Emphasizing The Multidisciplinary Approach To Diabetic Limb Salvage

   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

   Obviously, no clear answers exist regarding which providers should be involved in this team approach or the extent of involvement provided by each member. 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.

Recognizing The Need For Appropriate Referral

Therefore, the specific needs of the patient and significance of the current medical condition dictate the necessity of each medical discipline and the degree of team involvement. Political bias and professional ego can often block necessary members from working to their full potential in the setting of a limb salvage team. These barriers are present to a lesser and lesser degree but remain in place nonetheless.

   When we obtain a thorough history and perform the physical examination, it is vital to review and question the presence of any existing medial conditions or comorbidities. In addition, one must properly assess neurovascular status, dermatological involvement, musculoskeletal deformities and the presence of infection. After compiling this information, team members can be properly engaged to aid in the realization of limb salvage.

   Depending upon the individual patient’s presentation, the patient’s lower extremity care may be provided solely by the podiatrist or there may be the need for referrals to vascular surgery, orthopedic surgery, plastic surgery, interventional radiology, internal medicine, endocrinology, infectious disease, nephrology and/or neurology. Beyond the physicians, it is vital to consider the involvement of a nutritionist, physical therapist, pedorthotist, prosthetist, nurse practitioner, wound care nurse, home health and/or certified diabetic educator in the team approach to diabetic limb salvage.

In Conclusion

Evaluation on an individual basis with quick recognition of the need for adjustment or assistance in the course of treatment is imperative to caring for these patients. Communication is crucial to the effectiveness and survival of this multidisciplinary team approach. Providers from the aforementioned disciplines may already be involved in the care of your patient but are all of you communicating as a team?

   Each team member must recognize the individual patient’s goal and convey the requirements needed to meet that goal in relation to each medical discipline. It is vital to strive for clear communication between each discipline. In addition, physicians must properly inform the patient and his or her family, and ensure a clear understanding of the treatment plan as a whole.

   Dr. Adams is a third-year resident of the INOVA Fairfax Podiatric Residency Program in Falls Church, Va.

   Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. Dr. Steinberg is a Fellow of the American College of Foot and Ankle Surgeons.

References:

1. Center for Disease Control and Prevention (CDC): National Diabetes Fact Sheet, United States, 2005. Available from https://apps.nccd.cdc.gov/ddtstrs/template/ndfs_2005.pdf Accessed December 4, 2007. 2. Driver VR, et al. Reducing Amputation Rates in Patients With Diabetes at a Military Medical Center. Diabetes Care. 28(2):248-53, 2005. 3. Brem H, et al. Evidence-based protocol for diabetic foot ulcers. Plast Reconstr Surg 117(7 Suppl):193S-209S, 2006. 4. Lipsky, BA et al. Diagnosis and treatment of diabetic foot infections. Plast Reconstr Surg 117(7 Suppl):212S-238S,2004. 5. Steed DL, et al. Organization and development of a university multidisciplinary wound care clinic. Surgery 114(4):775-8, 1993. 6. DeNamur C, et al. Diabetic Limb Salvage: A Team Approach at a Teaching Institution. J Am Podiatric Med Assoc 92(8):457-462, 2002. 7. Ierardi RP, et al. Control of vascular disease in patients with diabetes mellitus. Surg Clin North Am 78(3):385-92, 1998. 8. Strauss MB. The orthopaedic surgeon’s role in the treatment and prevention of diabetic foot wounds. Foot Ankle Int 26(1):5-14, 2005. 9. Sumpio BE, et al. The multidisciplinary approach to limb salvage. Acta Chir Belg 104(6):647-53, 2004. 10. Keyser JE. Foot wounds in diabetic patients. A comprehensive approach incorporating use of topical growth factors. Postgrad Med 91(4):98-102, 1992. 11. Holstein PE, et al. Limb salvage experience in a multidisciplinary diabetic foot unit. Diabetes Care 22(Suppl 2):B97-103, 1999. 12. Aksoy DY, et al. Change in the Amputation Profile in Diabetic Foot in a Tertiary Reference Center: Efficacy of Team Working. Exp Clin Endocrinol Diabetes 112(9):526-30, 2004. 13. Giurini JM, et al. Diabetic foot complications: diagnosis and management. Int J Low Extrem Wounds 4(3):171-82, 2005. 14. McDermott, JE. The diabetic foot: diagnosis and prevention. Instr Course Lect 42:117-20, 1993.