Offloading strategies for diabetic foot ulcers: A systematic review and network meta-analysis of randomized controlled trials.

BACKGROUND: Previous network meta-analyses of diabetic foot ulcer (DFU) offloading focused mainly on non-surgical interventions, leaving the role of surgical offloading uncertain. This study compared and ranked surgical and non-surgical offloading strategies for DFU healing. METHODS: Randomized controlled trials (RCTs) evaluating offloading interventions for DFUs were systematically reviewed. The primary outcome was ulcer healing rate. A random-effects network meta-analysis was performed, and interventions were ranked using P-scores. RESULTS: Twenty-eight RCTs, involving 2016 participants, were included. Because the primary analysis demonstrated network inconsistency, conclusions were based on a sensitivity analysis that resolved inconsistency. Surgical offloading (RR 1.47), non-removable knee-high customized devices (RR 1.36), and non-removable knee-high prefabricated devices (RR 1.32) were superior to usual care. CONCLUSIONS: Surgical offloading and non-removable knee-high devices demonstrated the most robust effectiveness for DFU healing, supporting current guideline recommendations and the use of surgical offloading in selected patients. LEVEL OF EVIDENCE: Level I.