Offloading Foot Wounds in People with Diabetes

Up to 25% of people with diabetes will develop a foot ulcer at some point during their lifetime, and 1 in 5 will require an amputation. In 2006, more than 65,700 lower-limb amputations were performed in the United States alone in people with diabetes, and the 5-year mortality rate following an amputation is worse than for most malignancies. Along with an interdisciplinary team approach to diabetic limb salvage, "toe and flow," a vertical and horizontal approach to wound healing, is changing the way these patients are cared for. The vertical strategy for wound healing refers to covering important structures and filling defects with negative pressure wound therapy, while the horizontal strategy utilizes skin grafting, bioengineered skin substitutes, and aggressive offloading. The gold standard for offloading foot wounds in people with diabetes is total contact casting, however, recent studies have shown that the modality is seldom used in the current clinical setting. Other offloading devices include removable cast walkers, half shoes, healing sandals, and, more recently, lightweight, rapidly custom-built braces. Offloading of the diabetic foot is often overlooked as a critical part of wound healing, but past experience guides the authors to the conclusion that it is often not what one puts on the wound, but rather what is taken off that primarily affects healing in many of these patients.