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

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

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

Offloading devices, footwear Slides courtesy IWGDF; available at: www.iwgdfguidelines.org 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?

Offloading devices, footwear and other

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

Surgical Offloading

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

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

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

Non-plantar foot ulcers

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

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