The Multidisciplinary Team Approach To The Diabetic Foot

As the international population of individuals with diabetes continues to increase rapidly, so does the need for a joint effort in patient care. Throughout the course of a lifetime, approximately one in four individuals with diabetes will experience foot ulcers, half of which will become infected and require hospitalization.^1,2  

Furthermore, 20 percent of individuals requiring hospitalization due to a wound infection will require amputation, which precedes a mortality rate higher than that of most malignant cancers.^1-4 Understanding the collinear relationship of uncontrolled diabetes, vascular compromise, foot deformity, diabetic foot infection and other comorbidities promotes an approach to treat the whole patient, not just the hole in the patient.

Appropriate and adept podiatric care is fundamental in the prevention, surgical intervention and postoperative management in patients with diabetic foot complications. Equally as critical as podiatrists are peer physicians who specialize in the management and treatment of concomitant or compounding disease states or conditions. A solution to the complexity of individuals with diabetic foot wounds is simple: a multidisciplinary team treatment approach to the diabetic foot.
    
Educating Primary Care Physicians On Diabetic Foot Assessment And Appropriate Referrals
All too often, the initial discussion with a patient with a diabetic foot wound is in the emergency department with the discussion being about acute surgical intervention. With a focus on getting ahead of the curve, we should consider the primary care physician as the fundamental gatekeeper when it comes to the diabetic foot. Since patients with diabetes progress toward complications that require specialized intervention, the primary care physician is in the prime position for early referrals for specialist care or direct intervention. Researchers have found, however, that primary care practitioners often have insufficient instruction in diabetic foot care and that regular and comprehensive foot exams on patients with diabetes occur infrequently in the office.^5-6

Specialists, including podiatrists, are in the forefront of the dissemination of information concerning their specialty with their physician peers. Methods to promote increased primary care physician participation in the multidisciplinary team approach include:

• sharing the three-minute foot exam and promoting its utility with every patient with diabetes;
• reviewing American Diabetes Association (ADA) guidelines for primary care physicians, including risk factors for foot ulcers and the ADA Comprehensive Foot Examination and Risk Assessment guidelines;
• creating collaborative risk assessment scores considering who would benefit from care and when to initiate referrals; and
• promoting the team approach in discussing when a patient should see other team members for specialized care.^7,8

Why A Vascular Specialist Is Invaluable In Diabetic Foot Care
The prevalence of low to high level peripheral arterial disease (PAD) in the diabetic population is between 10 and 40 percent.⁸ Recent estimates have also found that a component of peripheral arterial disease is a compounding factor for nearly 65 percent of all diabetic foot ulcerations.⁹ Apelqvist and colleagues reported that patients who have peripheral neuropathy and PAD have higher rates of reulceration, twice the amputation rate, and decreased overall physical function than those with peripheral neuropathy alone.¹⁰ Considering the elevated prevalence of PAD with the increase in diabetes prevalence, increased vascular intervention has been associated with decreased amputation rates in patients with diabetic foot wounds.^11,12

In February 2016, the Society for Vascular Surgery, along with the American Podiatric Medical Association (APMA) and the Society for Vascular Medicine, published recommendations concerning joint management of the diabetic foot.¹³ These recommendations outline the critical importance of vascular evaluation, treatment and monitoring. In addition to having a vascular specialist treat patients who present with limb ischemia and diabetic foot wounds, this joint team recommends including a vascular specialist in the treatment, surveillance and management of the diabetic foot. With this in mind, they recommend the following measures.

1. At the age of 50, all patients with diabetes should have ankle brachial index (ABI) testing. All patients with a prior diabetic foot ulcer and a history of or previous intervention for PAD or cardiovascular disease should have ABI tests with evaluation of toe pressures annually.
2. For all patients with diabetic foot ulcers, clinicians should annually assess pedal perfusion via ABI testing, foot and ankle Doppler arterial waveforms, and toe systolic or transcutaneous oxygen pressure testing.
3. Patients with a diabetic foot wound and PAD should have endovascular or surgical bypass therapy intervention.¹³

Not only can vascular specialists aid in identifying patients with PAD but they can also grade disease severity. All patients with known or suspected vascular compromise or disease should get referrals to a vascular specialist for evaluation.

In a team approach, using disease classification guidelines such as the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System provides clinicians with a unified grading tool for classifying diabetic foot wounds as well as a predicting mechanism to help identify those who will require intervention.^14,15

When A Consult With The Infectious Disease Specialist Is Necessary
Infection is the driving force toward amputation in diabetic foot wounds even in the presence of ischemia. Infectious disease specialists consider many factors when evaluating and prescribing treatment options. These factors include the patient’s overall state of health, wound history, nature of the ulceration and the introduction or onset of infection. An appropriately acquired deep tissue sample provides critical direction in the identification of infecting pathogens and associated susceptibility profile. Early consultation with an infectious disease specialist may provide insight to biopsy or tissue site preferences that optimally guide treatment toward infecting pathogens rather than contaminants.¹⁶ Finally, consider regional factors including resistance profiles for treatment centers in the overall treatment plan and outlook for each individual patient.

Researchers recommend that every podiatrist follow the Infectious Diseases Society of America (IDSA) published guidelines on the antibiotic treatment of diabetic foot infections.¹⁷ In many cases, these recommendations are sufficient for infection eradication. In other situations, such as when the infection is severe or polymicrobial, the patient has confounding factors or other infectious processes, or when the patient has failed courses of antibiotics, the infectious disease specialist should be actively involved.

What You Should Know About Plastic Surgery Referrals
In a less acute setting, the plastic surgeon provides a critical surgical expertise in covering exposed bone, advancing soft tissue, performing fat grafting and accomplishing optimal tissue relocation and replacement to protect and prevent further areas of soft tissue breakdown. We frequently refer patients to plastic surgery team members for advanced soft tissue manipulation surgeries with impressive and long-lasting results.

Furthermore, as the mean age of the diabetic population decreases, the physical changes secondary to surgical intervention for the control of diabetic foot infections may be increasingly emotionally and socially unappealing. Plastic surgeons are highly trained in restoring function as well as the anatomic contour of the extremities. This expertise may increase the quality of life of patients with personal or social concerns regarding postoperative appearances.

When To Consult The Orthotist Or Prosthetist
The ADA recommends accommodative shoe gear or insoles to all patients with peripheral neuropathy with or without deformity, those with PAD and neuropathy, and patients with a history of diabetic foot ulceration or amputation of any kind.¹⁸ The International Working Group on the Diabetic Foot recommends the incorporation of therapeutic shoes, custom-made insoles or orthoses whenever a foot deformity or pre-ulcerative sign is present. This same organization promotes pressure relieving footwear to decrease the risk of recurrent plantar ulcerations in the at-risk population.¹⁸ Concerning non-plantar diabetic foot ulcerations, researchers have found that improperly fitting shoes and other footwear are major contributing factors.¹⁹

The combination of proper biomechanical evaluation (including gait evaluation and casting for orthoses) with the fabrication of the devices used in the treatment and maintenance of the diabetic foot is extremely costly. The multidisciplinary approach to the diabetic foot should include specialists with state of the art equipment, the highest adherence to quality standards and comprehensive knowledge in the form, fit and function of diabetic shoe gear. The podiatrist should evaluate the diabetic shoe gear at each visit. If subsequent attention or modifications to the diabetic shoe gear are necessary and beyond one’s expertise, promptly refer patients to a orthotist or prosthetist for the appropriate alterations.

In Conclusion
Combining a multidisciplinary approach to the diabetic foot along with a systematic approach toward controlling ischemia, wound and foot infection will help identify the dominant risk during the lifetime of a patient’s care. Utilizing a simple system such as the Society for Vascular Surgery’s Lower Extremity Threatened Limb Classfication System provides “three intersecting rings of risk” that easily indicate treatment priority for the team’s consideration when treating the diabetic foot.¹⁵

The benefits of a multidisciplinary approach are wide and far reaching. The benefits include a focused approach to each patient’s particular need, the optimization of multifaceted management of the patient with diabetes and enhanced patient surveillance.²⁰ Researchers have shown that a coordinated care team approach decreases the frequency of limb loss in patients with diabetes worldwide.^21-23

When considering the makeup of the multidisciplinary treatment team, there is no established set of team members. Depending on each physician’s particular circumstance, whether he or she is a member of a large teaching facility or a rural community, several to only a few members may be requisite for multidisciplinary care. In fact, the only assumed requirements should be that the entire team is able to participate in the management of a patient need and that each physician anticipates and relays open and clear communication.

Dr. Hatch is a first-year resident within the Tucson Medical Center/Midwestern University residency program in podiatric medicine and surgery.

Dr. Armstrong is the Director of the Southern Arizona Limb Salvage Alliance and a Professor of Surgery at the University of Arizona Medical Center in Tucson, Ariz.

References

1. Singh N. Preventing foot ulcers in patients with diabetes. J Am Med Assoc. 2005; 293(2):217.
2. Lavery LA, Armstrong DG, Wunderlich RP, et al. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006; 29(6):1288-293.
3. Armstrong DG, Wrobel J, Robbins JM. Guest editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007; 4(4):286-87.
4. Armstrong DG, Mills JL. Toward a change in syntax in diabetic foot care. J Am Podiatr Med Assoc. 2013; 103(2):161-62.
5. Wylie-Rosett J. Assessment of documented foot examinations for patients with diabetes in inner-city primary care clinics. Arch Fam Med. 1995; 4(1):46-50.
6. Del Aguila MA, Reiber GE, Koepsell TD. How does provider and patient awareness of high-risk status for lower-extremity amputation influence foot-care practice? Diabetes Care. 1994; 17(9):1050-054.
7. Miller JD, Carter E, Shih J, et al. How to do a 3-minute diabetic foot exam. J Fam Pract. 2014; 63(11):646-9,653-6.
8. Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment. Endocrine Practice. 2008; 14(5):576-83.
9. Hinchliffe RJ, Andros G, Apelqvist J, Bakker K, Friederichs S, Lammer J, et al. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev. 2012; 28(Suppl 1):179-217.
10. Apelqvist J, Elgzyri T, Larsson J, et al. Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients. J Vasc Surg. 2011; 53(6):1582-8.
11. Li Y, Burrows NR, Gregg EW, et al. Declining Rates of hospitalization for nontraumatic lower-extremity amputation in the diabetic population aged 40 years or older: U.S., 1988-2008. Diabetes Care. 2012; 35(2):273-77.
12. Goodney PP, Holman K, Henke PK, et al. Regional intensity of vascular care and lower extremity amputation rates. J Vasc Surg. 2013; 57(6):1471-9.
13. Hingorani A, LaMuraglia GM, Henke P, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016; 63(2 Suppl):3S-21S.
14. Schaper NC, Andros G, Apelqvist J, et al. Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot. Diabetes Metab Res Rev. 2012; 28(Suppl 1):218-24.
15. Mills JL, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014; 59(1):220-34.
16. Sotto A, Richard JL, C, et al. Beneficial effects of implementing guidelines on microbiology and costs of infected diabetic foot ulcers. Diabetologia. 2010; 53(10):2249-255.
17. Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012; 54(12):e132-73.  
18. Bus SA, Armstrong DG, Van Deursen RW, et al. IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. Diabetes Metab Res Rev. 2016; 32(Suppl 1):25-36.
19. Apelqvist J, Larsson J, Agardh CD. The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers. J Diabetic Complications. 1990; 4(1):21-25.
20. Sumpio BE, Armstrong DG, Lavery LA, Andros G. The role of interdisciplinary team approach in the management of the diabetic foot. J Vasc Surg. 2010; 51(6):1504-506.
21. Tseng CL, Rajan M, Miller DR, et al. Trends in initial lower extremity amputation rates among veterans health administration health care system users from 2000 to 2004. Diabetes Care. 2011; 34(5):1157-163.
22. Larsson J, Stenström A, Apelqvist J, Agardh CD. Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach? Diabetic Medicine. 1995; 12(9):770-76.
23. Krishnan S, Nash F, Baker N, et al. Reduction in diabetic amputations over 11 years in a defined UK population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care. 2007; 31(1):99-101.

For further reading, see “Emphasizing The Multidisciplinary Approach To Diabetic Limb Salvage” in the November 2008 issue of Podiatry Today or “When Wounds Require Multidisciplinary Care” in the January 2005 issue.