Knee-high offloading beats usual care for diabetic foot ulcers, custom or prefabricated

A systematic review and network meta-analysis of randomised controlled trials comparing offloading strategies for diabetic foot ulcers, published in Foot and Ankle Surgery on 16 September 2026 by a team from Thailand. It is rated Level I evidence.

It pooled 28 RCTs covering 2,016 participants, comparing offloading approaches against each other and against usual care, with ulcer healing as the outcome.

The primary network was inconsistent. When the direct and indirect evidence in a network disagree, the rankings it produces are unreliable. The authors reported this rather than burying it, and based their conclusions on a sensitivity analysis instead.

Three approaches beat usual care. In the sensitivity analysis, healing rates were higher than usual care for:

A risk ratio compares how often ulcers healed with each approach against usual care. At 1.0 there is no difference; 1.36 means ulcers were 36% more likely to heal than with usual care. It is a relative figure, so the real gain depends on how often usual care heals ulcers to begin with: if it heals half, 1.36 takes that to about two-thirds.

The authors declare no competing financial interests. No funding source is stated.

The figures compare each device with usual care, not with each other. Risk ratios of 1.36 and 1.32 look close, but they are two separate comparisons with usual care, and with the network already inconsistent they do not show the two devices perform the same. In guideline terminology a total contact cast is a customised non-removable knee-high device, and a prefabricated knee-high walker made non-removable is a prefabricated one. Choosing prefabricated for fit, availability or cost is a reasonable call, but this paper does not show nothing is lost on healing.

It is consistent with current guidance. Non-removable knee-high offloading is already the first choice for neuropathic plantar ulcers in international diabetic foot guidelines. This paper supports that position.

The order among the top three is uncertain. Because of the network inconsistency, the ranking between surgical, customised and prefabricated offloading is less solid than the finding that all three beat usual care. Surgery ranking first does not make it a first-line option; it remains one for selected patients.

Non-removable knee-high offloading, customised or prefabricated, heals more diabetic foot ulcers than usual care. Surgical offloading also beats usual care and belongs with selected patients. The paper does not establish that prefabricated devices match customised ones, and the exact ranking is uncertain because of the network inconsistency.

For measuring whether patients actually wear their offloading, see objectively measuring offloading adherence in the diabetic foot.