Stress fractures: diagnosis, treatment, and prevention.

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Abstract

[Indexed for MEDLINE] 7. Diabetes Metab Res Rev. 2024 Mar;40(3):e3647. doi: 10.1002/dmrr.3647. Epub 2023 May 25. Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Bus SA(1)(2), Armstrong DG(3), Crews RT(4), Gooday C(5), Jarl G(6)(7), Kirketerp-Moller K(8)(9), Viswanathan V(10), Lazzarini PA(11)(12). Author information: (1)Department of Rehabilitation Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands. (2)Amsterdam Movement Science, Program Rehabilitation & Development, Amsterdam, Netherlands. (3)Department of Surgery, Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine of University of Southern California (USC), Los Angeles, California, USA. (4)Dr. William M. Scholl College of Podiatric Medicine's Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University, North Chicago, Illinois, USA. (5)Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals, Norwich, UK. (6)Faculty of Medicine and Health, Department of Prosthetics and Orthotics, Örebro University, Örebro, Sweden. (7)Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden. (8)Copenhagen Wound Healing Center, Bispebjerg University Hospital, Copenhagen, Denmark. (9)Steno Diabetes Center, Copenhagen, Denmark. (10)MV Hospital for Diabetes, Chennai, India. (11)School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia. (12)Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia. AIMS: Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline. MATERIALS AND METHODS: We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability. RESULTS: For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice. CONCLUSION: These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation. © 2023 The Authors. Diabetes/Metabolism Research and Reviews published by John Wiley & Sons Ltd. DOI: 10.1002/dmrr.3647