Perioperative Offloading for Diabetic Foot Ulcers: A Systematic Review and Evidence Synthesis

Diabetic foot ulcers (DFUs) affect approximately 18.6 million people worldwide each year. Abnormal plantar pressure during the perioperative period impairs wound healing and promotes ulcer recurrence. Although offloading interventions are fundamental to DFU management, available evidence remains fragmented, and clinical implementation lacks standardization, particularly in perioperative settings. This systematic review and evidence synthesis aimed to systematically retrieve, appraise, and synthesize the best available evidence on perioperative offloading management for DFU patients and to provide evidence-based recommendations for clinical nursing practice. A systematic search following the "6S" evidence pyramid model was conducted across PubMed, Web of Science, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, China National Knowledge Infrastructure (CNKI), Wanfang, and Chinese Biomedical Literature Database (CBM) databases, as well as professional society websites, from January 2015 to March 2025. Eligible publication types included clinical guidelines, expert consensus statements, clinical decisions, evidence summaries, and systematic reviews. Quality appraisal used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument for guidelines and Joanna Briggs Institute (JBI) critical appraisal tools for systematic reviews and expert consensus. Evidence was graded using the JBI Evidence Grading System (2014 version). Fifteen publications were included: 8 guidelines, 2 expert consensus statements, and 5 systematic reviews. Thirty-one evidence items were summarized across seven domains: perioperative risk screening and assessment, multidisciplinary team composition, surgical strategy selection, offloading principles, preoperative offloading, postoperative offloading, and health education with monitoring. Evidence levels ranged from 1 to 5, with the majority at Level 5. This systematic review synthesizes comprehensive evidence on perioperative offloading management in patients with DFU. Healthcare providers should contextualize evidence selection based on clinical settings and individual patient characteristics to optimize wound outcomes and quality of life.