Basic Low-cost Removable Footwear for Diabetic Foot Ulcer Offloading: A Systematic Review

Offloading is an established foot care practice for diabetic foot ulcers (DFUs) involving the use of footwear, casts, and other devices to reduce plantar pressure, promote healing, and prevent ulcer formation. Currently, the criterion standard for offloading diabetic foot involves the irremovable total contact cast (TCC); however, application is resource-intensive, and patient adherence can be challenging because of functional limitations. The objective of this study was to determine the efficacy of removable offloading footwear for DFU healing and prevention. MEDLINE and Embase databases were searched on July 25, 2023, with keywords relating to "diabetic foot" and "offloading devices." Two researchers screened articles initially by title and abstract, followed by full-text screening. Articles were included if they reported on patients with DFU who were treated with removable offloading devices. Data extraction was completed by 2 researchers independently. Data extracted included patient demographics, healing time, amputation rate, recurrence rate, and offloading devices used. Outcomes, including healing time, healing rate, amputation rate, and recurrence rate, were pooled. Studies were assessed for quality using the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence. Twenty-three studies were included, reflecting 1694 patients. In 618 cases with an active ulcer, a mean healing rate of 71% was observed. The mean time required for healing was 68.4 days. Mean amputation rate was 15.4%. In 760 cases evaluating prevention of recurrence, the mean recurrence rate documented was 22.5% with a follow-up duration of 39.7 months. Three hundred sixteen cases evaluated the prevention of new DFUs, noting an ulcer incidence rate of 2%. Simple and removable offloading devices may be an accessible and low-cost option for the prevention of new or recurrent ulcers. Healing and amputation outcomes were not superior to published literature regarding TCC. Nonetheless, they may provide moderate utility in patients unable to tolerate TCC or in low-resource settings.

To present the results of a systematic review evaluating the utility of accessible and removable offloading footwear for diabetic foot ulcer (DFU) prevention, healing, and recurrence.

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin, wound, and diabetic foot care.

After completing this continuing education activity, the participant will: Summarize the evidence the authors considered when evaluating the use of offloading footwear for DFUs.Identify the characteristics of the patients and clinical environments in which offloading devices were used.Illicit the results of the authors' study detailing the utility of basic offloading footwear for prevention, healing, and recurrence of DFUs.Elucidate the authors' conclusions about the efficacy and safety of basic offloading footwear for high-risk diabetic foot, active ulcers, and recurrent ulcer risk.