1. 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:
Working group
Guideline meeting Berlin September 2018

3. 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

4. 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

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

6. Offloading devices, footwear
Slides courtesy IWGDF; available at:
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?

7. Offloading devices, footwear and other

8. 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?

9. Surgical Offloading

10. 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?

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

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

13. Non-plantar foot ulcers

14. 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

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