plantar pressure of the forefoot [25,26]), can be considered as a valid alternative to TCC, mainly because it has been designed to be nonremovable by the patient.

The availability of an off-the-shelf nonremovable device would help in increasing the actual application of off-loading to more patients not only because it is easier but also because it takes significantly less time to apply and remove, and this can make a difference in a busy diabetic foot clinic. Patient acceptance of the treatment was clearly favorable to i-TCC, and this should not be surprising in view not only of the effectiveness but also of the relatively low impact on everyday activities of this option compared with TCC.

Cost of treatment is also an issue in the management of DFU, since it has been demonstrated that diabetic foot is likely to be the most expensive and resource consuming among the chronic complications of diabetes (27). Our study demonstrated how the cost of the treatment with an i-TCC, which can be repositioned only by changing the plastic lace, is less than one-quarter of the treatment with TCC. This is possible because, in contrast to TCC, which is replaced at every checkup, i-TCC can last for the whole treatment. Because of its effectiveness, these costs can be considered an investment, as they stop the progression of ulceration toward more severe and costly stages of the pathology of the diabetic foot. A recent study with an econometric model calculated 874 U.S. dollars as the 6-month treatment cost for a superficial ulcer and 1,872 U.S. dollars as the cost for a deep ulcer, with an increase of 114% in the management costs (28).

Our data are consistent with those reported by Katz et al. (14) in a recent well-designed study comparing TCC with a cast walker rendered irremovable. Results in terms of efficacy, placement, and removal times of the TCC and RCW were superimposable, while in our study higher costs for TCC were observed, probably due to higher costs of materials in Italy compared with the U.S.

Our study, though encouraging, is not conclusive because it has many limitations. The number of patients is small; it was conducted by highly specialized personnel in a single center, which is a site of excellence for diabetic foot management; and the results cannot be extended to other centers in which there is no such focused clinical activity and where there would be potentially the most interest in an easily applicable, effective, and safe off-loading option. For these reasons, we are designing a prospective multicenter trial involving diabetes centers throughout Italy to test i-TCC in a larger sample of patients and in different clinical settings.

The irremovable Optima Diab walker is as safe and effective as TCC in the management of neuropathic foot and is more practical, less expensive, and more accepted by the patients. Its application may help in expanding the possibilities of real application of an effective off-loading regimen to diabetic patients with a neuropathic ulceration also in the many centers that cannot afford the technology and investments for manufacturing TCCs. It therefore contributes to reducing the risk of evolution of the pathology toward more severe stages and eventually to preventing amputations.

Figure 1—
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 1—

The Optima Diab device.

Figure 2—
  • Download figure
  • Open in new tab
  • Download powerpoint
Figure 2—

Kaplan-Meier survival analysis of ulcers in group A (dotted line) and group B (solid line). No significant differences were observed between the groups.

View this table:
  • View inline
  • View popup
Table 1—

Characteristics of patients in the two groups

Acknowledgments

We acknowledge the generous contribution of Salvatelli srl, Civitanova Marche, Italy, manufacturers of the Optima Diab Molliter walkers used in this study.

We also acknowledge the help of Bridget Walker for revising the English in this article.

Footnotes

  • A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

    The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C Section 1734 solely to indicate this fact.

    • Accepted December 9, 2006.
    • Received August 18, 2006.
  • DIABETES CARE

References

  1. ↵
    Reiber GE, Boyko EJ, Smith DG: Lower extremity foot ulcers and amputations in diabetes. In Diabetes in America. 2nd ed. National Diabetes Data Group, Eds. Washington, DC, National Institutes of Health, 1995, p. 409–428
  2. ↵
    Pecoraro RE: Chronology and determinants of tissue repair in diabetic lower extremity ulcers. Diabetes 40: 1305–1313, 1991
    OpenUrlAbstract/FREE Full Text
  3. ↵
    Centers for Disease Control and Prevention (CDC): Lower extremity disease among persons aged > or =40 years with and without diabetes—United States, 1999–2002. MMWR Morb Mortal Wkly Rep 54:1158–1160, 2005
    OpenUrlPubMed
  4. ↵
    Mayfield JA, Reiber GE, Sanders LJ, Janise D, Pogach LM: Preventive foot care in people with diabetes. Diabetes Care 21:2161–2177, 1998
    OpenUrlFREE Full Text
  5. ↵
    Boulton AJ: The diabetic foot: from art to science: the 18th Camillo Golgi lecture. Diabetologia 47:1343–1353, 2004
    OpenUrlPubMedWeb of Science
  6. ↵
    Litzelman DK, Marriot DJ, Vinicor F: Independent physiological predictors of foot lesions in patients with NIDDM. Diabetes Care 20:1273–1278, 1997
    OpenUrlAbstract/FREE Full Text
  7. ↵
    Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L, Veves A: Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care 21:1714–1719, 1998
    OpenUrlAbstract/FREE Full Text
  8. Caravaggi C, De Giglio R, Pritelli C, Sommariva M, Dalla Noce S, Faglia E, Mantero M, Clrici G, Fratino P, Dalla Paola L, Mariani G, Mingardi R, Morabito A: Hyaff 11–based autologous derma and epidermal grafts in the treatment of noninfected diabetic plantar and dorsal foot ulcers: a prospective, multicenter, controlled, randomized clinical trial. Diabetes Care 26:2853–2859, 2003
    OpenUrlAbstract/FREE Full Text
  9. ↵
    Caravaggi C, Faglia E, De Giglio R, Mantero M, Quarantiello A, Sommariva E, Gino M, Pritelli C, Morabito A: Effectiveness and safety of a nonremovable feberglass off-bearing cast versus a therapeuthic shoe in the treatment of neuropathic foot ulcers. Diabetes Care 23:1746–1751, 2000
    OpenUrlAbstract/FREE Full Text
  10. ↵
    Armstrong DG, Ngyugen HC, Lavery LA, van Schie CHM, Boulton AJM, Harkless LB: Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care 24:1019–1022, 2001
    OpenUrlAbstract/FREE Full Text
  11. ↵
    Cavanagh PR, Lipsky BA, Bradbury AW, Botek G: Treatment for diabetic foot ulcers: review. Lancet 336:1725–1735, 2005
    OpenUrl
  12. ↵
    Wukich DK, Motko J: Safety of total contact casting in high risk patients with diabetic foot ulcers. Foot Ankle Int 25:556–560, 2004
    OpenUrlAbstract/FREE Full Text
  13. ↵
    Armstrong DG, Short B, Espensen EH, Abu-Rumman PL, Nixon BP, Boulton AJM: Technique for fabrication of an “instant total contact cast” for treatment of neuropathic diabeticfoot ulcers. J Am Podistr Asso c92:405–408, 2002
    OpenUrl
  14. ↵
    Katz IA, Harlan A, Miranda-Palma B, Prietoi-Sanchez L, Armstrong DG, Bowker JH, Mizel MS, Boulton AJM: A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. Diabetes Care 28:555–559, 2005
    OpenUrlAbstract/FREE Full Text
  15. ↵
    Young MJ, Breddy JL, Veves A, Boulton AJM: The prediction of diabetic neuropathic foot using vibration perception threshold: a prospective study. Diabetes Care 17:557–560, 1994
    OpenUrlAbstract/FREE Full Text
  16. ↵
    Armstrong DG, Lavery LA, Harkless LB: Validation of a diabetic wound classification system: the contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 21:855–859, 1999
    OpenUrl
  17. ↵
    International Working Group on the Diabetic Foot: International Consensus on the Diabetic Foot. Apelqvist J, Bakker K, Nabuurs-Franssen MH, Schaper NC, Van Houtum WH, Eds. Maastricht, Netherlands, 1999
  18. ↵
    Petre M, Tokar P, Kostar D, Cavanagh PR: Revisiting the total contact cast: maximizing off-loading by wound isolation. Diabetes Care 28:929–930, 2005
    OpenUrlFREE Full Text
  19. ↵
    Armstrong DG, Lavery LA, Nixon BP, Boulton AJ: 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 39(Suppl. 2):S92–S99, 2004
    OpenUrl
  20. ↵
    Piaggesi A, Viacava P, Rizzo L, Naccarato G, Baccetti F, Romanelli M, Zampa V, Del Prato S: Semiquantitative analysis of the histopathological features of the neuropathic foot ulcer: effect of pressure relief. Diabetes Care 26:3123–3128, 2003
    OpenUrlAbstract/FREE Full Text
  21. ↵
    Armstrong DG, Lavery LA, WU S, Boulton AJM: Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds. Diabetes Care 28:551–554, 2005
    OpenUrlAbstract/FREE Full Text
  22. ↵
    Ha Van G, Siney H, Hartmann-Heurtier A, Jaqueminet S, Greau F, Grimaldi A: Nonremovable, windowed, fiberglass cast boot in the treatment of diabetic plantar ulcers: efficacy, safety, and compliance. Diabetes Care 26:2848–2852, 2003
    OpenUrlAbstract/FREE Full Text
  23. ↵
    Armstrong DG, Lavery LA, Kimbriel HR, Nixon BP, Boulton AJM: Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen. Diabetes Care 26:2595–2597, 2003
    OpenUrlAbstract/FREE Full Text
  24. ↵
    Nabuurs-Fransenn M, Sleegers R, Huijberts MSP, Wijnen W, Sanders AP, Walenkamp G, Schaper NC: Total contact casting of the diabetic foot in daily practice: a prospective follow-up study. Diabetes Care 28:243–247, 2005
    OpenUrlAbstract/FREE Full Text
  25. ↵
    Brown D, Wertsch JJ, Harris GF, Klein J, Janisse D: Effect of rocker soles on plantar pressures. Arch Phys Med Rehabil 85:81–86, 2004
    OpenUrlCrossRefPubMedWeb of Science
  26. ↵
    Lavery LA, Vela SA, Lavery DC, Quebedeaux TL: Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulceration: a comparison of treatments. Diabetes Care 19:818–821, 1996
    OpenUrlAbstract/FREE Full Text
  27. ↵
    Garattini L, Chiaffarino F, Cornago D, Coscelli C, Parazzini F, the Study Group RECORD (Rilevazione Economica dei Costi e Risorse del Diabete): Direct medical costs unequivocally related to diabetes in Italian diabetes centers. Eur J Health Econom 5:15–21, 2004
    OpenUrl
  28. ↵
    Ortegon MM, Redekop WK, Niessen LW: Cost-effectiveness of prevention and treatment of the diabetic foot: a Markov analysis. Diabetes Care 27:901–907, 2004
    OpenUrlAbstract/FREE Full Text
PreviousNext
Back to top
Diabetes Care: 30 (3)

In this Issue

March 2007, 30(3)
  • Table of Contents
  • About the Cover
  • Index by Author
Sign up to receive current issue alerts
View Selected Citations (0)
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word about Diabetes Care.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
An Off-the-Shelf Instant Contact Casting Device for the Management of Diabetic Foot Ulcers
(Your Name) has forwarded a page to you from Diabetes Care
(Your Name) thought you would like to see this page from the Diabetes Care web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Citation Tools
An Off-the-Shelf Instant Contact Casting Device for the Management of Diabetic Foot Ulcers
Alberto Piaggesi, Silvia Macchiarini, Loredana Rizzo, Francesca Palumbo, Anna Tedeschi, Laura Ambrosini Nobili, Elisa Leporati, Vincenzo Scire, Ilaria Teobaldi, Stefano Del Prato
Diabetes Care Mar 2007, 30 (3) 586-590; DOI: 10.2337/dc06-1750

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Add to Selected Citations
Share

An Off-the-Shelf Instant Contact Casting Device for the Management of Diabetic Foot Ulcers
Alberto Piaggesi, Silvia Macchiarini, Loredana Rizzo, Francesca Palumbo, Anna Tedeschi, Laura Ambrosini Nobili, Elisa Leporati, Vincenzo Scire, Ilaria Teobaldi, Stefano Del Prato
Diabetes Care Mar 2007, 30 (3) 586-590; DOI: 10.2337/dc06-1750
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • RESEARCH DESIGN AND METHODS—
    • RESULTS—
    • CONCLUSIONS—
    • Acknowledgments
    • Footnotes
    • References
  • Figures & Tables
  • Info & Metrics
  • PDF

Related Articles

Cited By...

More in this TOC Section

  • Autologous Umbilical Cord Blood Transfusion in Young Children With Type 1 Diabetes Fails to Preserve C-Peptide
  • Effects of MK-0941, a Novel Glucokinase Activator, on Glycemic Control in Insulin-Treated Patients With Type 2 Diabetes
  • Diabetes Antibody Standardization Program
Show more Emerging Treatments and Technologies

Similar Articles

Navigate

  • Current Issue
  • Standards of Care Guidelines
  • Online Ahead of Print
  • Archives
  • Submit
  • Subscribe
  • Email Alerts
  • RSS Feeds

More Information

  • About the Journal
  • Instructions for Authors
  • Journal Policies
  • Reprints and Permissions
  • Advertising
  • Privacy Policy: ADA Journals
  • Copyright Notice/Public Access Policy
  • Contact Us

Other ADA Resources

  • Diabetes
  • Clinical Diabetes
  • Diabetes Spectrum
  • Scientific Sessions Abstracts
  • Standards of Medical Care in Diabetes
  • BMJ Open - Diabetes Research & Care
  • Professional Books
  • Diabetes Forecast

 

  • DiabetesJournals.org
  • Diabetes Core Update
  • ADA's DiabetesPro
  • ADA Member Directory
  • Diabetes.org

© 2021 by the American Diabetes Association. Diabetes Care Print ISSN: 0149-5992, Online ISSN: 1935-5548.