Use of locally made off‐loading techniques for diabetic plantar foot ulcer in Karachi, Pakistan

Abstract

The aim of this study was to evaluate the effectiveness of applying locally made pressure off-loading techniques on plantar foot ulcer in individuals with diabetes. This prospective study of 70 diabetic patients was conducted at the foot clinic of Baqai Institute of Diabetology & Endocrinology. Plantar foot ulcer, stages 1A and 2A according to the University of Texas classification, was treated by using three off-loading techniques: modified foot wear (sandal), modified plaster of Paris cast with plywood platform and Scotchcast boot. The outcome was assessed at either complete wound healing (defined as complete epithelialisation) or at 12 weeks, whichever came first. Of the 70 patients, 24 were in modified foot wear group, 23 in modified plaster of Paris cast and 23 in Scotchcast boot group. There was almost equal proportion of patients healed within 12 weeks period treated with these three off-loading techniques, i.e. 22 (95·7%) for modified foot wear group, 19 (95%) for modified plaster cast and 18 (94·7%) for Scotchcast boot group. No significant difference was observed in median healing time and cumulative wound survival at 12 weeks in the three off-loading techniques. Modified foot wear group was the most cost effective ($7) amongst the three off-loading techniques. It is concluded that in this cohort, no significant difference in healing time was observed in the three off-loading techniques, although modified foot wear (sandal) was found to be a more cost-effective treatment modality.

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2019 update)

“…The meta‐analysis found no difference in ulcers healed using TCCs and nonremovable walkers ( P = 0.82) . Another low‐quality RCT also found no significant difference between a TCC and nonremovable knee‐high walker for ulcers healed ( P = 0.99) or time‐to‐healing ( P = 0.77) . However, none of these four RCTs was based on a sample size calculation for equivalence .…”

“…Another high‐quality meta‐analysis, including two lower‐quality RCTs, reported removable offloading devices were 76% more likely to heal these ulcers than therapeutic footwear, but the difference was non‐significant ( P = 0.184) . A low‐quality RCT not included in the meta‐analyses found no difference between TCCs, nonremovable knee‐high walkers or modified footwear for healing rates ( P = 0.99) and time‐to‐healing ( P = 0.77) …”

“…Four RCTs reported on the costs of using a TCC or nonremovable knee‐high walker. One low‐quality RCT reported that the one‐off device/material costs for a TCC were lower than for a nonremovable offloading device ($20 vs $35, P < 0.01) . Three other, high‐quality, RCTs reported that treatment costs were lower for nonremovable knee‐high walkers than for TCCs .…”

Differences between national and international guidelines for the management of diabetic foot disease

“…Thus, there seems to be a need for the development of new offloading interventions that not only demonstrate effectiveness in healing DFU but also are inexpensive, readily available, and suitable for local situations particularly in developing countries . A number of promising offloading interventions have recently been developed that may help provide the evidence for future gold standard guideline offloading recommendations that are more easily implementable in future …”

Impact of multidisciplinary foot care team on outcome of diabetic foot ulcer in term of lower extremity amputation at a tertiary care unit in Karachi, Pakistan

“…Interventional radiologists were involved in the management of DFU. Other cost‐effective strategies included manufacturing and distribution of low‐cost offloading devices developed with locally available material . Domiciliary foot care service and stationed 24‐hour phone helpline service was also established to improve the compliance of DFU.…”