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

Abstract

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.

Australian guideline on offloading treatment for foot ulcers: part of the 2021 Australian evidence‐based guidelines for diabetes‐related foot disease

“…Pressure offloading aims to reduce high plantar tissue stress and has been found to be critical to achieve timely and complete DFU healing [ 1 , 9 , 11 ]. To do this effectively, offloading should maximise the desirable effects (benefits) of reducing high plantar tissue stress; whilst also minimising any undesirable effects (risks), such as adverse events and high costs [ 10 , 12 , 13 ]. Various offloading treatments have been used clinically, including offloading devices, footwear and corrective surgery [ 12 , 14 ].…”

Personalized Offloading Treatments for Healing Plantar Diabetic Foot Ulcers

“…Previous reviews in the area have found that NRKHDs reduce more PP than other offloading treatments by incorporating more key mechanical features, such as customized insoles/foot-device interfaces, rocker-bottom soles, controlled ankle motion, and higher cast walls/struts preferably extending up to the knee. 20 These features typically also reduce foot and ankle joint movements [21][22][23] and subsequent horizontal shear forces by using the contact surfaces as loadbearing surfaces. 24 In addition, restricted ankle movement will necessitate strategies of reducing mobility and/or increasing requirements on the contralateral limb.…”

“…51,55 Existing knee-high offloading devices can be hot to wear. 20 Already, 3D-printed ankle fracture casts and cervical orthoses with improved ventilation have been designed to improve patient comfort 56,57 which could easily be translated to offloading device design. Hence, it may be possible to create a personalized device from a 3D scan that is lighter, has improved ventilation, and effectively reduces plantar tissue stresses.…”

The Outcome of Surgical Treatment for the Neuropathic Diabetic Foot Lesions—A Single-Center Study

“…In addition, recommended exercises are those that help develop joint mobility and reduce plantar pressure. Another important measure is custom footwear, used for pressure relief and adapted to the patient’s lesion [ 14 , 15 ].…”