Table 5 Summary implementation considerations for the Australian evidence-based offloading treatment guidelines

1a

Irremovable knee-high offloading devices.

For those with high falls risk [32], moderate-to-severe infection and/or moderate-to-severe ischaemia [22, 33, 34] consider Recommendations 3, 7B and 7C, respectively. Consider personal circumstances [22], such as because of occupation, family care requirements, frequent driving, hot climates, social impacts or infrequent ability to attend follow-up care. For these people we suggest also considering Recommendation 2.

We strongly advise that the benefits, risks and contraindications are always carefully explained and people with DFU have an opportunity to discuss their personal circumstances to gain full informed consent.

Offloading treatment is always performed in conjunction with a good standard of DFU care that includes DFU measurement, appropriate debridement, wound dressings, antimicrobial treatment if infected, revascularisation considerations if ischaemic [9, 35]. We refer the reader to the specific recommendations for such care in the relevant accompanying guidelines (REFS).

We suggest all people have their offloading regularly reviewed within ≤1 week of initial offloading device use and ~ 1–2 weekly thereafter - to monitor DFU healing, adverse events and plantar pressure where available.

Geographically remote people

Aboriginal and Torres Strait Islander people.

See eTable B1 for further detailed information

1b

Total contact casts (TCC) and instant total contact cats (iTCC)

The same contraindications as in Recommendation 1A also apply for this recommendation. Additionally, large foot deformity is likely a contraindication for iTCCs

The same monitoring considerations as outlined in Recommendations 1A apply.

Capture as data items/options to monitor the organisations use of either TCC or iTCC in the Australian context for audit and quality review and reporting purposes.

See eTable B2 for further detailed information

2

Removable knee-high offloading devices

The same contraindications as in Recommendation 1A.

The same procedures as in Recommendation 1A apply. Additionally, we agree with IWGDF that persons should be strongly advised to wear the device consistently.

Determine if the device is still optimally reducing plantar pressure and if the person is adhering to wearing the device as much as possible.

See eTable B3 for further detailed information.

3

Removable ankle-high offloading devices

People at high risk of mid-foot fractures if using half-shoe devices and people with very large foot deformity(s). Refer to Recommendation 4.

The same procedure considerations as in Recommendation 2. it is likely that higher ankle-high devices and those with rocker-soles may offer more plantar pressure reduction

See eTable B4 for further detailed information.

4

Medical grade footwear

People with a large foot deformity(s) that cannot be safely accommodated in prefabricated medical grade footwear.

Similar procedure considerations as outlined in Recommendations 1–3.

The same monitoring considerations as outlined in Recommendations 1–3.

See Recommendations 1–3. Often medical grade footwear is more difficult to source in geographically remote settings than removable offloading devices. Consider whether culturally appropriate.

See eTable B5 for further detailed information.

5

Felted foam (adhesive felt)

People with severe ischaemia, very fragile skin or heavily exudating ulcers are likely to be contraindicated to using felted foam that is adhered to the foot itself. Therefore, adhere the felted foam to the pressure offloading insole.

Similar procedure considerations as outlined in Recommendations 1–3. Ensure there is enough room in the device or footwear to safely accommodate the foot and felted foam, use a bevelled technique. Monitor for adverse events.

The same monitoring considerations as outlined in Recommendation 2 also apply.

Geographically remote people

Aboriginal and Torres Strait Islander people.

See eTable B6 for further detailed information.

6a

Surgical offloading

A significant contraindication for these surgical procedures is moderate-to-severe ischaemia [22]. Relative contraindications include those with moderate-to-severe infection, moderate-to-severe oedema, cognitive impairment impairing capacity to provide informed consent, or conditions precluding anaesthesia. Lastly, we suggest people with normal (> 5 degrees of) ankle dorsiflexion are not likely to benefit from Achilles tendon lengthening or Gastrocnemius Recession procedures, and metatarsal head resections should be the surgical procedure considered instead.

People with a rigid toe deformity are unlikely to benefit from Recommendation 6b.

The same monitoring considerations as outlined in Recommendations 1A also apply to this recommendation.

See eTable B7 for further detailed information.

6b

We strongly agreed with IWGDF that these surgical offloading procedures should only be considered if the person has failed to heal following 4–6 weeks of a good standard of DFU care

See eTable B8 for further detailed information.

7a

DFU complicated by infection or ischaemia

NA. The infection or ischaemia treatment plan should be instigated first. Please refer to Australian Guidelines on Infection and PAD [33, 34, 36].

See Recommendation 1

The same monitoring considerations as outlined in Recommendations 1–3 apply.

See eTable B9, 10 and B11 for further detailed information

7b

See Recommendation 2

7c

See Recommendation 3

8

Plantar heel DFU

The same contraindications as outlined in Recommendations 1–2

If considering ankle-high devices we highlight that such a device needs to demonstrate it can reduce more plantar pressure at the ulcer site than knee-high devices

The same monitoring considerations as outlined in Recommendations 1–2. Additionally, collect site of the ulcer as routine characteristics.

See eTable B12 for further detailed information

9

Non-plantar DFU

The same contraindications in Recommendations 2–5 apply.

Given there is a substantial lack of evidence, various removable non-surgical offloading modalities can be considered.

The same monitoring considerations in Recommendations 2–5 & 8 apply.

See eTable B13 for further detailed information.