Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

Area of Science:

• Diabetology
• Podiatry
• Wound Healing

Background:

• Diabetes-related foot ulcers (DFUs) pose a significant risk for infection, hospitalization, and amputation.
• Effective offloading of mechanical tissue stress is paramount for DFU healing.
• This guideline updates the 2019 International Working Group on the Diabetic Foot (IWGDF) recommendations.

Purpose of the Study:

• To provide evidence-based guidelines on offloading interventions for promoting DFU healing.
• To update and refine recommendations from the previous IWGDF guideline.
• To guide healthcare professionals in managing DFUs.

Main Methods:

• Systematic review and meta-analyses following the GRADE approach.
• Formulation of clinical questions using the PICO format.
• Development of recommendations based on evidence, expert opinion, and GRADE criteria (desirable/undesirable effects, certainty of evidence, patient values, resources, cost-effectiveness, equity, feasibility, acceptability).

Main Results:

• First-choice offloading for neuropathic plantar forefoot/midfoot ulcers: non-removable knee-high device.
• Second-choice: removable knee-high or ankle-high offloading device (if contraindications/intolerance).
• Third-choice: appropriately fitting footwear with felted foam if devices unavailable.
• Surgical options (tendon lengthening, osteotomy, etc.) considered if non-surgical offloading fails.
• Digital flexor tendon tenotomy for specific toe ulcers.
• Specific recommendations for rearfoot, non-plantar, or complicated ulcers.

Conclusions:

• These offloading guidelines aim to improve care and outcomes for individuals with DFUs.
• Implementation of these recommendations can reduce the risk of infection, hospitalization, and amputation.
• The guideline provides a clinical pathway to facilitate practical application in healthcare settings.