Nadia Dembskey expands on the role of the podiatrist as well the multi-disciplinary team in avoiding amputation of the diabetic foot.

Lower limb ulceration

The podiatrist is a key member of the multi-disciplinary healthcare team involved in managing the diabetic foot and its complications. Lower limb ulceration is common throughout the world and poses a major threat to limb integrity.

Although trauma and cancer can result in amputations, most new amputations occur because of complications associated with diabetes; podiatrists are frequently managing these issues. Foot ulcers occur in up to 25% of patients with diabetes and precede more than 8 in 10 non-traumatic amputations. Nearly half of all patients who undergo amputation will develop limb-threatening ischemia in the other limb, and many will ultimately require an amputation of the opposite limb within five years.

Prevention

Preventing ulcerations and/or amputations is critical from both medical and economical standpoints. Foot assessments by podiatrists, to identify the high-risk foot, is aimed at preventing the serious complications of ulceration and amputation.

In addition, podiatric management involves individualised foot health education, management of non-ulcerative pathologies and ulcer care. The International Working Group on the Diabetic Foot (IWGDF) Consensus Guidelines is a useful tool to enable podiatrists to perform their multi-factorial role in diabetic foot care.

In South Africa, this role is hampered by a lack of resources in personnel and finance. A national plan for the management of the diabetic foot, based on evidence-based practice, is urgently needed to focus scarce podiatric skills on improving diabetic foot care.

Diabetic foot disease

The mechanisms underlying diabetic foot disease are multi-factorial and include neuropathy, infection, ischemia (reduced blood flow), and abnormal foot structure and biomechanics. It is, therefore, not surprising that the management of the diabetic foot is a complex clinical problem requiring a multi-disciplinary approach.

Although nerve injury (peripheral neuropathy) has a central role and is present in nearly all patients with diabetic foot lesions, vascular specialists maintain a critical management role since untreated insufficient blood flow to a limb will always result in a non-healing wound and possible amputation. Lack of arterial blood flow decreases tissue integrity, leads to rapid death of tissue, and prevents wound healing. As a rule, this generally requires an aggressive revascularisation strategy by vascular surgeons.

Podiatrists play key roles in the multi-disciplinary approach. Successful management of foot ulcers involves recognition and correction of the underlying cause as well as appropriate wound care and prevention of recurrence.

Off-loading strategies, such as total contact casting and removable walkers, have resulted in significant accelerations in healing times. Stresses placed upon the foot can be from the inside (bones/tissues) or the outside (footwear/injury/foreign bodies). Tight- or shallow-fitting shoes are a frequent and preventable component, which often leads to the development of ulcerations. It has been shown that, by utilising a variety of shoe modifications, it is possible to reduce foot pressures, thereby decreasing risk of ulceration.

Reconstructive foot surgery

Reconstructive foot surgery often becomes a conservative treatment to avoid major amputation and chronic wounds. The endpoints for chronic diabetic foot wounds include a decrease in the number of amputations, prevention of infection, decreased possibility of ulceration, maintenance of skin integrity, and improvement of function. Thus, an aggressive multi-disciplinary approach to foot disease should provide optimal medical and surgical care and improved outcomes.

Multi-disciplinary team

The presence of multiple practitioners caring for the same patient increases the opportunity for life-long follow-up observation of vascular and podiatric disease. Numerous centres around the world have reported significant reductions in amputations and ulcer reappearance when limb assessment protocols have been established and a multi-disciplinary team assembled. Many groups describe their team consisting of a vascular surgeon, a podiatrist, an orthopaedic surgeon, and an endocrinologist.

It is understandable that there are many barriers to forming a team and establishing the right support structure for it to become successful. This may be partly due to the fact that various levels of team involvement are required in caring for the needs of each individual patient.

Regardless, it is clear that limb preservation requires a series of steps including re-establishing adequate perfusion, serial wound debridements, appropriate wound coverage, aggressive infection management, and correction of underlying biomechanical abnormalities. At a minimum, vascular surgeons and podiatrists are essential components of the team.

Diabetic foot care checklist

Unfortunately, not all critical components of a multi-disciplinary team are available in either clinics, hospitals (public/private) or wound care facilities. Some individual physicians and surgeons with experience and training across a broad spectrum of disciplines may appropriately treat conditions in areas that lack dedicated limb preservation centres, but for complex cases, the preservation results will likely be substandard to the team approach. Therefore, there are certain critical elements on a diabetic foot care checklist that comprise an essential, professional skill set required of a diabetic foot care team:

1. Ability to perform blood flow assessment with revascularisation, as necessary.
2. Ability to perform biomechanical and podiatric assessment with surgical and non-surgical intervention, as necessary.
3. Ability to perform a nerve examination.
4. Ability to perform wound assessment and staging/grading of infection and lack/loss of blood flow.
5. Ability to perform site-specific bedside and intra-operative cutting and surgical/mechanical cleaning.
6. Ability to initiate and modify culture-specific and patient appropriate antibiotic therapy.
7. Ability to perform appropriate foot surveillance monitoring to evaluate the risk of a foot to develop diabetic problems.
8. Ability to reduce risk of re-ulceration and infection by various protective mechanisms.

Patients are not the only beneficiaries of a collaborative approach amongst specialists. The presence of a truly multi-disciplinary centre enables the hospital to efficiently link and coordinate a team of specialists to effectively manage patients with complex co-morbidities, in addition to their foot pathology. Patients can be assessed by a variety of specialists within a brief time period, resulting in a coordinated plan of care. The initial screening determines the priority by which disciplines need to be involved in each patient’s plan of care.

Conclusion

In summary, the multi-disciplinary team approach to diabetic foot issues is beneficial for patients and required for achieving optimal management and prevention of complications. Collectively, the multi-disciplinary team should direct its efforts toward restoring and maintaining an ulcer free lower extremity with functional limb salvage as the ultimate goal.

Collaboration amongst specialists should be extended to creation of consensus documents and structured educational programmes that emphasise the multi-disciplinary care of patients with diabetes.

Legislative advocacy to ensure adequate healthcare resources to support these guidelines will be more effective when multiple specialty groups are heard as one voice. It is with this level of inter-professional collaboration that we can realise the goal of reducing the unnecessarily high number of diabetes-related amputations in South Africa.

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