Abstract
BackgroundOffloading is key to preventing or healing plantar neuropathic foot ulcers in diabetes. Total contact casts or walkers rendered irremovable are recommended in guidelines as first-line options for offloading, however the use of such devices has been found to be low. This study aimed to investigate offloading practices for diabetes-related plantar neuropathic ulcers.MethodsAn online survey of closed and open-ended questions was administered via SurveyMonkey®. Forty-one podiatrists experienced in high-risk foot practice, from 21 high-risk foot services around Australia, were approached to participate.ResultsThe response rate was 88%. Participants reported using 21 modalities or combinations of modalities, for offloading this ulcer type. The most frequently used modalities under the forefoot and hallux were felt padding, followed by removable casts or walkers, then non-removable casts or walkers. Participants indicated that many factors were considered when selecting offloading modality, including: compliance, risk of adverse effects, psycho-social factors, restrictions on activities of daily living, work needs and features of the wound. The majority of participants (83%) considered non-removable casts or walkers to be the gold-standard for offloading this ulcer type, however they reported numerous, particularly patient-related, barriers to their use.ConclusionsSelecting offloading for the management of foot ulceration is complex. Felt padding, not the gold-standard non-removable cast or walker, was reported as the most commonly selected modality for offloading plantar neuropathic ulceration. However, further evaluation of felt padding in high quality clinical trials is required to ascertain its effectiveness for ulcer healing.
Highlights
Offloading is key to preventing or healing plantar neuropathic foot ulcers in diabetes
Types and frequency of offloading modalities used for non-complicated plantar neuropathic ulceration Results for Questions 1 and 2 indicate that a wide variety of offloading modalities were selected by participants for the management of both plantar forefoot and plantar hallux ulcers, with 21 offloading options being reported overall (12 pre-specified modalities and 9 additional modalities nominated by participants)
For plantar forefoot and plantar hallux ulcers respectively, this equated to: padding being used by 94% and 91% of participants 35% of the time, removable casts or walkers being used by 73% and 62% of participants 16% of the time, and non-removable casts or walkers being used by 68% and 53% of participants 11% of the time
Summary
Offloading is key to preventing or healing plantar neuropathic foot ulcers in diabetes. Clinical guidelines recommend total contact casts (TCCs) or other devices rendered irremovable, such as below-knee walkers, as first line offloading options for the treatment of uncomplicated, diabetes-related neuropathic foot ulcers. There is evidence that such devices heal a significantly higher proportion of ulcers and lead to faster healing [6,7], but the use of these devices is not high, suggesting that there are important barriers to their use in everyday practice [8,9,10] Where these interventions are not available, or if they are deemed inappropriate, ‘other’ offloading modalities should be considered, including: post-operative shoes, felt padding, half-shoes and cast-shoes [11,12,13]. The evidence for the effectiveness of ‘other’ offloading modalities for ulcer healing is limited [12]
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