The document summarizes updates to guidelines for offloading treatments to heal diabetic foot ulcers from the International Working Group on the Diabetic Foot. It outlines the first, second, third, and fourth choice offloading treatments for plantar forefoot and midfoot ulcers. New recommendations address offloading complicated ulcers, plantar heel ulcers, and comparisons of removable versus non-removable devices. Key issues discussed include a lack of studies directly comparing offloading techniques and for complicated ulcers, as well as a need for more research on adherence, surgical options, potential harms, and cost-effectiveness.

1. www.iwgdfguidelines.org
Sicco Bus
David Armstrong
Catherine Gooday
Gustav Jarl
Carlo Caravaggi
Vijay Viswanathan
Peter Lazzarini

2. Working group
• Guideline meeting
Berlin September 2018
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

3. Background
• Offloading is arguably the most important treatment for neuropathic
ulcers
• Long standing clinical tradition of using offloading to heal DFUs
• Over the last 4 years, several well-designed controlled studies but
mainly several meta-analyses on offloading devices and a HTA have
added to the evidence base for offloading
• This guideline updated the previous IWGDF 2015 guideline on
footwear and offloading
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

4. What’s new?
• Removed any recommendations on the prevention of foot ulcers
• Outlined clearly the first-, second-, third- and fourth-choice of
offloading treatment to heal a plantar forefoot or midfoot ulcer
• Added one new recommendation on considerations for choosing
between either a total contact cast or non-removable knee-high
walker
• New recommendations on offloading ulcers that are complicated by
infection or ischemia
• Recommendation on offloading plantar heel ulcers
• Offloading diagram
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

5. Offloading
diagram
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

6. Offloading devices, footwear
• Are non-removable offloading devices compared to removable
offloading devices effective to heal the DFU?
• Are total contact casts (TCC) compared to other non-removable knee-
high offloading devices effective to heal the DFU?
• Are removable knee-high offloading devices compared to other
removable offloading devices effective to heal the DFU?
• Are any other offloading techniques that are not device or footwear-
related, effective to heal a DFU?
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

7. Offloading devices, footwear and other

8. Surgical offloading
• Are surgical offloading techniques compared to non-surgical
offloading interventions effective to heal the DFU?
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

9. Surgical Offloading

10. Other foot ulcers
• In people with a plantar DFU complicated by infection or ischaemia,
which offloading intervention is effective for healing the DFU?
• In people with a plantar rearfoot DFU, which offloading intervention
is effective to heal the DFU?
• In people with a non-plantar DFU, which offloading intervention is
effective to heal the DFU?
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

11. Complicated foot ulcers
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

12. Plantar rearfoot ulcers
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

13. Non-plantar foot ulcers

14. Key controversies
1. Many versions and types of TCC and knee-high and ankle-high offloading
devices. Studies should compare the devices
2. There are few offloading studies of complicated ulcers
3. A stronger focus is required on the measurement and improvement of
adherence to treatment
4. Surgical offloading interventions lack a strong evidence base
5. Underpowered studies for analysis of harms, adverse events, patient
preferences and feasibility.
6. Cost-effectiveness of an intervention is rarely reported
7. Guidance on approaches to promote healing in lower income regions with
challenging climates is required
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org

15. www.iwgdfguidelines.org
Slides courtesy IWGDF; available at: www.iwgdfguidelines.org