Bus SA, Armstrong DG, Crews RT, Gooday C, Jarl G, Kirketerp-Moller K, Viswanathan V, Lazzarini PA, et al.
Diabetes/metabolism research and reviews. Date of publication 2023 May 25;volume ():e3647.
1. Diabetes Metab Res Rev. 2023 May 25:e3647. doi: 10.1002/dmrr.3647. Online
ahead of print.
Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023
update).
Bus SA(1)(2), Armstrong DG(3), Crews RT(4), Gooday C(5), Jarl G(6)(7),
Kirketerp-Moller K(8)(9), Viswanathan V(10), Lazzarini PA(11)(12).
Author information:
(1)Department of Rehabilitation Medicine, Amsterdam UMC, Location University of
Amsterdam, Amsterdam, The Netherlands.
(2)Amsterdam Movement Science, Program Rehabilitation & Development, Amsterdam,
Netherlands.
(3)Department of Surgery, Southwestern Academic Limb Salvage Alliance (SALSA),
Keck School of Medicine of University of Southern California (USC), Los Angeles,
California, USA.
(4)Dr. William M. Scholl College of Podiatric Medicine's Center for Lower
Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University, North
Chicago, Illinois, USA.
(5)Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals,
Norwich, UK.
(6)Faculty of Medicine and Health, Department of Prosthetics and Orthotics,
Örebro University, Örebro, Sweden.
(7)Faculty of Medicine and Health, University Health Care Research Center,
Örebro University, Örebro, Sweden.
(8)Copenhagen Wound Healing Center, Bispebjerg University Hospital, Copenhagen,
Denmark.
(9)Steno Diabetes Center, Copenhagen, Denmark.
(10)MV Hospital for Diabetes, Chennai, India.
(11)School of Public Health and Social Work, Queensland University of
Technology, Brisbane, Australia.
(12)Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane,
Australia.
AIMS: Offloading mechanical tissue stress is arguably the most important of
multiple interventions needed to heal diabetes-related foot ulcers. This is the
2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based
guideline on offloading interventions to promote healing of foot ulcers in
persons with diabetes. It serves as an update of the 2019 IWGDF guideline.
MATERIALS AND METHODS: We followed the GRADE approach by devising
clinical questions and important outcomes in the PICO
(Patient-Intervention-Control-Outcome) format, undertaking a systematic review
and meta-analyses, developing summary of judgement tables and writing
recommendations and rationales for each question. Each recommendation is based
on the evidence found in the systematic review, expert opinion where evidence
was not available, and a careful weighing of GRADE summary of judgement
items including desirable and undesirable effects, certainty of evidence,
patient values, resources required, cost effectiveness, equity, feasibility, and
acceptability.
RESULTS: For healing a neuropathic plantar forefoot or midfoot ulcer in a person
with diabetes, use a non-removable knee-high offloading device as the
first-choice offloading intervention. If contraindications or patient
intolerance to non-removable offloading exist, consider using a removable
knee-high or ankle-high offloading device as the second-choice offloading
intervention. If no offloading devices are available, consider using
appropriately fitting footwear combined with felted foam as the third-choice
offloading intervention. If such a non-surgical offloading treatment fails to
heal a plantar forefoot ulcer, consider an Achilles tendon lengthening,
metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For
healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile
toe deformity, use digital flexor tendon tenotomy. For healing rearfoot,
non-plantar or ulcers complicated with infection or ischaemia, further
recommendations have been outlined. All recommendations have been summarised in
an offloading clinical pathway to help facilitate the implementation of this
guideline into clinical practice.
CONCLUSION: These offloading guideline recommendations should help healthcare
professionals provide the best care and outcomes for persons with
diabetes-related foot ulcers and reduce the person's risk of infection,
hospitalisation and amputation.
© 2023 The Authors. Diabetes/Metabolism Research and Reviews published by John
Wiley & Sons Ltd.
DOI: 10.1002/dmrr.3647
PMID: 37226568
