Australian guideline on offloading treatment for foot ulcers: part of the 2021 Australian evidence‐based guidelines for diabetes‐related foot disease

Abstract

Background Pressure offloading treatment is critical for healing diabetes-related foot ulcers (DFU). Yet the 2011 Australian DFU guidelines regarding offloading treatment are outdated. A national expert panel aimed to develop a new Australian guideline on offloading treatment for people with DFU by adapting international guidelines that have been assessed as suitable to adapt to the Australian context. Methods National Health and Medical Research Council procedures were used to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines to the Australian context. We systematically screened, assessed and judged all IWGDF offloading recommendations using best practice ADAPTE and GRADE frameworks to decide which recommendations should be adopted, adapted or excluded in the Australian context. For each recommendation, we re-evaluated the wording, quality of evidence, strength of recommendation, and provided rationale, justifications and implementation considerations, including for geographically remote and Aboriginal and Torres Strait Islander peoples. This guideline, along with five accompanying Australian DFU guidelines, underwent public consultation, further revision and approval by ten national peak bodies (professional organisations). Results Of the 13 original IWGDF offloading treatment recommendations, we adopted four and adapted nine. The main reasons for adapting the IWGDF recommendations included differences in quality of evidence ratings and clarification of the intervention(s) and control treatment(s) in the recommendations for the Australian context. For Australians with plantar DFU, we recommend a step-down offloading treatment approach based on their contraindications and tolerance. We strongly recommend non-removable knee-high offloading devices as first-line treatment, removable knee-high offloading devices as second-line, removable ankle-high offloading devices third-line, and medical grade footwear as last-line. We recommend considering using felted foam in combination with the chosen offloading device or footwear to further reduce plantar pressure. If offloading device options fail to heal a person with plantar DFU, we recommend considering various surgical offloading procedures. For people with non-plantar DFU, depending on the type and location of the DFU, we recommend using a removable offloading device, felted foam, toe spacers or orthoses, or medical grade footwear. The six new guidelines and the full protocol can be found at: https://diabetesfeetaustralia.org/new-guidelines/. Conclusions We have developed a new Australian evidence-based guideline on offloading treatment for people with DFU that has been endorsed by ten key national peak bodies. Health professionals implementing these offloading recommendations in Australia should produce better DFU healing outcomes for their patients, communities, and country.

Australian guideline on prevention of foot ulceration: part of the 2021 Australian evidence‐based guidelines for diabetes‐related foot disease

“…improperly cut toenails, unwashed feet, superficial fungal infection, or unclean socks), physical limitations that may hinder foot self-care (e.g. visual acuity, obesity); and foot care knowledge are also suggested; • Any foot ulcer identified during screening should be treated according to the principles outlined in the suite of IWGDF Guidelines [ 26 , 39 , 41 – 44 ] and/or the Australian DFD Guidelines [ 40 , 45 – 48 ]. Note: DFD Diabetes-related foot disease, IWGDF International Working Group on the Diabetic Foot * Adapted from: Bus SA, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Sacco ICN, et al Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update).…”

Rehabilitation for people wearing offloading devices for diabetes‐related foot ulcers: a systematic review and meta‐analyses

“…Offloading devices, such as total contact casts and boots, are recommended for the treatment of DFUs by international working groups [ 5 , 6 ] and the UK National Institute of Health and Care Excellence (NICE) [ 7 ]. These devices redistribute pressure away from the ulcer site, aiming to reduce trauma and promote healing.…”

“…These devices redistribute pressure away from the ulcer site, aiming to reduce trauma and promote healing. Non-removable knee-high devices are recommended as the first choice of offloading treatment, although removable devices may be equally preferred by both patients and clinicians as they allow greater freedom and mobility [ 5 , 6 ].…”

Innovative and accessible multidisciplinary care is needed to improve diabetes‐related foot disease outcomes in Australia and New Zealand

“…Despite the hot and humid climate of Darwin, offloading with a non‐removable device was only prematurely ceased in 2.1% because of discomfort or non‐compliance. Non‐removable knee‐high casts/walkers (e.g., Total Contact Casts) are strongly recommended in both the 2021 Australian guidelines for diabetes‐related foot disease and the Foot Forward Active Foot Disease Pathway to manage forefoot and midfoot ulcers 18,19 . However, over two‐thirds of Australian podiatrists working in HRFS reported using non‐removable below‐knee casts or walkers only 11.2% of the time 20 .…”

“…Non-removable knee-high casts/walkers (e.g., Total Contact Casts) are strongly recommended in both the 2021 Australian guidelines for diabetes-related foot disease and the Foot Forward Active Foot Disease Pathway to manage forefoot and midfoot ulcers. 18,19 However, over two-thirds of Australian podiatrists working in HRFS reported using non-removable below-knee casts or walkers only 11.2% of the time. 20 Barriers to application are attributed to patient acceptance, clinician skill and resources and wound-related concerns.…”