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

Bus, Sicco A.; Armstrong, David G.; Crews, Ryan T.; Gooday, Catherine; Jarl, Gustav; Kirketerp‐Møller, Klaus; Viswanathan, Vijay; Lazzarini, Peter A

doi:10.1002/dmrr.3647

Cited by 24 publications

(45 citation statements)

References 79 publications

(246 reference statements)

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“…55 The most effective treatment for off-loading a plantar foot ulcer is a knee-high nonremovable off-loading device, either a total contact cast or a knee-high walker rendered nonremovable. 51 A total contact cast is a special cast boot applied with minimal padding by a cast technician. The knee-high walker is a prefabricated boot that is generally applied with Velcro or straps.…”

Section: Wound Managementmentioning

confidence: 99%

“…59 When patient use of removable devices is suboptimal and the foot ulcer does not heal despite use of nonremovable off-loading devices, surgical reconstruction to help off-load pressure may help. 51 For an ulcer on the apex of the lesser toes, flexor tendon tenotomy has become a first-line treatment, based on a recent single-center randomized clinical trial of 16 people with diabetic foot ulcers at the distal plantar digits (100% healing in the tenotomy group vs 37.5% in the group not receiving tenotomy; P = .03). 60 Achilles tendon lengthening may reduce risk of ulcer recurrence (RR, 3.4; 95% CI, 1.4-8.2 [absolute rates not provided]) for plantar forefoot ulcers.…”

Section: Clinical Review and Education Reviewmentioning

confidence: 99%

“…60 Achilles tendon lengthening may reduce risk of ulcer recurrence (RR, 3.4; 95% CI, 1.4-8.2 [absolute rates not provided]) for plantar forefoot ulcers. 51,58 These studies are summarized in Table 3.…”

Section: Clinical Review and Education Reviewmentioning

confidence: 99%

“…First-choice off-loading treatment in international guidelines. 51 Removable knee-high and ankle-high walkers 51 Off-loading devices that can be removed by the patient Reduces pressure effectively but does not promote healing as well as nonremovable walkers or total contact cast. Second-choice off-loading treatment in international guidelines.…”

Section: Hydrogelsmentioning

confidence: 99%

“…Second-choice off-loading treatment in international guidelines. 51 A study of 20 patients wearing waist-mounted activity monitor and device-mounted monitor reported patients engaged in only 28% of their total daily activity while wearing the protective boot compared with when it was not worn (345 [SD, 219] min vs 874 [SD, 828] min; P = .01). 59 Felted foam in appropriately fitting shoes Felted foam applied to at least the ulcer region Reduces pressure and heals plantar ulcers less effectively than nonremovable and removable devices.…”

Section: Hydrogelsmentioning

confidence: 99%

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Diabetic Foot Ulcers

Armstrong

Tan

Boulton

et al. 2023

JAMA

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119

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ImportanceApproximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death.ObservationsNeurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years.Conclusions and RelevanceDiabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.

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Section: Wound Managementmentioning

confidence: 99%

Section: Clinical Review and Education Reviewmentioning

confidence: 99%

Section: Clinical Review and Education Reviewmentioning

confidence: 99%

Section: Hydrogelsmentioning

confidence: 99%

Section: Hydrogelsmentioning

confidence: 99%

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Diabetic Foot Ulcers

Armstrong

Tan

Boulton

et al. 2023

JAMA

Self Cite

119

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Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update)

Chen,

Vilorio,

Dhatariya

et al. 2023

Diabetes Metabolism Res

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AimsPrinciples of wound management, including debridement, wound bed preparation, and newer technologies involving alternation of wound physiology to facilitate healing, are of utmost importance when attempting to heal a chronic diabetes‐related foot ulcer. However, the rising incidence and costs of diabetes‐related foot ulcer management necessitate that interventions to enhance wound healing of chronic diabetes‐related foot ulcers are supported by high‐quality evidence of efficacy and cost effectiveness when used in conjunction with established aspects of gold‐standard multidisciplinary care. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence‐based guideline on wound healing interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.Materials and MethodsWe followed the GRADE approach by devising clinical questions and important outcomes in the Patient‐Intervention‐Control‐Outcome (PICO) format, undertaking a systematic review, developing summary of judgements tables, and writing recommendations and rationale for each question. Each recommendation is based on the evidence found in the systematic review and, using the GRADE summary of judgement items, including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability, we formulated recommendations that were agreed by the authors and reviewed by independent experts and stakeholders.ResultsFrom the results of the systematic review and evidence‐to‐decision making process, we were able to make 29 separate recommendations. We made a number of conditional supportive recommendations for the use of interventions to improve healing of foot ulcers in people with diabetes. These include the use of sucrose octasulfate dressings, the use of negative pressure wound therapies for post‐operative wounds, the use of placental‐derived products, the use of the autologous leucocyte/platelet/fibrin patch, the use of topical oxygen therapy, and the use of hyperbaric oxygen. Although in all cases it was stressed that these should be used where best standard of care was not able to heal the wound alone and where resources were available for the interventions.ConclusionsThese wound healing recommendations should support improved outcomes for people with diabetes and ulcers of the foot, and we hope that widescale implementation will follow. However, although the certainty of much of the evidence on which to base the recommendations is improving, it remains poor overall. We encourage not more, but better quality trials including those with a health economic analysis, into this area.

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Guidelines on the diagnosis and treatment of active Charcot neuro‐osteoarthropathy in persons with diabetes mellitus (IWGDF 2023)

Wukich

Schaper

Gooday

et al. 2023

Diabetes Metabolism Res

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The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This is the first guideline on the diagnosis and treatment of active Charcot neuro‐osteoarthropathy in persons with diabetes published by the IWGDF. We followed the GRADE Methodology to devise clinical questions in the PACO (Population, Assessment, Comparison, Outcome) and PICO (Population, Intervention, Comparison, Outcome) format, conducted a systematic review of the medical literature, and developed recommendations with the rationale. The recommendations are based on the evidence from our systematic review, expert opinion when evidence was not available, and also taking into account weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to an intervention. We here present the 2023 Guidelines on the diagnosis and treatment of active Charcot neuro‐osteoarthropathy in persons with diabetes mellitus and also suggest key future topics of research.

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

Cited by 24 publications

References 79 publications

Diabetic Foot Ulcers

Diabetic Foot Ulcers

Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update)

Guidelines on the diagnosis and treatment of active Charcot neuro‐osteoarthropathy in persons with diabetes mellitus (IWGDF 2023)

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