Preferred Offloading Modalities for Management of Diabetic Foot Ulcers in Private Clinical Settings: A Survey of Australian Podiatrists

Abstract

Background Diabetic peripheral neuropathy is a common complication of diabetes mellitus. Neuropathy predisposes patients to diabetic foot ulcers (DFU) due to the loss of protective sensation and associated deformities. Management of foot ulcers are multifactorial, but pressure offloading can be considered as one of the most important aspects of management. According to IWGDF Guidelines, non-removable knee-high offloading devices are recommended as the 1st line of treatment for these ulcers. However, this is a very underutilised treatment modality. This study aimed to evaluate the practitioner preferred offloading modalities and reasons for their preference. Methods This project was approved by the university’s human research ethics committee. An online survey was distributed amongst Australian podiatrist via an industry related social media group. The survey collected simple demographical information, management strategies, preferred offloading modalities for the management of diabetic foot ulcers and reasons for their preferred method. Results Sixty-three podiatrists completed the survey with the majority practicing in private clinics. All practitioners treat diabetic foot ulcers regularly with most participants treating up to ten ulcer cases per week and 14% of participants treating more than 20 ulcers per week. Contrary to the IWGDF guidelines, standard therapeutic footwear was the most preferred method of management for the treatment of diabetic foot ulcers, with ease of use reported as the main reason for practitioners using this modality. Non-compliance to the use of non-removable knee-high offloading devices include perceived patient non-compliance and poor tolerance. Conclusion This study shows that practitioners’ offloading strategies do not adhere to the IWGDF guidelines. The reasons for not adhering to the guidelines seems to be a clinical practicality rather than evidence-based practice. Reasons for choosing a management strategy is multi-factorial (not just reducing plantar pressures). Further studies may be required to evaluate the effectiveness of therapeutic footwear in ulcer healing, taking into consideration other factors such as practitioner and patient preference, clinical practicality, and access to support. Based on the findings, this study provides suggestions on how to overcome the barriers that prevent podiatrist from adhering to the recommendations of the IWGDF when selecting offloading devices in general clinical practice.

Offloading of diabetes‐related neuropathic foot ulcers at Swedish prosthetic and orthotic clinics

“…Some of the differences between countries might be explained by the fact that the questionnaire in the current study may vere foot ulcers as most of them worked in private non-high-risk foot settings. 15 The results of the current study and the study by Raspovic and…”

“…However, Erasmus et al. reported in a preprint study 15 that Australian podiatrists used therapeutic footwear as a first‐choice treatment for plantar forefoot ulcers. This finding is similar to the results of the current study but differs from the Australian study of Raspovic and Landrof.…”

“…The reason for the different offloading preferences in the two Australian studies could potentially be because participants in the study by Erasmus et al. treated less severe foot ulcers as most of them worked in private non‐high‐risk foot settings 15 …”