• 1

    Snyder RJ, Kirsner RS, Warriner RA III, et al: Consensus recommendations on advancing the standard of care for treating neuropathic foot ulcers in patients with diabetes. Ostomy Wound Manage 56: S1, 2010.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Frykberg RG, Zgonis T, Armstrong DG, et al: Diabetic foot disorders: a clinical practice guideline (2006 revision). J Foot Ankle Surg 45: S1, 2006.

  • 3

    Boulton AJ: Pressure and the diabetic foot: clinical science and offloading techniques. Am J Surg 187: 17S, 2004.

  • 4

    Atkins D, Best D, Briss PA, et al: Grading quality of evidence and strength of recommendations. BMJ 328: 1490, 2004.

  • 5

    Steed DL, Attinger C, Brem H, et al: Guidelines for the prevention of diabetic ulcers. Wound Repair Regen 16: 169, 2008.

  • 6

    Cavanagh PR, Bus SA: Off-loading the diabetic foot for ulcer prevention and healing. J Vasc Surg 52: 37S, 2010.

  • 7

    Bus SA: Priorities in offloading the diabetic foot. Diabetes Metab Res Rev 28: 54, 2012.

  • 8

    Lipsky BA, Berendt AR, Cornia PB, et al: 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 54: e132, 2012.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Sumpio BE, Lee T, Blume PA: Vascular evaluation and arterial reconstruction of the diabetic foot. Clin Podiatr Med Surg 20: 689, 2003.

  • 10

    Lewis J, Lipp A: Pressure-relieving interventions for treating diabetic foot ulcers. Cochrane Database Syst Rev 1: CD002302, 2013.

  • 11

    Schaper NC, Andros G, Apelqvist J, et al: Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer: a progress report of the International Working Group on the Diabetic Foot. Diabetes Metab Res Rev 28: 218, 2012.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Kirsner RS, Bell D, Gibbons G, et al: Expert recommendations for optimizing outcomes utilizing Apligraf® for diabetic foot ulcers. http://www.woundresearch.com/pdfs/wounds_orgo.pdf. Published 2012. Accessed May 30, 2013.

    • Search Google Scholar
    • Export Citation
  • 13

    Bakker K, Apelqvist J, Schaper NC: Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 28: 225, 2012.

  • 14

    Rathur HM, Boulton AJ: Pathogenesis of foot ulcers and the need for offloading. Horm Metab Res 37: 61, 2005.

  • 15

    Frykberg RG, Wittmayer B, Zgonis T: Surgical management of diabetic foot infections and osteomyelitis. Clin Podiatr Med Surg 24: 469, 2007.

  • 16

    Armstrong DG, Holtz-Neiderer K, Wendel C, et al: Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients. Am J Med 120: 1042, 2007.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Lavery LA, Armstrong DG: Temperature monitoring to assess, predict, and prevent diabetic foot complications. Curr Diab Rep 7: 416, 2007.

  • 18

    Lipsky BA, Peters EJ, Berendt AR, et al: Specific guidelines for the treatment of diabetic foot infections 2011. Diabetes Metab Res Rev 28: 234, 2012.

  • 19

    Lavery LA, Higgins KR, Lanctot DR, et al: Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. Diabetes Care 30: 14, 2007.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Nabuurs-Franssen MH, Sleegers R, Huijberts MS, et al: Total contact casting of the diabetic foot in daily practice: a prospective follow-up study. Diabetes Care 28: 243, 2005.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Eneroth M, Apelqvist J, Stenstrom A: Clinical characteristics and outcome in 223 diabetic patients with deep foot infections. Foot Ankle Int 18: 716, 1997.

  • 22

    Zou D, Mueller MJ, Lott DJ: Effect of peak pressure and pressure gradient on subsurface shear stresses in the neuropathic foot. J Biomech 40: 883, 2007.

  • 23

    Castronuovo JJ Jr, Adera HM, Smiell JM, et al: Skin perfusion pressure measurement is valuable in the diagnosis of critical limb ischemia. J Vasc Surg 26: 629, 1997.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 24

    Edelson GW, Armstrong DG, Lavery LA, et al: The acutely infected diabetic foot is not adequately evaluated in an inpatient setting. JAPMA 87: 260, 1997.

    • Search Google Scholar
    • Export Citation
  • 25

    Landsman AS, Meaney DF, Cargill RS II, et al: 1995 William J. Stickel Gold Award: high strain rate tissue deformation: a theory on the mechanical etiology of diabetic foot ulcerations. JAPMA 85: 519, 1995.

    • Search Google Scholar
    • Export Citation
  • 26

    Gibbons GW, Shaw PM: Diabetic vascular disease: characteristics of vascular disease unique to the diabetic patient. Semin Vasc Surg 25: 89, 2012.

  • 27

    Bus SA, Valk GD, van Deursen RW, et al: Specific guidelines on footwear and offloading. Diabetes Metab Res Rev 24: S192, 2008.

  • 28

    Bus SA, Waaijman R, Arts M, et al: Effect of custom-made footwear on foot ulcer recurrence in diabetes: a multicenter randomized controlled trial. Diabetes Care 36: 4109, 2013.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Sumpio BE, Aruny J, Blume PA: The multidisciplinary approach to limb salvage. Acta Chir Belg 104: 647, 2004.

  • 30

    Steed DL, Attinger C, Colaizzi T, et al: Guidelines for the treatment of diabetic ulcers. Wound Repair Regen 14: 680, 2006.

  • 31

    Armstrong DG, Short B, Espensen EH, et al: Technique for fabrication of an “instant total-contact cast” for treatment of neuropathic diabetic foot ulcers. JAPMA 92: 405, 2002.

    • Search Google Scholar
    • Export Citation
  • 32

    Rogers LC, Frykberg RG, Armstrong DG, et al: The Charcot foot in diabetes. Diabetes Care 34: 2123, 2011.

  • 33

    Piaggesi A, Macchiarini S, Rizzo L, et al: An off-the-shelf instant contact casting device for the management of diabetic foot ulcers: a randomized prospective trial versus traditional fiberglass cast. Diabetes Care 30: 586, 2007.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Armstrong DG, Nguyen HC, Lavery LA, et al: Off-loading the diabetic foot wound: a randomized clinical trial. Diabetes Care 24: 1019, 2001.

  • 35

    Van De Weg FB, Van Der Windt DA, Vahl AC: Wound healing: total contact cast vs. custom-made temporary footwear for patients with diabetic foot ulceration. Prosthet Orthot Int 32: 3, 2008.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Gutekunst DJ, Hastings MK, Bohnert KL, et al: Removable cast walker boots yield greater forefoot off-loading than total contact casts. Clin Biomech (Bristol, Avon) 26: 649, 2011.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 37

    Owings TM, Apelqvist J, Stenström A, et al: Plantar pressures in diabetic patients with foot ulcers which have remained healed. Diabet Med 26: 1141, 2009.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Bus SA, Valk GD, van Deursen RW, et al: The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes Metab Res Rev 24: S162, 2008.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Foley L: Pressure point offloading in the diabetic foot. Primary Intention Aug: 102, 1999.

  • 40

    Snyder RJ, Lanier KK: Offloading difficult wounds and conditions in diabetic patient. Ostomy Wound Manage 48: 22, 2002.

  • 41

    Birke JA, Pavich MA, Patout CA Jr, et al: Comparison of forefoot ulcer healing using alternative off-loading methods in patients with diabetes mellitus. Adv Skin Wound Care 15: 210, 2002.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Armstrong DG, Lavery LA, Wu S, et al: Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. Diabetes Care 28: 551, 2005.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Beuker BJ, van Deursen RW, Price P, et al: Plantar pressure in offloading devices used in diabetic ulcer treatment. Wound Rep Regen 13: 537, 2005.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 44

    Jimenez A: “Total Contact Casting,” in Update 2003, p 282, The Podiatry Institute, Decatur, GA, 2003.

  • 45

    Faglia E, Caravaggi C, Clerici G, et al: Effectiveness of removable walker cast versus nonremovable fiberglass off-bearing cast in the healing of diabetic plantar foot ulcer: a randomized controlled trial. Diabetes Care 33: 1419, 2010.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Katz IA, Harlan A, Miranda-Palma B, et al: A randomized trial of two irremovable off-loading devices in the management of neuropathic diabetic foot ulcers. Diabetes Care 28: 555, 2005.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47

    Wertsch JJ, Frank LW, Zhu H, et al: Plantar pressures with total contact casting. J Rehabil Res Dev 32: 205, 1995.

  • 48

    de Souza LJ: Charcot arthropathy and immobilization in a weight-bearing total contact cast. J Bone Joint Surg Am 90: 754, 2008.

  • 49

    Pinzur MS, Lio T, Posner M: Treatment of Eichenholtz stage I Charcot foot arthropathy with a weightbearing total contact cast. Foot Ankle Int 27: 324, 2006.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 50

    Trepman E, Pinzur MS, Shields NN: Application of the total contact cast. Foot Ankle Int 26: 108, 2005.

  • 51

    Fife CE, Carter MJ, Walker D: Why is it so hard to do the right thing in wound care? Wound Repair Regen 18: 154, 2010.

  • 52

    Sinacore DR: Total contact casting for diabetic neuropathic ulcers. Phys Ther 76: 296, 1996.

  • 53

    Ha Van G, Siney H, Hartmann-Heurtier A, et al: Nonremovable, windowed, fiberglass cast boot in the treatment of diabetic plantar ulcers: efficacy, safety, and compliance. Diabetes Care 26: 2848, 2003.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 54

    Reiber GE, Smith DG, Wallace C, et al: Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. JAMA 287: 2552, 2002.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55

    Lavery LA, Vela SA, Fleischli JG, et al: Reducing plantar pressure in the neuropathic foot: a comparison of footwear. Diabetes Care 20: 1706, 1997.

  • 56

    Schuster MA, McGlynn EA, Brook RH: How good is the quality of health care in the United States? Milbank Q 76: 517, 1998.

  • 57

    Armstrong DG, Lavery LA, Kimbriel HR, et al: Activity patterns of patients with diabetic foot ulceration: patients with active ulceration may not adhere to a standard pressure off-loading regimen. Diabetes Care 26: 2595, 2003.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 58

    Wu SC, Jensen JL, Weber AK, et al: Use of pressure offloading devices in diabetic foot ulcers: do we practice what we preach? Diabetes Care 31: 2118, 2008.

  • 59

    Maciejewski ML, Reiber GE, Smith DG, et al: Effectiveness of diabetic therapeutic footwear in preventing reulceration. Diabetes Care 27: 1774, 2004.

  • 60

    Prompers L, Huijberts M, Apelqvist J, et al: Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study. Diabet Med 25: 700, 2008.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 61

    Veves A, Falanga V, Armstrong DG, et al: Apligraf Diabetic Foot Ulcer Study: Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care 24: 290, 2001.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 62

    Kashefsky H, Marston W: Total contact casting combined with human fibroblast-derived dermal tissue in 15 DFU patients. J Wound Care 21: 236, 2012.

  • 63

    Sheehan P, Jones P, Caselli A, et al: Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care 26: 1879, 2003.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 64

    Edmonds M: European and Australian Apligraf Diabetic Foot Ulcer Study Group: Apligraf in the treatment of neuropathic diabetic foot ulcers. Int J Low Extrem Wounds 8: 11, 2009.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 65

    Marston WA, Hanft J, Norwood P, et al: The efficacy and safety of Dermagraft in improving the healing of chronic diabetic foot ulcers: results of a prospective randomized trial. Diabetes Care 26: 1701, 2003.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 66

    Ozdemir BA, Brownrigg JR, Jones KG, et al: Systematic review of screening investigations for peripheral arterial disease in patients with diabetes mellitus. Surg Technol Int 23: 51, 2013.

    • PubMed
    • Search Google Scholar
    • Export Citation

The Management of Diabetic Foot Ulcers Through Optimal Off-Loading

Building Consensus Guidelines and Practical Recommendations to Improve Outcomes

View More View Less
  • 1 Barry University School of Podiatric Medicine, Miami Shores, FL.
  • | 2 ‡Intellicure Inc, The Woodlands, TX.
  • | 3 §St. Luke's Wound Care Clinic, The Woodlands, TX.
  • | 4 |||Healogics, Jacksonville, FL.
  • | 5 Carl T. Hayden Veteran Affairs Medical Center, Phoenix, AZ.
  • | 6 Midwestern University School of Podiatric Medicine, Glendale, AZ.
  • | 7 Amputation Prevention Center, Sherman Oaks Hospital, Los Angeles, CA.
  • | 8 |Comprehensive Wound Center of Baylor University Medical Center, Dallas, TX.
  • | 9 Save a Leg, Save a Life Foundation, Jacksonville, FL.
  • | 10 Limb Salvage Institute and Wound Care on Wheels, Jacksonville, FL.
  • | 11 *Memorial Hospital of Jacksonville, St. Vincent's Medical Center Southside and Specialty Hospital of Jacksonville, Jacksonville, FL.
  • | 12 †Trinity Center for Wound Care and Hyperbaric Medicine, Trinity Bettendorf and Moline Clinics, Trinity Regional Medical Center, Bettendorf, IA.
Restricted access

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.

Corresponding author: Robert J. Snyder, DPM, MSc, Barry University School of Podiatric Medicine, Paul & Margaret Brand Research Center, 11300 NE Second Ave, Miami Shores, FL 33161. (E-mail: drwound@aol.com)