Bus SA, van Deursen RW, Armstrong DG, Lewis JE, Caravaggi CF, Cavanagh PR, International Working Group on the Diabetic Foot., et al.
Diabetes/metabolism research and reviews. Date of publication 2016 Jan 1;volume 32 Suppl 1():99-118.
1. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:99-118. doi: 10.1002/dmrr.2702.
Footwear and offloading interventions to prevent and heal foot ulcers and reduce
plantar pressure in patients with diabetes: a systematic review.
Bus SA(1), van Deursen RW(2), Armstrong DG(3), Lewis JE(4), Caravaggi CF(5),
Cavanagh PR(6); International Working Group on the Diabetic Foot.
Author information:
(1)Department of Rehabilitation Medicine, Academic Medical Centre, University of
Amsterdam, Amsterdam, The Netherlands.
(2)School of Health Care Sciences, College of Biomedical and Life Sciences,
Cardiff University, Cardiff, UK.
(3)Southern Arizona Limb Salvage Alliance (SALSA), University of Arizona College
of Medicine, Tucson, Arizona, USA.
(4)Cardiff and Vale University Health Board and Cardiff School of Health Science,
Cardiff Metropolitan University, Cardiff, UK.
(5)University Vita Salute San Raffaele and Diabetic Foot Clinic, Istituto Clinico
Città, Studi, Milan, Italy.
(6)Department of Orthopaedics and Sports Medicine, University of Washington
Medical Centre, Seattle, WA, USA.
BACKGROUND: Footwear and offloading techniques are commonly used in clinical
practice for preventing and healing of foot ulcers in persons with diabetes. The
goal of this systematic review is to assess the medical scientific literature on
this topic to better inform clinical practice about effective treatment.
METHODS: We searched the medical scientific literature indexed in PubMed, EMBASE,
CINAHL, and the Cochrane database for original research studies published since 1
May 2006 related to four groups of interventions: (1) casting; (2) footwear; (3)
surgical offloading; and (4) other offloading interventions. Primary outcomes
were ulcer prevention, ulcer healing, and pressure reduction. We reviewed both
controlled and non-controlled studies. Controlled studies were assessed for
methodological quality, and extracted key data was presented in evidence and risk
of bias tables. Uncontrolled studies were assessed and summarized on a narrative
basis. Outcomes are presented and discussed in conjunction with data from our
previous systematic review covering the literature from before 1 May 2006.
RESULTS: We included two systematic reviews and meta-analyses, 32 randomized
controlled trials, 15 other controlled studies, and another 127 non-controlled
studies. Several randomized controlled trials with low risk of bias show the
efficacy of therapeutic footwear that demonstrates to relief plantar pressure and
is worn by the patient, in the prevention of plantar foot ulcer recurrence. Two
meta-analyses show non-removable offloading to be more effective than removable
offloading for healing plantar neuropathic forefoot ulcers. Due to the limited
number of controlled studies, clear evidence on the efficacy of surgical
offloading and felted foam is not yet available. Interestingly, surgical
offloading seems more effective in preventing than in healing ulcers. A number of
controlled and uncontrolled studies show that plantar pressure can be reduced by
several conservative and surgical approaches.
CONCLUSIONS: Sufficient evidence of good quality supports the use of
non-removable offloading to heal plantar neuropathic forefoot ulcers and
therapeutic footwear with demonstrated pressure relief that is worn by the
patient to prevent plantar foot ulcer recurrence. The evidence base to support
the use of other offloading interventions is still limited and of variable
quality. The evidence for the use of interventions to prevent a first foot ulcer
or heal ischemic, infected, non-plantar, or proximal foot ulcers is practically
non-existent. High-quality controlled studies are needed in these areas.
Copyright © 2015 John Wiley & Sons, Ltd.
DOI: 10.1002/dmrr.2702
PMID: 26342178 [Indexed for MEDLINE]
