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Table 3 Summary of the original IWGDF recommendation compared with the new Australian guideline recommendations for offloading

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

No. Original IWGDF Recommendation Decision No. New Australian Recommendation
1a In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer, use a non-removable knee-high offloading device with an appropriate foot-device interface as the first-choice of offloading treatment to promote healing of the ulcer. (Strong; High) Adapted 1a In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer, use a non-removable knee-high offloading device rather than a removable offloading device to promote healing of the ulcer (GRADE strength of recommendation: Strong; Quality of evidence: Moderate).
1b When using a non-removable knee-high offloading device to heal a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use either a total contact cast or non-removable knee-high walker, with the choice dependent on the resources available, technician skills, patient preferences and extent of foot deformity present. (Strong; Moderate) Adapted 1b When using a non-removable knee-high offloading device to heal a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, consider using either a total contact cast or nonremovable knee-high walker, with the choice dependent on the local resources and technical skills available, and person’s preferences and extent of foot deformity (Weak; Low).
2 In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer for whom a non-removable knee-high offloading device is contraindicated or not tolerated, consider using a removable knee-high offloading device with an appropriate foot-device interface as the second-choice of offloading treatment to promote healing of the ulcer. Additionally, encourage the patient to wear the device at all times. (Weak; Low) Adapted 2 In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer, when non-removable knee-high offloading devices are contraindicated or not tolerated, consider using a removable knee-high offloading device (and explain the importance of using) during all weight-bearing activities rather than a removable ankle-high offloading device to reduce plantar pressure and promote healing of the ulcer (Weak; Low).
3 In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer for whom a knee-high offloading device is contraindicated or not tolerated, use a removable ankle-high offloading device as the third-choice of offloading treatment to promote healing of the ulcer. Additionally, encourage the patient to wear the device at all times. (Strong; Low) Adapted 3 In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer, when knee-high offloading devices are contraindicated or not tolerated, use a removable ankle-high offloading device (and explain the importance of using) during all weight-bearing activities rather than medical grade footwear to promote healing of the ulcer (Strong; Very low)
4a In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer, do not use, and instruct the patient not to use, conventional or standard therapeutic footwear as offloading treatment to promote healing of the ulcer, unless none of the above-mentioned offloading devices is available. (Strong; Moderate) Adapted 4 In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer, when ankle-high offloading devices are contraindicated or not tolerated, use medical grade footwear rather than other footwear types or no footwear to reduce plantar pressure and promote healing of the ulcer (Strong; Low).
4b In that case, consider using felted foam in combination with appropriately fitting conventional or standard therapeutic footwear as the fourth choice of offloading treatment to promote healing of the ulcer. (Weak; Low) Adapted 5 In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer, consider using felted foam in combination with an offloading device or footwear rather than using the offloading device or footwear alone to further reduce plantar pressure and promote healing of the ulcer (Weak; Very Low).
5 In a person with diabetes and a neuropathic plantar metatarsal head ulcer, consider using Achilles tendon lengthening, metatarsal head resection(s), or joint arthroplasty to promote healing of the ulcer, if non-surgical offloading treatment fails. (Weak; Low) Adapted 6a If the best recommended offloading device option fails to heal a person with diabetes and a neuropathic plantar metatarsal head ulcer, consider using Achilles tendon lengthening or Gastrocnemius recession, metatarsal head resection(s), or joint arthroplasty to promote healing of the ulcer (Weak; Low).
6 In a person with diabetes and a neuropathic plantar or apex digital ulcer, consider using digital flexor tenotomy to promote healing of the ulcer, if non-surgical offloading treatment fails. (Weak; Low) Adapted 6b If the best recommended offloading device option fails to heal a person with diabetes and a neuropathic plantar or apical ulcer on a non-rigid toe, consider using digital flexor tenotomy to promote healing of the ulcer (Weak; Low).
7a In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer with either mild infection or mild ischemia, consider using a non-removable knee-high offloading device to promote healing of the ulcer. (Weak; Low) Adopted 7a As stated in original the IWGDF Recommendation
7b In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer with both mild infection and mild ischemia, or with either moderate infection or moderate ischaemia, consider using a removable knee-high offloading device to promote healing of the ulcer. (Weak; Low) Adopted 7b As stated in original the IWGDF Recommendation
7c In a person with diabetes and a neuropathic plantar forefoot or midfoot ulcer with both moderate infection and moderate ischaemia, or with either severe infection or severe ischemia, primarily address the infection and/or ischemia, and consider using a removable offloading intervention based on the patient’s functioning, ambulatory status and activity level, to promote healing of the ulcer. (Weak; Low) Adopted 7c As stated in original the IWGDF Recommendation
8 In a person with diabetes and a neuropathic plantar heel ulcer, consider using a knee-high offloading device or other offloading intervention that effectively reduces plantar pressure on the heel and is tolerated by the patient, to promote healing of the ulcer. (Weak; Low) Adopted 8 As stated in original the IWGDF Recommendation
9 In a person with diabetes and a non-plantar foot ulcer, use a removable ankle-high offloading device, footwear modifications, toe spacers, or orthoses, depending on the type and location of the foot ulcer, to promote healing of the ulcer. (Strong; Low) Adapted 9 In a person with diabetes and a non-plantar foot ulcer, use a removable offloading device, medical grade footwear, felted foam, toe spacers or orthoses, depending on the type and location of the foot ulcer, rather than no offloading intervention to promote healing of the ulcer and to prevent further ulceration (Strong; Very Low).
  1. Note: underlined wording indicates the specific adapted changes to the original IWGDF recommendation