**3.2 Wound care and Total contact casting (TCC)**

TCC resulted in healing in 90% (64/71) of foot ulcers [45]. However ulcer recurrence at 18 months follow-up occurred in 34% (22/64). A high complication rate of 31% (22/70) has also been reported with TCC [32]. A comparison of healed ulcers at two year follow-up revealed 81% (21/26) recurred after TCC but only 38% (10/ 27) recurred after Achilles lengthening was added in the only controlled randomized study available [33].

TCC is apparently not needed for forefoot ulcer healing, since TCC was not used in most more recent studies after Mueller's article [26, 29, 33, 35, 41]. Wound care healed only 31% (142/458) of diabetic foot ulcers in 5 months in a meta-analysis of the literature [38]. An average of 80% of diabetic foot ulcers healed with TCC [39]. Tendon lengthening has better healing rate for ulcers than wound care and TCC [2, 24–26, 29, 33–36, 38–41].

Tendon lengthening also has less complications and a much lower recurrence rate than TCC [2, 24–26, 29, 32–36, 41]. This author agrees with other authors that tendon lengthening rather than TCC should be considered the "gold standard" treatment for forefoot ulcers [26, 36, 41].
