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Digest: “Mind the gap” ulcer offloading: International guidelines good, implementation poor

Neil Baker OBE
Welcome to this edition of Diabetes Digest. I hope you find something interesting in the selection of recent papers I’ve chosen.

The featured paper this issue is from Sweden. It sought to explore whether there is a gap between clinical practice and the International Working Group on the Diabetic Foot Ulcer offloading guidelines. 

At the outset, I will say that this study may not be truly reflective of clinical practice universally. This paper was an observational cross-sectional study and the aims were to assess the use of different offloading interventions, factors that influence offloading choices, and gold standard offloading awareness for healing plantar neuropathic forefoot diabetic foot ulcers (DFUs). 

In Sweden, prosthetic and orthotic clinics are predominately responsible for offloading DFUs. Following a pilot questionnaire of 29 questions, a final version comprising of seven closed-ended questions with a glossary list was produced. 

The final survey was distributed via SurveyMonkey to the 51 prosthetic and orthotic clinics in Sweden. This was then answered by practitioners who were experienced and responsible for offloading DFUs. 

The questions included: identification of the types and percentage use of 14 predefined offloading interventions, with free text for additional methods; ranked responses on a five-point Likert scale regarding consideration to practitioner, patient, intervention and wound-related factors in the provision of offloading interventions (i.e. choice preferences); and awareness regarding the gold standard for DFU offloading. 

Overall, 35 (69%) clinicians responded to the questionnaire. Findings were that 86% of clinics provided modified off-the-shelf footwear with insoles (to a mean of 59% of patients); while 49% provided modified off-the-shelf footwear without insoles (to 30% of patients). Post-operative shoes were provided by 71% (to 12% of patients). Removable knee-high walkers and removable casts were provided by 49% (to 9% of patients), and 20% provided total contact casts (TCCs; to 8% of patients). None provided non-removable knee-high walkers. 

When asked if they were aware that TCC was the gold standard DFU offloading intervention, 26% of practitioners were aware, 37% were unsure and 37% were unaware. The average percentage of patients provided with TCC was 2% (practitioners aware), 3% (unsure) and 0% (unaware).

Thus, in Sweden there certainly appears to be a huge gap between the recommended international evidence-based guidelines and clinical practice. In fact, this study shows a complete reverse of the guidelines. 

Of course, this study has many questions regarding methodology and one cannot suggest the results are the norm. However, there is a body of evidence that the gold standard TCC is not used widely throughout the world for many identified reasons, and this study further adds to this. 

Perhaps it’s time to put more energy and resources into aiding guideline implementation and not further refining existing guidelines.


Gigante I, Sigurjónsdóttir ED, Jarl G, Hellstrand Tang U (2023) Offloading of diabetes-related neuropathic foot ulcers at Swedish prosthetic and orthotic clinics. Diabetes Metab Res Rev [Online ahead of print]

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