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

Background: Pressure offloading treatment is critical for healing diabetes-related foot ulcers (DFU). Yet the 2011Australian DFU guidelines regarding offloading treatment are outdated. A national expert panel aimed to develop anew Australian guideline on offloading treatment for people with DFU by adapting international guidelines thathave been assessed as suitable to adapt to the Australian context.Methods: National Health and Medical Research Council procedures were used to adapt suitable InternationalWorking Group on the Diabetic Foot (IWGDF) guidelines to the Australian context. We systematically screened,assessed and judged all IWGDF offloading recommendations using best practice ADAPTE and GRADE frameworksto decide which recommendations should be adopted, adapted or excluded in the Australian context. For eachrecommendation, we re-evaluated the wording, quality of evidence, strength of recommendation, and providedrationale, justifications and implementation considerations, including for geographically remote and Aboriginal andTorres Strait Islander peoples. This guideline, along with five accompanying Australian DFU guidelines, underwentpublic consultation, further revision and approval by ten national peak bodies (professional organisations).Results: Of the 13 original IWGDF offloading treatment recommendations, we adopted four and adapted nine. Themain reasons for adapting the IWGDF recommendations included differences in quality of evidence ratings andclarification of the intervention(s) and control treatment(s) in the recommendations for the Australian context. ForAustralians with plantar DFU, we recommend a step-down offloading treatment approach based on theircontraindications and tolerance. We strongly recommend non-removable knee-high offloading devices as first-linetreatment, removable knee-high offloading devices as second-line, removable ankle-high offloading devices thirdline,and medical grade footwear as last-line. We recommend considering using felted foam in combination withthe chosen offloading device or footwear to further reduce plantar pressure. If offloading device options fail to heala person with plantar DFU, we recommend considering various surgical offloading procedures. For people with non-plantar DFU, depending on the type and location of the DFU, we recommend using a removable offloadingdevice, felted foam, toe spacers or orthoses, or medical grade footwear. The six new guidelines and the fullprotocol can be found at: https://diabetesfeetaustralia.org/new-guidelines/.Conclusions: We have developed a new Australian evidence-based guideline on offloading treatment for peoplewith DFU that has been endorsed by ten key national peak bodies. Health professionals implementing theseoffloading recommendations in Australia should produce better DFU healing outcomes for their patients,communities, and country