Emphasizing The Multidisciplinary Approach To Diabetic Limb Salvage

Melissa Adams, DPM, and John S. Steinberg, DPM

   The prevalence of individuals with diabetes continues to rise. The disease now affects nearly 24 million Americans or 7.8 percent of the population of the United States.1 Consequently, the demand for diabetic foot care continues to increase and this is exemplified by the one-year incidence of newly occurring ulcerations in patients with diabetes ranging from 1 to 2.6 percent. 2

   It is important to realize that foot ulcers occur in 12 to 25 percent of patients with diabetes and ulcers precede 84 percent of all non-traumatic amputations. 3 Greater than 60 percent of non-traumatic lower limb amputations occur in people with diabetes. 1

   Ulcerations are the major predisposing factor to lower extremity infection and peripheral neuropathy is the primary cause of ulcerations. Peripheral vascular disease and immunological disturbances are major influences on the healing potential of ulcerations. 4 As a result of these comorbidities and complications of diabetic foot wounds, there has been a renewed focus in recent years on establishing a multidisciplinary approach to limb salvage. A complex problem necessitates a comprehensive treatment approach.

   Many questions arise regarding this methodology and why a team approach may be advantageous. There are many barriers to forming a team and establishing the right support structure for it to become successful.

   While most practitioners have the capability to treat a simple wound or lower extremity infection, there are many reasons to consider a limb salvage team referral when the complexity of the patient’s condition demands it.

What The Literature Reveals

Evidence-based data is limited on the topic of a team approach to limb salvage. There are also many questions as to who would make up and lead this team. Yet many trade publications and a few journal articles document the benefit of a multidisciplinary approach for diabetic foot care. This literature states that the multidisciplinary team approach to wound care is: beneficial for patients; required for achieving optimal management; effective in prevention and treatment of the diabetic foot; and can provide for a significant increase in the chance of successful healing and prevention of wound recurrence. 5-10

   Holstein, et al., demonstrated the team approach success in avoiding major amputation in 80 percent of patients with limb-threatening ischemia and in approximately 95 percent of patients with infected foot ulcerations. 11 Driver, et al., confirmed the benefits of a focused multidisciplinary limb preservation team with an 82 percent decrease in the number of lower extremity amputations despite a 48 percent increase in patients diagnosed with diabetes from 1999 to 2003. 2 Similarly, Aksoy, et al., reported a relative decrease in the rate of major amputations with the implementation of a diabetic foot care team. 12

   Collectively, the multidisciplinary team should direct its efforts toward restoring and maintaining an ulcer-free lower extremity with functional limb salvage as the ultimate goal. 6,13

Which Specialists Should Comprise The Multidisciplinary Team?

Surprisingly, with all the emphasis on the need for a team approach to diabetic wound care and limb salvage, little attention has actually been directed to which medical disciplines should be involved with this team.

   Lipsky, et al., emphasize that the team should include an infectious disease specialist or medical microbiologist. 4 Others described the multidisciplinary approach consisting of a podiatrist, orthopedic surgeons, vascular surgeons, nurses, physical therapists, shoe technicians, orthotists and pedorthists. 14 Keyser clearly states that understanding the contributing causes to a diabetic foot wound is vital to the healing process and recommends consultations with vascular or orthopedic surgeons, diabetic education nurses, orthotists and pedorthists. 10

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