Eleven Resolutions For Preventing And Treating DFUs In 2011

David G. Armstrong DPM MD PhD

As we begin 2011, we all want to put together our list of resolutions to accomplish in the new year. Lee C. Rogers, DPM, suggested we do the same for the diabetic foot and even got things started with a few of his own.

We need your help though. Please post some of your suggestions for diabetic foot resolutions. We'll try to put together a list of resolutions that we'll post on our www.toeandflow.com blog, on my Facebook page or on my Twitter feed. We will periodically use these in our www.DFCon.com e-mail blasts (and at DFCon in March) to highlight and raise awareness about this oft neglected area of care.

My SALSA partner, Joe Mills, MD, went on a creative tear, defining 11 diabetic foot strategies, one for every letter in the word “resolutions.”

Resolve. Let us resolve to practice what we preach. Always identify and stratify risk, practice prevention and offer offloading.

Evaluate. Always evaluate Toe (deformity, sensation, pressure, shear, shoe gear) and Flow (ankle and toe pressures, Doppler waveforms, O2 tension).

Sample at surgery. Sample culture bacteria from the wound at the time of debridement. Do not perform surface cultures.

Offload. Do not forget to emphasize offloading, a simple solution, based on sound science.

LOPS (loss of protective sensation). Loss of the gift of pain is the underlying cause of diabetic foot ulcers (DFU). To ameliorate this Loss, providers must Offer Preventive Services. Remember, prevention will always trump technology.

Under the ulcer. Ulcers are like icebergs. Do not focus on the surface. Investigate what is under the ulcer, such as a bony prominence, soft tissue infection or abscess. Consider the underlying causes including neuropathy, bony prominence, infection, trauma and ischemia.

Team. Team care improves DFU outcomes and prevents amputations. Resolve that if you are part of a team, you will strive to improve it. If you are not part of a team, resolve to create one in your community or region.

Investigate. One should investigate, classify and treat infection and ischemia.

Ongoing care. Treating DFUs is never simple. Provide ongoing treatment until healing and practice prevention with an integrated team approach.

NPWT. Negative pressure wound therapy, bioengineered tissues and other advanced modalities are important adjuncts. I will consider advanced therapies if wound area reduction is less than 50 percent at four weeks or if specific reconstructive circumstances call for them immediately.

Sisyphus. A team of professionals, working together, can prevent amputation and reduce DFU recidivism.1 The task is made less daunting by teamwork rather than toiling heroically in isolation.

I believe the late Paul Brand, MD, taught us that, "If you ignore your feet, they will go away." Let us do our best to counter that. Send us your diabetic foot/amputation prevention resolutions.

Most importantly, Happy New Year to you and yours. Let us make it even happier and healthier than 2010.


1. Mills JL, Armstrong DG, Andros G. Rescuing Sisyphus: the team approach to amputation prevention. J Vasc Surg 2010; 52(3 Suppl):1S-2S.

This blog has been adapted with permission from previous blogs that originally appeared at www.diabeticfootonline.blogspot.com .


My suggestion is for everyone involved in diabetic foot care is to have a "the buck stops here" approach. Instead of referring a patient to some other provider for nail or callus care (which they may not follow through with or may take weeks), do the appropriate preventive care right there and then.

This may entail having a staff member properly trained in nail and callus care, such as a Certified Foot Care Nurse, and the proper equipment, particularly a podiatry drill. Providing the proper care, there and then, could very well prevent an ulcer and save a limb!

What is a Certified Foot Care Nurse and how do they practice? Do they carry their own malpractice or do they function under the doctor that employs them? Where do they train for this certification? I've never heard of them and am interested to learn.

Put Washington on that list.

I see they have cut back tremendously on reimbursement, especially with debridements and advanced therapies (Apligraf, Dermagraft, no longer coverage for Integra, PRP, etc).

In my area, the VA will not approve advanced wound management, only BKA and AKA.

How about adding oxygen to that. Let us resolve to get qualified wounds into a hyperbaric chamber as soon as possible. Also, lets us get HBO2 approved for ischemic limb ulcers for non-diabetic patients.

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