Current Concepts In Diabetic Foot Surgery

By Jarrett D. Cain, DPM, and Vickie R. Driver, DPM, MS

      Patients with diabetes can be a quite an undertaking for any physician who manages them on a consistent basis. In the past, this has created reservations when it comes to managing these patients especially from a surgical standpoint. However, over the years, with greater understanding of the disease, improvements in surgical techniques and emerging research, the reservations have diminished and the role of surgical management is a viable option when it comes to successfully treating those with diabetic ulcerations, infections and other related complications that exist in the foot and ankle.       It is important to note that the prevalence of diabetes is steadily increasing. Wild et al., have projected that the diabetic population could reach 366 million by 2030.1 The multisystem disease has been associated with numerous complications and can have a critical impact in the lower extremity. The presence of ulceration in the lower extremity is a significant complication among patients with diabetes. In a United Kingdom study of 1,150 patients with diabetes with a defined age and sex structure, Walters, et. al., showed the prevalence of past or present foot ulcerations was 7.4 percent.2       Diabetes continues to be the most common underlying cause of nontraumatic lower extremity amputations in the United States and Europe.3 This creates a secondary byproduct of the disease of diabetes. Direct costs for diabetic lower extremity amputations in the U.S. range from $22,700 for a toe amputation to $51,300 for an above-the-knee amputation in 2001 dollars.4       Men with diabetes are 1.4 to 2.7 times more likely than women with diabetes to require an amputation.5 It is well known that after undergoing amputation, 30 percent of patients lose their contralateral limbs within three years and after the amputation of a leg, approximately two-thirds of patients die within five years.6

Emphasizing The Value Of A Multidisciplinary Approach

      These statistics paint a realistic view of the impact of diabetes on the patients’ quality of life. However, careful management with a multidisciplinary team can produce very good results. In a five-year retrospective study, Driver, et. al., showed that even though the number of patients with the diagnosis of diabetes increased 48 percent, the number of amputations decreased 82 percent.7 This provides hope to physicians and patients in this area of management.       The goal of surgical offloading for the diabetic foot is designed to prevent the development of more advanced and debilitating conditions, and provide a stable plantigrade foot.8 These objectives require a multidisciplinary team approach to get the maximum results for the patient. Due to these patients’ complex nature and numerous comorbidities, a multidisciplinary team approach to management is recommended.       An ideal foot care team should include the following: a podiatric surgeon; a vascular surgeon; an infectious disease specialist; an endocrinologist, family practice or internal medicine physician; an orthopedic surgeon; a certified wound care nurse; an orthotist; and a certified diabetes educator (CDE). Numerous references from U.S. and European literature document improvements in patient outcomes including a reduction of lower-extremity amputation rates as a result of implementing a multidisciplinary approach to diabetic foot care.9-13 However, healthcare providers frequently work in situations without this level and variety of expertise. Accordingly, when it comes to patients with diabetes who develop a foot problem, these providers often need to refer these patients to specialists.

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