Comparison of forefoot ulcer healing using alternative off-loading methods in patients with diabetes mellitus

Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot

The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

Total contact casts versus removable offloading interventions for the treatment of diabetic foot ulcers: a systematic review and meta-analysis

Objective

This study aimed to evaluate the effectiveness of total contact casts (TCCs) versus removable offloading interventions among patients with diabetic foot ulcers (DFUs).

Methods

A comprehensive search was done in databases Embase, Cochrane Library, and, PubMed. The references of retrieved articles were reviewed, up until February 2023. Controlled trials comparing the effects of TCCs with removable offloading interventions (removable walking casts and footwear) in patients with DFUs were eligible for review.

Results

Twelve studies were included in the meta-analysis, involving 591 patients with DFUs. Among them, 269 patients were in the intervention group (TCC), and 322 in the control group (removable walking casts/footwear). The analysis revealed that the TCC group had higher healing rates (Risk Ratio(RR)=1.22; 95% confidence interval(CI):1.11 to 1.34, p<0.001), shorter healing time (Standard Mean Difference(SMD)=-0.57; 95%CI: -1.01 to -0.13, P=0.010), and elevated occurrence of device-related complications (RR=1.70; 95%CI:1.01 to 2.88, P=0.047), compared with the control group. Subgroup analysis illustrated patients using TCCs had higher healing rates than those using removable walking casts (RR=1.20; 95%CI:1.08 to 1.34, p=0.001) and footwear (RR=1.25; 95%CI:1.04 to 1.51, p=0.019), but they required comparable time for ulcer healing compared with those using removable walking casts (SMD=-0.60; 95%CI: -1.22 to 0.02, P=0.058) or footwear group (SMD=-0.52; 95%CI: -1.17 to 0.12, P=0.110). Although patients using TCCs had significantly higher incidence of device-related complications than those using footwear (RR=4.81; 95%CI:1.30 to 17.74, p=0.018), they had similar one compared with those using the removable walking casts (RR=1.27; 95%CI:0.70 to 2.29, p=0.438).

Conclusion

The use of TCCs in patients with DFUs resulted in improved rates of ulcer healing and shorter healing time compared to removable walking casts and footwear. However, it is important to note that TCCs were found to be associated with increased prevalence of complications.

Does Offloading with Felt Foot Plates Heal Diabetic Foot Ulcers?

OBJECTIVE

To determine (1) if offloading with a felt foot plate heals a diabetic foot ulcer, (2) the rate of healing with the felt foot plate, and (3) the impact on rate of healing from the confounding factors of patient weight and growth factors on healing times.

METHODS

The researchers conducted a retrospective chart cohort review over 3 years.

RESULTS

Using a multivariable linear and logistic regression model, the data showed a statistically significant reduction in the diabetic foot ulcer area over time. Confounding factors of patient weight and growth factors did not impact healing times.

CONCLUSIONS

Offloading a diabetic foot ulcer with a felt foot plate is adequate for healing.

Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a leading cause of the global disease burden. Most DFUs are caused, and prolonged, by high plantar tissue stress under the insensate foot of a person with peripheral neuropathy. Multiple different offloading treatments have been used to try to reduce high plantar tissue stress and heal DFUs, including bedrest, casting, offloading devices, footwear, and surgical procedures. The best offloading treatments are those that balance the benefits of maximizing reductions in high plantar tissue stress, whilst reducing the risks of poor satisfaction, high costs and potential adverse events outcomes. This review aimed to summarize the best available evidence on the effects of offloading treatments to heal people with DFUs, plus review their use in clinical practice, the common barriers and solutions to using these treatments, and discuss promising emerging solutions that may improve offloading treatments in future. Findings demonstrate that knee-high offloading devices, non-removable or removable knee-high devices worn for all weight-bearing activities, are the gold standard offloading treatments to heal most patients with DFU, as they are much more effective, and typically safer, quicker, and cheaper to use compared with other offloading treatments. The effectiveness of offloading treatments also seems to increase when increased offloading mechanical features are incorporated within treatments, including customized insoles, rocker-bottom soles, controlled ankle motion, and higher cast walls. However, in clinical practice these gold standard knee-high offloading devices have low rates of prescription by clinicians and low rates of acceptance or adherence by patients. The common barriers resulting in this low use seem to surround historical misperceptions that are mostly dispelled by contemporary evidence. Further, research is now urgently required to close the implementation gap between the high-quality of supporting evidence and the low use of knee-high devices in clinical practice to reduce the high global disease burden of DFU in future.

The effects of felted foam in diabetic foot treatment: systematic review with meta-analysis

OBJECTIVE

To evaluate the effects of felted foam in the treatment of diabetic foot plantar ulcer.

METHOD

Systematic review with meta-analysis. Research was conducted in Cochrane Library, PubMed, CINAHL, Science Direct, Web of Science, SCOPUS, IBECS and LILACS. Cochrane Collaboration Risk of Bias Tool was employed to evaluate risk of bias. The meta-analyses were calculated in the program Review Manager, while Grades of Recommendation, Assessment, Development and Evaluation was used for evaluating evidence quality.

RESULTS

Four clinical essays and two cohorts were included. Mean plantar pressure of individuals exposed to felt was reduced by 10.77 kilopascals (CI 95% -14.92, -6.62; p<0.001).

CONCLUSION

Higher reduction of plantar pressure was observed to be associated with the use of felt. Development of new models of relief orthosis with felted foam for plantar pressure is recommended, along with more clinical research elucidating related outcomes.

Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective?

BACKGROUND

Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference.

QUESTIONS/PURPOSES

To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data.

METHODS

A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty.

RESULTS

The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective.

CONCLUSIONS

Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

Effectiveness of offloading interventions to heal foot ulcers in persons with diabetes: a systematic review

BACKGROUND

Offloading interventions are commonly used in clinical practice to heal foot ulcers. The aim of this updated systematic review is to investigate the effectiveness of offloading interventions to heal diabetic foot ulcers.

METHODS

We updated our previous systematic review search of PubMed, EMBASE, and Cochrane databases to also include original studies published between July 29, 2014 and August 13, 2018 relating to four offloading intervention categories in populations with diabetic foot ulcers: (a) offloading devices, (b) footwear, (c) other offloading techniques, and (d) surgical offloading techniques. Outcomes included ulcer healing, plantar pressure, ambulatory activity, adherence, adverse events, patient-reported measures, and cost-effectiveness. Included controlled studies were assessed for methodological quality and had key data extracted into evidence and risk of bias tables. Included non-controlled studies were summarised on a narrative basis.

RESULTS

We identified 41 studies from our updated search for a total of 165 included studies. Six included studies were meta-analyses, 26 randomised controlled trials (RCTs), 13 other controlled studies, and 120 non-controlled studies. Five meta-analyses and 12 RCTs provided high-quality evidence for non-removable knee-high offloading devices being more effective than removable offloading devices and therapeutic footwear for healing plantar forefoot and midfoot ulcers. Total contact casts (TCCs) and non-removable knee-high walkers were shown to be equally effective. Moderate-quality evidence exists for removable knee-high and ankle-high offloading devices being equally effective in healing, but knee-high devices have a larger effect on reducing plantar pressure and ambulatory activity. Low-quality evidence exists for the use of felted foam and surgical offloading to promote healing of plantar forefoot and midfoot ulcers. Very limited evidence exists for the efficacy of any offloading intervention for healing plantar heel ulcers, non-plantar ulcers, and neuropathic ulcers with infection or ischemia.

CONCLUSION

Strong evidence supports the use of non-removable knee-high offloading devices (either TCC or non-removable walker) as the first-choice offloading intervention for healing plantar neuropathic forefoot and midfoot ulcers. Removable offloading devices, either knee-high or ankle-high, are preferred as second choice over other offloading interventions. The evidence bases to support any other offloading intervention is still weak and more high-quality controlled studies are needed in these areas.

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

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 guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.

Diabetic foot and disaster; risk factors for amputation during the Syrian crisis

BACKGROUND

Diabetic foot patients in Syria faced many challenges and difficulties during the recent long term crisis that has prevailed since 2011. This study establishes the risk factors of diabetic foot amputation, either minor or major amputation. It also suggests facilities to improve diabetic foot care in the disaster.

METHODS

This is a retrospective study that reviewed diabetic foot outpatients' charts between Jan 2012 and Dec 2017 in Diabetic Foot Clinic in Damascus Teaching Hospital, Syria. We classified the lesions according to the final outcome into: non-amputation, minor and major amputation. We predicted the independent risk factors of lower extremity amputation (LEA).

RESULTS

A total of 2317 diabetic patients visited our clinic regularly with 2722 diabetic foot symptoms. We studied 2006 lesions belong to 1630 diabetic foot patients. They were divided into: group A (outcome without amputation, n = 1372), group B (outcome with minor amputation, n = 528) and group C (final outcome with major amputation, n = 106). Males were slightly predominant (56.73%; n = 1138), but with clearly higher risk of major amputation (6.77%; n = 77). 15.10% of patients was older than 70 years, with no significant relationship between age and amputation risk. According to Meggitt-Wagner classification system, the major amputation rate was (5.28%) in the lesions grade 1 through 5, it went up to (87.30) in isolated grade 5 lesions. The study recorded a degree of infection in (42.07%; n = 844) of the cases. The amputation rate went up in this group of patients to 38.5% and 8.44% for minor and major amputation, respectively. The presence of peripheral occlusive artery disease (PAD) doubled the minor amputation incidence one time (44.02%), and major amputation incidence five times (15.16%). The heel ulcer showed a great tendency toward the major amputation (18.80%), while the incidence rate in the DFUs spared heel was (3.36%). The war injuries of the diabetic foot was followed up in three cases that were treated conservatively and didn't considered an independent risk factor for amputation as long as the standard care was applied.

CONCLUSION

This article is the first one that discussed the reality of the diabetic foot care in disasters. It figures out that diabetic foot patients are obviously at higher risk of neglect during the crisis. In the absence of early detecting of wounds, deformities and PAD, DFUs likely come to the podiatrists in advanced stages. The unhealthy environment drives DFUs toward injuries, cellulites and infection. Non-Governmental Organizations (NGOs) and local institutions that work in crisis areas should pay attention for special care requirements of diabetic foot patients, for the standard care of the diabetic foot and the regular follow-up till the healing eventually.

Outcomes Achieved With Use of a Prefabricated Roll-On Total Contact Cast

BACKGROUND

The total contact cast (TCC) is considered the gold standard for offloading of plantar diabetic foot ulcerations, yet its use remains suboptimal for a variety of reasons. Prefabricated TCC systems have been developed to help enhance TCC use. The primary objective of this study was to determine if healing rates obtained with use of a prefabricated roll-on TCC were similar to those reported with conventional TCC use. Secondary outcomes measured were the incidence of iatrogenic ulceration, amputation, and recurrent ulceration, and patient tolerance of the device.

METHODS

A retrospective chart review was performed on all patients in whom TCC was used for treatment of an ulceration at our institution from April 2013 to December 2016. Seventy patients (132 ulcerations) were identified.

RESULTS

An 85.6% healing rate was achieved. Five subjects (7.1%) sustained 11 iatrogenic ulcerations. All resolved with local treatment and continued casting. Thirteen subjects (18.6%) underwent amputation. No amputation occurred because of TCC application technique or use. Fifteen ulcerations (12 subjects, 17.1%) recurred. Greater than 70% resolved with re-initiation of TCC use. Forty-three subjects (61.4%) tolerated use of the prefabricated roll-on TCC.

CONCLUSION

Similar healing rates and reduced rates of iatrogenic ulceration, amputation, and recurrent ulceration were attained with use of a prefabricated roll-on TCC. These results, good patient tolerance, and the reduced administrative and clinical time related to supply acquisition, training, and proper application supports use of this device as a viable alternative to a conventional TCC for treatment of plantar neuropathic foot ulcerations.

LEVEL OF EVIDENCE

Level IV, case series.

The effectiveness of felt padding for offloading diabetes-related foot ulcers, at baseline and after one week of wear

AIM

Felt padding is used to offload diabetes-related foot ulceration although limited quality data exists to support its use. This study aimed to quantify pressure offloading from neuropathic plantar foot ulcers in a clinical setting, when felt padding is first applied and after wear.

METHODS

This study used a within-subjects, repeated measures design. Data was collected in a high-risk foot service. Peak plantar pressures, contact area and contact time were measured in 15 diabetes subjects with 16 non-complicated plantar neuropathic foot ulcers, with: no felt padding, newly applied felt padding and felt padding after one week of wear.

RESULTS

Statistically significant decreases in peak pressure of 49% and 32% were measured with newly applied felt padding (188.0kPa; p<0.001) and worn felt padding (248kPa; p=0.003) respectively, compared to no padding (367.2kPa). Worn felt offloaded 32% less pressure than new felt however this did not reach statistical significance (p=.069). Corresponding increases in contact area of 18% and 14% occurred with newly applied felt padding (156.9cm²; p<.001) and worn felt padding (150.6cm²; p=0.003) compared to no padding (132.5cm²). Contact time was constant across testing conditions.

CONCLUSIONS

New felt padding offloaded on average half the pressure applied to sites of plantar neuropathic ulceration, which reduced to one third after wear. Increased contact area under the foot is a possible mechanism contributing to pressure reduction. Further studies are required to evaluate effectiveness of felt padding directly on ulcer healing.

Total-Contact Casting as an Adjunct to Promote Healing of Pressure Ulcers in Amputees

Partial foot amputations have become increasingly prevalent among long-lived diabetic patients. These patients have lower extremity neuropathy and are prone to ulceration at their amputation site. These ulcers are difficult to heal, and they place a significant financial and resource burden on the healthcare system. We examined the efficacy of total-contact casts (TCC) in diabetic amputees with nonhealing partial foot amputation site neuropathic ulcers. Data were collected retrospectively on all patients with amputations who were treated with a total-contact cast between December 2000 and December 2003. Seventeen patients (13 men, 4 women) with amputation site ulceration were identified. All patients were diagnosed with neuropathy secondary to diabetes and none had wound healing compromised by ischemia. The initial ulcer averaged 1,169 mm2 with a depth of 2.77 mm. Patients were treated with an average of 7.9 cast applications over 8.4 weeks; 47% (8/17) of ulcers healed, but 29% (5/17) of patients were unable to complete their recommended treatment course secondary to complications from the TCC. Of the patients who were able to complete their treatment course, the healing rate was 66.7% (8/12). The recurrence rate for healed ulcers was 63% (5/8). Partial foot amputations with neuropathic ulcers present a very difficult problem to the vascular surgeon. Patient compliance and underlying medical comorbidities limit the success rate. In patients who can complete a TCC treatment course, good short term results can be expected. However, recurrence rates are high following discontinuation of mechanical TCC off-loading.

The Applicability of Plantar Padding in Reducing Peak Plantar Pressure in the Forefeet of Healthy AdultsImplications for the Foot at Risk

BACKGROUND

We investigated the effectiveness and durability of two types of plantar padding, the plantar metatarsal pad and the single wing plantar cover, which are commonly used for reducing forefoot plantar pressures.

METHODS

Mean peak plantar pressure and impulse at the hallux and at the first, second, third, and fourth metatarsophalangeal joints across both feet were recorded using the two-step method in 18 individuals with normal asymptomatic feet. Plantar paddings were retained for 5 days, and their durability and effectiveness were assessed by repeating the foot plantar measurement at baseline and after 3 and 5 days.

RESULTS

The single wing plantar cover devised from 5-mm felt adhesive padding was effective and durable in reducing peak plantar pressure and impulse at the first metatarsophalangeal joint (P = .001 and P = .015, respectively); however, it was not found to be effective in reducing peak plantar pressure and impulse at the hallux (P = .782 and P = .845, respectively). The plantar metatarsal pad was not effective in reducing plantar forefoot pressure and impulse at the second, third, and fourth metatarsophalangeal joints (P = .310 and P = .174, respectively).

CONCLUSIONS

These results imply limited applicability of the single wing plantar cover and the plantar metatarsal pad in reducing hallux pressure and second through fourth metatarsophalangeal joint pressure, respectively. However, the single wing plantar cover remained durable for the 5 days of the trial and was effective in reducing the peak plantar pressure and impulse underneath the first metatarsophalangeal joint.

Total contact cast wall load in patients with a plantar forefoot ulcer and diabetes

BACKGROUND

The total contact cast (TCC) is an effective intervention to reduce plantar pressure in patients with diabetes and a plantar forefoot ulcer. The walls of the TCC have been indirectly shown to bear approximately 30 % of the plantar load. A new direct method to measure inside the TCC walls with capacitance sensors has shown that the anterodistal and posterolateral-distal regions of the lower leg bear the highest load. The objective of this study was to directly measure these two regions in patients with Diabetes and a plantar forefoot ulcer to further understand the mechanism of pressure reduction in the TCC.

METHODS

A TCC was applied to 17 patients with Diabetes and a plantar forefoot ulcer. TCC wall load (contact area, peak pressure and max force) at the anterodistal and posterolateral-distal regions of the lower leg were evaluated with two capacitance sensor strips measuring 90 cm(2) (pliance®, novel GmbH, Germany). Plantar load (contact area, peak pressure and max force) was measured with a capacitance sensor insole (pedar®, novel GmbH, Germany) placed inside the TCC. Both pedar® and pliance® collected data simultaneously at a sampling rate of 50Hz synchronised to heel strike. The magnitude of TCC wall load as a proportion of plantar load was calculated. The TCC walls were then removed to determine the differences in plantar loading between the TCC and the cut down shoe-cast for the whole foot, rearfoot, midfoot and forefoot (region of interest).

RESULTS

TCC wall load was substantial. The anterodistal lower leg recorded 48 % and the posterolateral-distal lower leg recorded 34 % of plantar contact area. The anterodistal lower leg recorded 28 % and the posterolateral-distal lower leg recorded 12 % of plantar peak pressure. The anterodistal lower leg recorded 12 % and the posterolateral-distal lower leg recorded 4 % of plantar max force. There were significant differences in plantar load between the TCC and the cut down shoe-cast for the whole foot, rearfoot, midfoot and forefoot (region of ulcer). Contact area significantly increased by 5 % beneath the whole foot, 8 % at the midfoot and 6 % at the forefoot in the shoe-cast (p < 0.05). Peak pressure significantly increased by 8 % beneath the midfoot and 13 % at the forefoot in the shoe-cast (p < 0.05). Max force significantly increased 6 % beneath the midfoot in the (shoe-cast p < 0.05).

CONCLUSION

In patients with diabetes and a plantar forefoot ulcer, the walls of the TCC bear considerable load. Reduced plantar contact area in the TCC compared to the shoe-cast suggests that the foot is suspended by the considerable load bearing capacity of the walls of the TCC which contributes mechanically to the pressure reduction and redistribution properties of the TCC.

Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review

BACKGROUND

Footwear and offloading techniques are commonly used in clinical practice for preventing and healing of foot ulcers in persons with diabetes. The goal of this systematic review is to assess the medical scientific literature on this topic to better inform clinical practice about effective treatment.

METHODS

We searched the medical scientific literature indexed in PubMed, EMBASE, CINAHL, and the Cochrane database for original research studies published since 1 May 2006 related to four groups of interventions: (1) casting; (2) footwear; (3) surgical offloading; and (4) other offloading interventions. Primary outcomes were ulcer prevention, ulcer healing, and pressure reduction. We reviewed both controlled and non-controlled studies. Controlled studies were assessed for methodological quality, and extracted key data was presented in evidence and risk of bias tables. Uncontrolled studies were assessed and summarized on a narrative basis. Outcomes are presented and discussed in conjunction with data from our previous systematic review covering the literature from before 1 May 2006.

RESULTS

We included two systematic reviews and meta-analyses, 32 randomized controlled trials, 15 other controlled studies, and another 127 non-controlled studies. Several randomized controlled trials with low risk of bias show the efficacy of therapeutic footwear that demonstrates to relief plantar pressure and is worn by the patient, in the prevention of plantar foot ulcer recurrence. Two meta-analyses show non-removable offloading to be more effective than removable offloading for healing plantar neuropathic forefoot ulcers. Due to the limited number of controlled studies, clear evidence on the efficacy of surgical offloading and felted foam is not yet available. Interestingly, surgical offloading seems more effective in preventing than in healing ulcers. A number of controlled and uncontrolled studies show that plantar pressure can be reduced by several conservative and surgical approaches.

CONCLUSIONS

Sufficient evidence of good quality supports the use of non-removable offloading to heal plantar neuropathic forefoot ulcers and therapeutic footwear with demonstrated pressure relief that is worn by the patient to prevent plantar foot ulcer recurrence. The evidence base to support the use of other offloading interventions is still limited and of variable quality. The evidence for the use of interventions to prevent a first foot ulcer or heal ischemic, infected, non-plantar, or proximal foot ulcers is practically non-existent. High-quality controlled studies are needed in these areas.

The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and practical recommendations to improve outcomes

BACKGROUND

We sought to develop a consensus statement for the use of off-loading in the management of diabetic foot ulcers (DFUs).

METHODS

A literature search of PubMed for evidence regarding off-loading of DFUs was initially conducted, followed by a meeting of authors on March 15, 2013, in Philadelphia, Pennsylvania, to draft consensus statements and recommendations using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to assess quality of evidence and develop strength of recommendations for each consensus statement.

RESULTS

Evidence is clear that adequate off-loading increases the likelihood of DFU healing and that increased clinician use of effective off-loading is necessary. Recommendations are included to guide clinicians on the optimal use of off-loading based on an initial comprehensive patient/wound assessment and the necessity to improve patient adherence with off-loading devices.

CONCLUSIONS

The likelihood of DFU healing is increased with off-loading adherence, and, current evidence favors the use of nonremovable casts or fixed ankle walking braces as optimum off-loading modalities. There currently exists a gap between what the evidence supports regarding the efficacy of DFU off-loading and what is performed in clinical practice despite expert consensus on the standard of care.

A comparison of two total contact cast constructs with variable body mass

OBJECTIVE

There is a growing body of evidence implicating obesity as having a negative effect on the development and treatment of diabetic foot disease. The aim of this study was to increase the body of knowledge on the effects of obesity on foot function, specifically as it relates to peak plantar pressures in the total contact cast (TCC). Our investigational objectives were to compare the effect of two different TCC designs on mean peak plantar pressures, and to evaluate the efficacy of two TCC constructs with increasing body mass.

METHOD

The primary outcome measure was mean peak plantar pressure in the heel, midfoot, forefoot and first metatarsal as measured with an in-shoe pressure measurement system. The variables were patient weight (from 'normal' body mass index (BMI) to 'overweight', 'obese' and 'morbidly obese') and the TCC construct (with both a standard and alternate cast design). The standard TCC is considered the gold standard for off-loading of the diabetic foot. The alternate TCC was designed to use the essential offloading component of the traditional TCC, namely the total contact leg section, with use of an open cell polyurethane foam to transfer load from the foot to the lower leg, thereby offloading the foot by suspending it within a padded fiberglass walking cast.

RESULTS

We did not observe statistically significant differences in mean peak plantar pressures in any plantar foot anatomic area or with any body mass between the two TCC designs.

CONCLUSION

Based on the results, we concluded that the alternate TCC design provides another viable TCC construct option for practitioners working with the neuropathic foot. This investigation also provides specific data on changes that occur in peak plantar pressures with use of the total contact cast and variable BMIs.

DECLARATION OF INTEREST

none.

Pressure-relieving interventions for treating diabetic foot ulcers

BACKGROUND

Diabetes-related foot ulceration is a major contributor to morbidity in diabetes. Diabetic foot ulcers are partly a consequence of abnormal foot pressures and pressure relief is a widely used treatment for healing diabetes-related plantar foot ulcers, but the most effective method for healing is unclear.

OBJECTIVES

To determine the effects of pressure-relieving interventions on the healing of foot ulcers in people with diabetes.

SEARCH METHODS

For this update we searched the Cochrane Wounds Group Specialised Register (searched 2 November 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 10); Ovid MEDLINE (1950 to October Week 4 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, October 31, 2012); Ovid EMBASE (1980 to 2012 Week 43); and EBSCO CINAHL (1982 to 1 November 2012). There were no restrictions based on language or publication status.

SELECTION CRITERIA

Randomised controlled trials evaluating the effects of pressure-relieving interventions on the healing of foot ulcers in people with diabetes.

DATA COLLECTION AND ANALYSIS

Data from eligible trials were extracted, and summarised using a data extraction sheet, by two review authors independently.

MAIN RESULTS

Fourteen trials (709 participants) met the inclusion criteria for the review. One study compared two different types of non-removable casts with no discernable difference between the groups. Seven studies (366 participants) compared non-removable casts with removable pressure-relieving devices. In five of those studies non-removable casts were associated with a statistically significant increase in the number of ulcers healed compared with the removable device (RR 1.17 95% CI 1.01 to 1.36: P value = 0.04).Two studies (98 participants) found that significantly more ulcers healed with non-removable casts than with dressings alone. Achilles tendon lengthening combined with a non-removable cast in one study resulted in significantly more healed ulcers at 7 months than non-removable cast alone (RR 2.23; 95% CI 1.32 to 3.76). More ulcers remained healed at two years in this group (RR 3.41; 95% CI 1.42 to 8.18).Other comparisons included surgical debridement of ulcers; felt fitted to the foot; felted foam dressings and none of these showed a statistically significant treatment effect in favour of the intervention.

AUTHORS' CONCLUSIONS

Non-removable, pressure-relieving casts are more effective in healing diabetes related plantar foot ulcers than removable casts, or dressings alone. Non-removable devices, when combined with Achilles tendon lengthening were more successful in one forefoot ulcer study than the use of a non-removable cast alone.

Effectiveness of removable walker cast versus nonremovable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial

OBJECTIVE

To evaluate the efficacy of a removable cast walker compared with that of a nonremovable fiberglass off-bearing cast in the treatment of diabetic plantar foot ulcer.

RESEARCH DESIGN AND METHODS

Forty-five adult diabetic patients with nonischemic, noninfected neuropathic plantar ulcer were randomly assigned for treatment with a nonremovable fiberglass off-bearing cast (total contact cast [TCC] group) or walker cast (Stabil-D group). Treatment duration was 90 days. Percent reduction in ulcer surface area and total healing rates were evaluated after treatment.

RESULTS

A total of 48 patients were screened; however, 2 patients in the TCC group and 1 patient in the Stabil-D group did not complete the study and were considered dropouts. There were no significant differences in demographic and clinic characteristics of the 45 patients completing the study. Ulcer surface decreased from 1.41 to 0.21 cm(2) (P < 0.001) in the TCC group and from 2.18 to 0.45 cm(2) (P < 0.001) in the Stabil-D group, with no significant differences between groups (P = 0.722). Seventeen patients (73.9%) in the TCC group and 16 patients (72.7%) in the Stabil-D group achieved healing (P = 0.794). Average healing time was 35.3 +/- 3.1 and 39.7 +/- 4.2 days in the TCC and Stabil-D group, respectively (P = 0.708).

CONCLUSIONS

The Stabil-D cast walker, although removable, was equivalent in efficacy to the TCC in terms of ulcer size reduction and total healing rate. The easier use of Stabil-D may help increase the use of off-loading devices in the management of plantar neuropathic diabetic foot ulcers.

Transitional off-loading: an evidence-based approach to pressure redistribution in the diabetic foot

PURPOSE

To enhance the learner's competence in providing pressure redistribution therapy for the diabetic foot.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.

OBJECTIVES

After participating in this educational activity, the participant should be better able to: 1. Relate diabetic foot problems to the need for using off-loading devices. 2. Distinguish between the various types of dressings and off-loading devices used for diabetic foot wounds. 3. Apply the "transitional approach" to off-loading the diabetic foot.

Bioengineered skin in diabetic foot ulcers

OBJECTIVE

Bioengineered skin (BS) has been shown to play an important role in the treatment of diabetic foot ulcers (DFUs). Whether BS in the therapy of DFU can improve the outcomes still remains uncertain. We performed a quantitative meta-analysis of available randomized controlled trials to determine the effectiveness and safety of BS in the treatment of patients with DFUs.

DESIGN AND METHODS

Comprehensive search strategies of various electronic databases were used for this study to evaluate the effectiveness and safety between BS and conventional treatment (CT) in patients with DFU, and only randomized controlled trials were adopted in our review. Search terms included 'bioengineered skin', 'tissue-engineering skin', 'human-tissue graft', 'human-skin device', 'living-skin equivalent' and 'diabetic foot', 'diabetic ulcer', 'diabetic wound'. Analysis outcomes included complete wound closure, complications, ulcer recurrence and adverse severe events (ASEs).

RESULTS

Seven randomized controlled trials on BS vs. CT were included, and 880 participants met inclusion criteria. Pooled analysis showed a significant effectiveness and safety advantages for BS treatment compared to CT for patients with DFUs. In analysis of complications, only statistically significant difference of infection was noted. And no included trials reported ASEs related to these treatments.

CONCLUSIONS

Based on the meta-analysis, patients with DFUs may benefit from the BS because of its high effectiveness and safety and reduced risk for infections in comparison to CT.

Treatment of Charcot foot and ankle with a prefabricated removable walker brace and custom insole

BACKGROUND

Removable walker braces have been used successfully to treat acute and chronic foot and ankle conditions including diabetic foot ulcers. We hypothesized that a removable walker brace may be successfully used in the management of the Charcot foot and ankle.

METHODS

Twenty-five feet and ankles with Charcot arthropathy in 21 patients (bilateral in 4 patients) were treated with a prefabricated, pneumatic removable walker brace fitted with a custom orthotic insole. Follow-up data were collected from patient interview, examination, and radiography.

RESULTS

Brace fitting was accomplished usually with a single visit to the prosthetist or pedorthist/orthotist. At the most recent evaluation, 17 (68%) feet and ankles had consolidation (stage III) of the Charcot arthropathy (average duration of brace use, 29+/-19 weeks) and were subsequently treated with rocker sole shoes, insoles, and ankle foot orthoses; 8 (32%) feet and ankles had ongoing brace treatment. Three feet developed new deformity during brace treatment, but average radiographic parameters of hindfoot to forefoot alignment had minimal change between initial and final radiographs at an average of 36+/-24 weeks after initial radiographic evaluation.

CONCLUSIONS

The prefabricated, pneumatic removable walker brace fitted with a custom insole was successful in the management of the Charcot foot and ankle and had a high satisfaction rate and safety profile despite frequent, albeit usually minor, complications.

The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review

BACKGROUND

Footwear and offloading techniques are commonly used in clinical practice for the prevention and treatment of foot ulcers in diabetes, but the evidence base to support this use is not well known. The goal of this review was to systematically assess the literature and to determine the available evidence on the use of footwear and offloading interventions for ulcer prevention, ulcer treatment, and plantar pressure reduction in the diabetic foot.

METHODS

A search was made for reports on the effectiveness of footwear and offloading interventions in preventing or healing foot ulcers or reducing plantar foot pressure in diabetic patients published prior to May 2006. Both controlled and uncontrolled studies were included. Assessment of the methodological quality of studies and data extraction was independently performed by two reviewers. Interventions were assigned into four subcategories: casting, footwear, surgical offloading and other offloading techniques.

RESULTS

Of 1651 articles identified in the baseline search, 21 controlled studies were selected for grading following full text review. Another 108 uncontrolled and cross-sectional studies were examined. The evidence to support the use of footwear and surgical interventions for the prevention of ulceration is meagre. Evidence was found to support the use of total contact casts and other non-removable modalities for treatment of neuropathic plantar ulcers. More studies are needed to support the use of surgical offloading techniques for ulcer healing. Plantar pressure reduction can be achieved by several modalities including casts, walkers, and therapeutic footwear, but the diversity in methods and materials used limits the comparison of study results.

CONCLUSIONS

This systematic review provides support for the use of non-removable devices for healing plantar foot ulcers. Furthermore, more high-quality studies are urgently needed to confirm the promising effects found in both controlled and uncontrolled studies of footwear and offloading interventions designed to prevent ulcers, heal ulcers, or reduce plantar pressure.

The football: an intuitive dressing for offloading neuropathic plantar forefoot ulcerations

A reproducible, affordable, efficacious and safe modality for offloading neuropathic plantar foot ulcerations was previously presented in a pilot study. A follow-up retrospective multicentre analysis of the football dressing is now presented. Wound healing rates are compared with published data on the total contact cast (TCC) and instant total contact cast (iTCC). Overall wound healing rates for University of Texas Health Science Center class 1A, 1B, 1C, 1D, 2A, 2B, 2C and 3B plantar forefoot ulcerations is 2.91 weeks with a 95% confidence interval of 2.36-3.47 weeks for complete wound epithelialisation. The cost associated with this dressing technique is a fraction of that associated with the TCC and iTCC. The ease of application coupled with reliable healing rates and affordable materials makes the football dressing a worthy partner against the sequelae of plantar forefoot ulcerations.

Off-loading of hindfoot and midfoot neuropathic ulcers using a fiberglass cast with a metal stirrup

BACKGROUND

This study was designed to assess the effectiveness of a method of off-loading large neuropathic ulcers of the hindfoot and midfoot. The device used is composed of a fiberglass cast with a metal stirrup and a window around the ulcer.

METHODS

A retrospective study of 14 diabetic and nondiabetic patients was performed. All had chronic plantar hindfoot or midfoot neuropathic ulcers that failed to heal with conventional treatment methods. A fiberglass total contact cast with a metal stirrup was applied. A window was made over the ulcer to allow daily ulcer care.

RESULTS

The average duration of ulcer before application of the metal stirrup was 26 + 13.2 (range 7 to 52) months. The ulcer completely healed in 12 of the 14 patients treated. The mean time for healing was 10.8 weeks for midfoot ulcers and 12.3 weeks for heel ulcers. Complications developed in four patients: three developed superficial wounds and one developed a full-thickness wound. In three of these four patients, local wound care was initiated, and the stirrup cast was continued to complete healing of the primary ulcer.

CONCLUSIONS

A fiberglass cast with a metal stirrup is an effective off-loading device for midfoot and hindfoot ulcers. It is not removable and does not depend on patient compliance. The window around the ulcer allows for daily wound care, drainage of the ulcer and the use of vacuum-assisted closure (VAC) treatment. The complication rate is comparable to that of total contact casting.

The treatment of diabetic foot ulcers: reviewing the literature and a surgical algorithm

PURPOSE

To provide an overview of the literature related to the treatment of diabetic foot ulcers.

TARGET AUDIENCE

This continuing education activity is intended for physicians and nurses with an interest in wound care.

OBJECTIVES

After reading this article and taking this test, the reader should be able to:

Diabetic foot disorders. A clinical practice guideline (2006 revision)

The prevalence of diabetes mellitus is growing at epidemic proportions in the United States and worldwide. Most alarming is the steady increase in type 2 diabetes, especially among young and obese people. An estimated 7% of the US population has diabetes, and because of the increased longevity of this population, diabetes-associated complications are expected to rise in prevalence. Foot ulcerations, infections, Charcot neuroarthropathy, and peripheral arterial disease frequently result in gangrene and lower limb amputation. Consequently, foot disorders are leading causes of hospitalization for persons with diabetes and account for billion-dollar expenditures annually in the US. Although not all foot complications can be prevented, dramatic reductions in frequency have been achieved by taking a multidisciplinary approach to patient management. Using this concept, the authors present a clinical practice guideline for diabetic foot disorders based on currently available evidence, committee consensus, and current clinical practice. The pathophysiology and treatment of diabetic foot ulcers, infections, and the diabetic Charcot foot are reviewed. While these guidelines cannot and should not dictate the care of all affected patients, they provide evidence-based guidance for general patterns of practice. If these concepts are embraced and incorporated into patient management protocols, a major reduction in diabetic limb amputations is certainly an attainable goal.

Treatment of diabetic foot ulcers with total contact casts: a critical review of the current literature

Peripheral neuropathy is a common complication of diabetes and may lead to ulcers, often resulting in amputations. Total contact casts are advocated for healing neuropathic ulcers but there are serious reservations about its use.

Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of a removable cast walker (RCW) and an "instant" total contact cast (iTCC) in healing neuropathic diabetic foot ulcerations.

RESEARCH DESIGN AND METHODS

We randomly assigned 50 patients with University of Texas grade 1A diabetic foot ulcerations into one of two off-loading treatment groups: an RCW or the same RCW wrapped with a cohesive bandage (iTCC) so patients could not easily remove the device. Subjects were evaluated weekly for 12 weeks or until wound healing.

RESULTS

An intent-to-treat analysis showed that a higher proportion of patients had ulcers that were healed at 12 weeks in the iTCC group than in the RCW group (82.6 vs. 51.9%, P = 0.02, odds ratio 1.8 [95% CI 1.1-2.9]). Of the patients with ulcers that healed, those treated with an iTCC healed significantly sooner (41.6 +/- 18.7 vs. 58.0 +/- 15.2 days, P = 0.02).

CONCLUSIONS

Modification of a standard RCW to increase patient adherence to pressure off-loading may increase both the proportion of ulcers that heal and the rate of healing of diabetic neuropathic wounds.

The use of telemedicine in the management of diabetes-related foot ulceration: a pilot study

OBJECTIVE

To determine if the management of forefoot ulcerations through telemedicine is medically equivalent to ulcer care at a diabetes foot program.

DESIGN

Nonrandomized comparison of forefoot ulcer healing rates.

SETTING

The Louisiana State University Health Sciences Center Diabetes Foot Program, Baton Rouge, LA, and Lallie Kemp Medical Center, Independence, LA.

PARTICIPANTS

Twenty consecutive patients with diabetes were treated for neuropathic forefoot ulcerations via telemedicine consultation and 120 consecutive patients with diabetes were treated face-to-face at a diabetes foot program.

INTERVENTIONS

Management of forefoot ulcers by a certified wound care nurse trained in the use of a staged management approach algorithm and alternative off-loading methods, supported by real-time interactive telemedicine consultation.

MAIN OUTCOME VARIABLES

Forefoot ulcer healing time in days, percentage of wounds healed in 12 weeks, and healing time ratio (adjusted for age, gender, ulcer duration, location, size, crossover, and grade).

RESULTS

No differences were found between the telemedicine and diabetes foot program groups in the average forefoot ulcer healing time (43.2 + 29.3 vs. and 45.5 + 43.4 days, P =.828), the percent of forefoot ulcers healed in 12 weeks (75 % vs. 81%, P =.546) and the adjusted healing time ratio (1.40 vs 1.00, P =.104).

CONCLUSION

These data appear to support the effectiveness of real-time interactive telemedicine consultation in the management of diabetes-related forefoot ulceration.