Diabetes-related foot disease (DFD) affects an estimated 200 million people globally, surpassing the disease burden of conditions like stroke and breast cancer. In their comprehensive article, Best Practice Offloading Treatments for Diabetic Foot Ulcer Healing, Remission, and Better Plans for the Healing-Remission Transition (Seminars in Vascular Surgery, 2025), Dr. Peter Lazzarini and Dr. Jaap J. van Netten examine the current state of offloading treatments and propose innovative plans for transitioning patients from ulcer healing to long-term remission.
The Need for Optimized Offloading
DFD is a major global health problem, largely driven by complications like ulcers, infections, and amputations that significantly reduce quality of life. Offloading treatments, which reduce mechanical stress on vulnerable foot areas, are critical for healing and preventing re-ulceration. However, the abrupt transition from aggressive offloading during healing to less effective offloading during remission often leads to high rates of re-ulceration—up to 40% within the first year.
The Gold Standard for Healing: Non-Removable Devices
Lazzarini and Van Netten emphasize the effectiveness of non-removable knee-high devices, such as total contact casts (TCCs) and instant TCCs, which are considered the gold standard for ulcer healing. These devices effectively redistribute pressure, heal ulcers more quickly, and prevent severe complications. However, their use comes with challenges, including patient discomfort, adherence issues, and a potential decline in quality of life.
To address these challenges, the authors recommend a personalized, evidence-based approach that carefully balances the benefits of aggressive offloading with its potential harms.
The Healing-Remission Gap: A Key Barrier
The transition from healing to remission remains a critical period where many patients experience re-ulceration. As patients move from effective but restrictive offloading devices to pressure-optimized footwear, there is often a sudden increase in plantar pressure and physical activity. Without proper management, this shift can overwhelm recently healed tissue, leading to breakdowns and new ulcers.
Bridging the Transition: Proposed Plans
Lazzarini and Van Netten propose a gradual transition model that combines decreasing offloading intensity with incremental increases in physical activity. Their suggested transition plan includes:1. Starting with non-removable knee-high devices.2. Progressing to removable ankle-high devices.3. Gradually integrating therapeutic footwear.4. Increasing daily weight-bearing activities in controlled steps.
This stepwise approach aims to reduce re-ulceration rates by providing recently healed tissue the time and support needed to strengthen and adapt.
Implications for the Future
The authors call for more research to validate their transition model and address unanswered questions, such as the optimal timing and personalized adjustments required for different patients. They advocate for interdisciplinary collaboration to improve guidelines, ultimately aiming for better long-term outcomes in diabetic foot care.
A Collaborative Effort to Reduce the Global Burden
Both Lazzarini and Van Netten’s contributions to the International Working Group on the Diabetic Foot (IWGDF) Guidelines reflect their commitment to advancing care for patients with DFD. Their research not only highlights current best practices but also serves as a catalyst for future innovations aimed at reducing the global burden of diabetic foot disease.
For further details, you can access their article here: Seminars in Vascular Surgery, 2025.
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