A multidisciplinary diabetic foot ulcer treatment programme significantly improved the outcome in patients with infected diabetic foot ulcers

Outcomes of Flap Reconstruction for Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis of Clinical Studies

BACKGROUND

People with diabetic foot ulcers (DFUs) are at risk of major amputation, which is associated with a high mortality rate (exceeding 50% at 5 years) and reduced quality of life. The authors hypothesized that flap reconstruction of DFUs improves patient outcomes in comparison with standard treatment modalities, including major amputation.

METHODS

MEDLINE, Embase, the Cochrane Library, and gray literature were searched on February 9, 2022. Comparative and single-arm studies reporting outcomes of DFUs treated with local, regional, or free flaps that included function, limb loss, mortality rates, and flap failure rates were included. Risk of bias was assessed, and meta-analysis of proportions was performed.

RESULTS

A total of 3878 records were retrieved, of which 45 met the inclusion criteria, including the records of 1681 patients who underwent flap reconstruction of DFUs. Free flaps were most commonly performed ( n = 1257 [72%]). Only one study used a verified functional outcome measure. At 12 months, the mortality rate was 6.35% (95% CI, 3.89% to 10.20%), the limb loss rate was 11.39% (95% CI, 7.02% to 17.96%), and the free flap failure rate was 9.95% (95% CI, 8.19% to 12.05%). All studies were at high risk of bias. A comparative meta-analysis of interventions was not performed because of study method and outcome heterogeneity.

CONCLUSIONS

There is short-term evidence that flap reconstruction (including microsurgical transfer) has low mortality, limb loss, and flap failure rates. However, there are limited high-quality comparative studies, and uncertainty remains regarding the outcome of DFU flap reconstruction in comparison to other treatments.

A Comparative Analysis of Patient-Reported Outcomes Following Free Tissue Transfer, Partial Foot Amputation, and Below-Knee Amputation in High-Risk Limb Salvage Patients

BACKGROUND

The surgical decision for limb-salvage with free tissue transfer (FTT), partial foot amputation (PFA), or below-knee amputation (BKA) for complex lower extremity (LE) wounds hinges on several factors, including patient choice and baseline function. However, patient-reported outcome measures (PROMs) on LE function, pain, and QoL for chronic LE wound interventions are limited. Thus, the study aim was to compare PROMs in patients who underwent FTT, PFA, or BKA for chronic LE wounds.

METHODS

PROMs were collected via QR code for all adult chronic LE wound patients who presented to a tertiary wound center between June 2022 and June 2023. A cross-sectional analysis of patients who underwent FTT, PFA, or BKA was conducted. The 12-Item Short Survey (SF-12), PROM Information System Pain Intensity (PROMIS-3a), and Lower Extremity Functional Scale (LEFS) were completed at 1, 3, and 6 months and 1, 3, and 5 years postoperatively. Patient demographics, comorbidities, preoperative characteristics, and amputation details were collected.

RESULTS

Of 200 survey sets, 71 (35.5%) underwent FTT, 51 (25.5%) underwent PFA, and 78 (39.0%) underwent BKA. Median postoperative time points of survey completion between FTT (6.2 months, IQR: 23.1), PFA (6.8 months, IQR: 15.5), and BKA (11.1 months, IQR: 21.3) patients were comparable (P = 0.8672). Most patients were male (n = 92, 76.0%) with an average age and body mass index (BMI) of 61.8 ± 12.6 years and 30.3 ± 7.0 kg/m2, respectively. Comorbidities for FTT, PFA, and BKA patients included diabetes mellitus (DM; 60.6% vs 84.2% vs 69.2%; P = 0.165), peripheral vascular disease (PVD; 48.5% vs 47.4% vs 42.3%; P = 0.790), and chronic kidney disease (CKD; 12.1% vs 42.1% vs 30.8%; P = 0.084). No significant differences were observed between FTT, PFA, and BKA patients in mean overall PROMIS-3a T-scores (49.6 ± 14.8 vs 54.2 ± 11.8 vs 49.6 ± 13.7; P = 0.098), LEFS scores (37.5 ± 18.0 vs 34.6 ± 18.3 vs 38.5 ± 19.4; P = 0.457), or SF-12 scores (29.6 ± 4.1 vs 29.5 ± 2.9 vs 29.0 ± 4.0; P = 0.298).

CONCLUSION

Patients receiving FTT, PFA, or BKA for chronic LE wounds achieve comparable levels of LE function, pain, and QoL postoperatively. Patient-centered functionally based surgical management for chronic LE wounds using interdisciplinary care, preoperative medical optimization, and proper patient selection optimizes postoperative PROMs.

Health professionals involved in diabetic foot and their tasks in a country without podiatrists: From a Japanese Nationwide Survey

Although there are no podiatrists in 85% of countries worldwide, how diabetic foot is managed in those countries is still unknown. We sought to identify the health professionals involved in diabetic foot and their tasks in Japan, where no podiatrists exist. This cross-sectional study used the Japanese Nationwide Survey on Foot Ulcer Management dataset, consisting of 249 medical doctors and 680 allied health professionals. The types of health professionals involved in the diabetic foot were identified, and the tasks performed by each professional were compared within subgroups (medical doctors and allied health professionals). We found that the primary medical doctors involved in diabetic foot care in Japan were plastic surgeons (33.5%), dermatologists (21%), cardiovascular/vascular surgeons (15.2%), and cardiologists (12.1%). Nurses were the main allied health professionals (80%), and the rest consisted of prosthetists/orthotists (7.6%), physical/occupational therapists (5.9%), and clinical engineering technologists (3.6%). Medical doctors performed tasks related to their specialties significantly more than others (p < 0.001); however, they also engaged in tasks outside of their specialty, such as plastic surgeons performing preventive foot care (72%). Among allied health professionals, clinical engineering technologists performed more vascular assessments (p < 0.001), and half were engaged in wound management, preventive foot care, and self-foot care education. In conclusion, the type and proportion of health professionals in our study differed from those in countries with podiatrists, and many performed tasks outside their specialties. This is the first nationwide cross-sectional study of diabetic foot care in a country without podiatrists and is unique in examining multiple specialists/professionals in one study.

Prevalence of extra-articular tibia valga morphology in valgus knees and its implications for primary total knee arthroplasty

INTRODUCTION

Tibia valga, an extra-articular valgus deformity of the tibia, is common in valgus knees and can result in component misplacement and early total knee arthroplasty (TKA) failure. However, the prevalence and importance of tibia valga in TKA have been seldom reported. This study aims to describe the prevalence and characteristics of tibia valga morphology in valgus knees and describe implications for surgical planning in primary TKA.

METHODS

We prospectively examined pre-operative weightbearing whole-body EOS digital radiographs of patients with knee osteoarthritis listed for TKA between December 2018 and December 2020. Hip-knee-ankle angle (HKA), mechanical lateral distal femoral angle (mLDFA), mechanical medial proximal tibial angle (mMPTA), joint line convergence angle (JLCA) and tibial morphology with centre of rotation of angulation of tibia (CORA-tibia) were measured and analysed.

RESULTS

In 830 knees, 253 (30%) and 577 (70%) were classified as valgus and varus, respectively. In valgus knees, 89 knees (35%) had tibia valga. Median CORA-tibia was 2.8° (range 0.2°-10.9°). Tibia valga knees had no difference in mLDFA, higher HKA (5.0^o versus 3.0°, p = 0.002) and mMPTA (89.6° versus 88.1°, p < 0.01), and lower JLCA (2.1° versus 2.3°, p < 0.01) compared to non-tibia valga knees. Tibia valga deformity was weakly positively correlated with valgus HKA (ρ = 0.23, p < 0.001) and mMPTA (ρ = 0.38, p < 0.001). In varus knees, there were 52 cases of tibia valga (9%) with median CORA-tibia of 3.0° (range 0.5°-5.5°). Tibia valga knees had higher mMPTA (87.0° versus 85.2°, p < 0.05) and no difference in HKA, mLDFA and JLCA. CORA-tibia was weakly positively correlated with mMPTA.

CONCLUSIONS

Valgus knees may have an extra-articular deformity of the tibia which might be the primary contributor of the overall valgus HKA deformity rather than the distal femoral anatomy. To detect the deformity, full leg-length radiographs should be acquired pre-operatively. Intramedullary instrumentation should be used cautiously in knees with tibia valga when performing TKA.

[Clinical application of microdissected thin thoracodorsal artery perforator flaps for repair of diabetic foot ulcers]

Objective

To explore the effectiveness of microdissected thin thoracodorsal arterial perforator flap (TDAP) in repairing diabetic foot ulcers (DFUs).

Methods

The clinical data of 11 patients with DFUs admitted between March 2020 and February 2021 were retrospectively analyzed, including 5 males and 6 females, aged from 22 to 67 years, with an average of 49.3 years. There were 10 cases of type 2 diabetes and 1 case of type 1 diabetes; the duration of diabetes ranged from 3 months to 25 years (median, 8 months). The duration of DFUs ranged from 6 days to 120 months (median, 1 month). There were 6 cases of grade 3 and 5 cases of grade 4 according to Wagner classification. The tissue necrosis and purulent secretions were found in all ulcer wounds, as well as different degrees of tendon and bone exposure; skin defects ranged from 5 cm×3 cm to 17 cm×6 cm. The DFUs were repaired by microdissected thin TDAP, including 6 cases of flaps (including 1 case of lobulated flap), ranging from 10.0 cm×4.5 cm to 26.0 cm×7.0 cm; 5 cases of chimeric perforator flaps, the range of the flap was 10.0 cm×4.5 cm to 16.0 cm×5.5 cm, and the range of the muscle flap was 6 cm×2 cm to 10 cm×3 cm. The donor site was sutured directly.

Results

The operation time ranged from 3.42 to 11.17 hours, with an average of 5.92 hours. All 11 flaps survived and no vascular crisis occurred; 1 patient had a sinus at the edge of the flap, and the surgical area healed well after dressing change. All 11 patients were followed up 6-12 months, with an average of 9 months. The flap texture was good, the recipient site was in good shape, and there was no swelling; the foot contour was good, the shoes were comfortable to wear, and the movement was good. The incision at the donor site healed by first intention, leaving only linear and concealed scar, without obvious depression deformity, and the shoulder joint function was good.

Conclusion

On the premise of ensuring sufficient blood supply to the lower extremities and strengthening perioperative management, the microdissected thin TDAP to repair DFUs wounds can achieve better effectiveness and appearance; however, the prolonged operation time increases the probability of anesthesia and surgical risks in patients with DFUs.

Can Clinical Outcomes Be Improved, and Inpatient Length of Stay Reduced for Adults With Diabetes? A Systematic Review

Aim

To examine the efficacy of clinical practice strategies in improving clinical outcomes and reducing length of hospital stay for inpatients with Type 1 and Type 2 diabetes.

Background

People living with diabetes are at increased risk of being admitted to hospital and to stay in hospital longer than those who do not have the condition. Diabetes and its complications cause substantial economic loss to those living with the condition, their families, to health systems and national economies through direct medical costs and loss of work and wages. Length of stay is a major factor driving up hospitalisation costs relating to those with Type 1 and Type 2 diabetes with suboptimal blood glucose management, hypoglycaemia, hyperglycaemia, and co-morbidities shown to considerably impact upon length of stay. The identification of attainable evidence-based clinical practice strategies is necessary to inform the knowledge base and identify service improvement opportunities that could lead to improved clinical outcomes for these patients.

Study Design

A systematic review and narrative synthesis.

Methods

A systematic search of CINAHL, Medline Ovid, and Web of Science databases was carried out to identify research papers reporting on interventions that have reduced length of hospital stay for inpatients living with diabetes for the period 2010-2021. Selected papers were reviewed, and relevant data extracted by three authors. Eighteen empirical studies were included.

Results

Eighteen studies spanned the themes of clinical management innovations, clinical education programmes, multidisciplinary collaborative care and technology facilitated monitoring. The studies demonstrated improvements in healthcare outcomes such as glycaemic control, greater confidence with insulin administration and reduced occurrences of hypoglycaemia and hyperglycaemia and decreased length of hospital stay and healthcare costs.

Conclusions

The clinical practice strategies identified in this review contribute to the evidence base for inpatient care and treatment outcomes. The implementation of evidence-based research can improve clinical practice and show that appropriate management can enhance clinical outcomes for the inpatient with diabetes, potentially leading to reductions in length of stay. Investment in and commissioning of practices that have the potential to afford clinical benefits and reduce length of hospital stay could influence the future of diabetes care.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=204825, identifier 204825.

Building a Center for Abdominal Core Health: The Importance of a Holistic Multidisciplinary Approach

BACKGROUND

This article seeks to be a collection of evidence and experience-based information for health care providers around the country and world looking to build or improve an abdominal core health center. Abdominal core health has proven to be a chronic condition despite advancements in surgical technique, technology, and equipment. The need for a holistic approach has been discussed and thought to be necessary to improve the care of this complex patient population.

METHODS

Literature relevant to the key aspects of building an abdominal core health center was thoroughly reviewed by multiple members of our abdominal core health center. This information was combined with our authors' experiences to gather relevant information for those looking to build or improve a holistic abdominal core health center.

RESULTS

An abundance of publications have been combined with multiple members of our abdominal core health centers members experience's culminating in a wide breadth of information relevant to those looking to build or improve a holistic abdominal core health center.

CONCLUSIONS

Evidence- and experience-based information has been collected to assist those looking to build or grow an abdominal core health center.

Lower extremity reamputation in people with diabetes: a systematic review and meta-analysis

In this study, we determined the reamputation-free survival to both limbs and to the contralateral limb only following an index amputation of any-level and assessed whether reamputation rates have changed over time. We completed a systematic search using PubMed and screened a total of 205 articles for data on reamputation rates. We reported qualitative characteristics of 56 studies that included data on reamputation rates and completed a meta-analysis on 22 of the studies which enrolled exclusively participants with diabetes. The random-effects meta-analysis fit a parametric survival distribution to the data for reamputations to both limbs and to the contralateral limb only. We assessed whether there was a temporal trend in the reamputation rate using the Mann-Kendall test. Incidence rates were high for reamputation to both limbs and to the contralateral limb only. At 1 year, the reamputation rate for all contralateral and ipsilateral reamputations was found to be 19% (IQR=5.1%-31.6%), and at 5 years, it was found to be 37.1% (IQR=27.0%-47.2%). The contralateral reamputation rate at 5 years was found to be 20.5% (IQR=13.3%-27.2%). We found no evidence of a trend in the reamputation rates over more than two decades of literature analyzed. The incidence of lower extremity reamputation is high among patients with diabetes who have undergone initial amputations secondary to diabetes, and rates of reamputation have not changed over at least two decades.

A systematic review with meta-analysis of the impact of access and quality of diabetic foot care delivery in preventing lower extremity amputation

AIMS

To assess the impact of diabetic foot care delivery in preventing lower extremity amputation (LEA).

METHODS

We systematically searched the MEDLINE database for research evaluating the association between any aspect of diabetic foot care delivery and risk of LEA. Meta-analysis was conducted by calculating a pooled odds ratio through a random effects model.

RESULTS

Our search retrieved 5093 articles. In total, 58 articles were included: 9 addressing healthcare access, 4 educating health professionals, 2 implementing guidelines, 6 receiving chiropody/podiatry care services and 37 implementing structured diabetic foot care services (SDFC). All of these aspects of diabetic foot care seemed to have a positive impact on preventing LEA. Only SDFC literature met criteria for performing a meta-analysis. For SDFC impact on preventing overall and major LEA but not for minor LEA compelling evidence was observed [aggregated odds ratio (OR) of 0.45 (95% CI 0.37-0.57), 0.40 (95% CI 0.32-0.51), and 0.87 (95% CI 0.67-1.14), respectively]. However, high heterogeneity (superior to 60%) was observed for all outcomes.

CONCLUSIONS

Results support a reduction in diabetic LEA frequency in association with structured diabetic foot care, and, in particular, major LEA. Less evidence is available for the remaining aspects of diabetic foot care delivery.

Regional health care services and rates of lower extremity amputation related to diabetes and peripheral artery disease: an ecological study

BACKGROUND

The care necessary to prevent amputation from diabetes and peripheral artery disease (PAD) remains disjointed in many jurisdictions. To help inform integrated regional care, this study explores the correlation between regional health care services and rates of lower extremity amputation.

METHODS

This ecological study included 14 administrative health regions in Ontario, Canada. All diabetes- or PAD-related major (above ankle) amputations (Apr. 1, 2007, to Mar. 31, 2017) were identified among residents 40 years of age and older. For each region, age-and sex-adjusted amputation rates were calculated as well as per capita counts of key health providers (podiatrists and chiropodists, as well as surgeons) and health care utilization among study patients in the year before the first major amputation (physician visits, publicly funded podiatry visits, emergency department visits, hospital admissions, home care nursing, minor amputation, limb revascularization).

RESULTS

A total of 11 658 patients with major amputation were identified (of whom 79.2% had diabetes and 96.5% had PAD). There was wide regional variation in amputation rates: 2.53 to 11.77 per 100 000 person-quarters. At a regional level, the proportion of study patients who received revascularization showed the strongest negative correlation with amputation rates. The regional proportion of study patients who saw a vascular surgeon showed the strongest negative correlation with amputation rates, relative to other health provider visits. Other measures of health care utilization among patients correlated poorly with regional amputation rates, as did the regional provider counts. The results were similar when we restricted the analysis to diabetes-related amputations.

INTERPRETATION

Amputation rates related to diabetes and PAD vary widely across Ontario. Access to vascular assessment and revascularization must be integrated into regional amputation prevention efforts.

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee

BACKGROUND

Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD.

OBJECTIVES

The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD.

METHODOLOGY

A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique.

RESULTS

A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.

A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers

OBJECTIVE

Multiple single-center studies have reported significant reductions in major amputations among patients with diabetic foot ulcers after initiation of multidisciplinary teams. The purpose of this study was to assess the association between multidisciplinary teams (ie, two or more types of clinicians working together) and the risk of major amputation and to compile descriptions of these diverse teams.

METHODS

We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials from inception through May 24, 2019 for studies reporting the association between multidisciplinary teams and major amputation rates for patients with diabetic foot ulcers. We included original studies if ≥50% of the patients seen by the multidisciplinary team had diabetes, they included a control group, and they reported the effect of a multidisciplinary team on major amputation rates. Studies were excluded if they were non-English language, abstracts only, or unpublished. We used the five-domain Systems Engineering Initiative for Patient Safety Model to describe team composition and function and summarized changes in major amputation rates associated with multidisciplinary team care. A meta-analysis was not performed because of heterogeneity across studies, their observational designs, and the potential for uncontrolled confounding (PROSPERO No. 2017: CRD42017067915).

RESULTS

We included 33 studies, none of which were randomized trials. Multidisciplinary team composition and functions were highly diverse. However, four elements were common across teams: teams were composed of medical and surgical disciplines; larger teams benefitted from having a "captain" and a nuclear and ancillary team member structure; clear referral pathways and care algorithms supported timely, comprehensive care; and multidisciplinary teams addressed four key tasks: glycemic control, local wound management, vascular disease, and infection. Ninety-four percent (31/33) of studies reported a reduction in major amputations after institution of a multidisciplinary team.

CONCLUSIONS

Multidisciplinary team composition was variable but reduced major amputations in 94% of studies. Teams consistently addressed glycemic control, local wound management, vascular disease, and infection in a timely and coordinated manner to reduce major amputation for patients with diabetic foot ulcerations. Care algorithms and referral pathways were key tools to their success.

Regional differences in cell-mediated immunity in people with diabetic peripheral neuropathy

AIM

To study cell-mediated immunity in the feet of people with type 2 diabetes with polyneuropathy.

METHODS

In a cohort comprising people with type 2 diabetes with polyneuropathy (n = 17) and without polyneuropathy (n = 12) and a healthy control group (n = 12) indurations due to delayed-type hypersensitivity responses to intracutaneous Candida albicans antigen were determined in the foot and compared with those in the arm (an area relatively spared in diabetic polyneuropathy). The sizes of indurations on the foot were correlated with electromyographic measurements in the participants with diabetes.

RESULTS

No differences were observed in the median size of indurations between the foot and arm in healthy controls and participants without polyneuropathy; in participants with polyneuropathy, induration sizes on the foot were smaller than on the arm: 0 (95% CI 0 to 1) vs 5 (95% CI 2 to 6) mm (P < 0.01). In participants with diabetes, larger indurations correlated with better nerve function (Spearman's rho 0.35 to 0.39).

CONCLUSION

Our findings suggest that diabetic peripheral polyneuropathy negatively affects cell-mediated immunity in the foot. (Clinical Trials registry no.: NCT01370837).

Short-term predictors of amputation in patients with diabetic foot ulcers

BACKGROUND

Diabetic foot ulcers are the leading cause of non-traumatic lower extremity amputation. The aim of this study was to establish short-term predictors of lower extremity amputation (LEA) in patients with diabetic foot ulcers (DFU).

METHODS

A retrospective observational study was performed. Patients observed for the first time in a multidisciplinary outpatient diabetic foot clinic during 1-year were reviewed. We examined demographic and clinical data and the occurrence of LEA within 180 days. Bivariate descriptive analysis was performed and three logistic regression models were created to predict short-term LEA.

RESULTS

During 1-year 613 patients were observed for the first time in our diabetic foot clinic. Relevant data and eligibility was available from 479 patients with DFU; 38.41%, 40,71% and 20,88% had neuropathic, neuroischemic and ischemic ulcers, respectively. Considering a follow-up of 180 days, amputation occurred in 10.02% (n = 48) of patients: 3.13% (n = 15) major amputation and 6.89% (n = 33) minor amputation. Independent predictors of short-term LEA included moderate to severe infection [OR 5.23 (IC 95% 2.51-10.80; p < 0.001)], previous history of LEA [OR 3.93 (IC 95% 1.81-8.53; p = 0.001)], peripheral arterial disease [OR 3.51 (IC 95% 1.29-9.58; p = 0.014)] and presence of any walking disability [OR 3.35 (IC 95% 1.58-7.13; p = 0.002)].

CONCLUSION

In DFU patients the risk of LEA at 180 days is associated to moderate to severe infection at the initial presentation, previous history of LEA, peripheral arterial disease and presence of any walking disability. To prevent future amputations these patients should be identified early and managed by a multidisciplinary team.

LEVEL OF CLINICAL EVIDENCE

Level 2.

General practitioners' perceptions of their role and their collaboration with district nurses in wound care

Aim

To explore the perceptions of general practitioners (GPs) regarding their role and their collaboration with district nurses (DNs) in the management of leg ulcers in primary healthcare.

Background

Earlier research regarding the treatment of leg ulcers in a primary care context has focussed primarily on wound healing. Less is known about GPs’ understandings of their role and their collaboration with DNs in the management of leg ulcers. Since the structured care of patients with leg ulcers involving both GP and DN is currently rather uncommon in Swedish primary care, this study sets out to highlight these aspects from the GP’s perspective.

Methods

Semi-structured individual interviews with 16 GPs including both private and county council run healthcare centres. Thematic analysis was used to analyse the data.

Results

Four themes were identified. The first theme: ‘role as consultant and coordinator’ shows how the GPs perceived their role in wound care. In the second theme: ‘responsibility for diagnosis’ the GPs’ views on responsibility for wound diagnosis is presented. The third theme: ‘desire for continuity’ is based on the GPs’ desire for continuity concerning various aspects. In the fourth theme: ‘collaboration within the organisation’ the importance of the organisation for collaboration between GPs and DNs is presented.

Conclusions

The GP’s often work on a consultation-like basis and feel that they become involved late in the patients’ wound treatment. This can have negative consequences for the medical diagnosis and, thereby, lead to a prolonged healing time for the patient. Shortcomings regarding collaboration are mainly attributed to organisational factors.

Fighting diabetic foot ulcers-The diabetologist: A king maker of the fight

Diabetic foot ulcer is a costly and serious complication of diabetes mellitus and is the major cause of non-traumatic limb amputations worldwide. Its development is primarily the result of diabetic neuropathy and/or peripheral arterial disease with accompanied bone abnormalities and is complicated by invasive infection. The management of this clinical condition focuses on identification of the "at-risk" foot, treatment of the ulcerated foot, and prevention of further complications. As diabetic foot ulcer represents the sum of multiple etiologies, its treatment requires a multidisciplinary team, which can result in a significant reduction in the incidence of ulcers, infections and amputations. The team should include a diabetologist, a podiatrist, an orthoptist, an educator and a plaster technician, in close collaboration with a vascular surgeon, an orthopedic/podiatric surgeon and a dermatologist. It is recommended that a diabetologist be the multidisciplinary team leader, as diabetic foot ulcer is a complication of diabetes and chronic hyperglycemia represents the main cause for its development. The appropriate composition of professionals involved in the team is institution-dependent and may vary worldwide, depending on the diabetic population. The concept of establishing a diabetic foot care team is recommended by all National and International Diabetes Scientific Societies and Associations.

Effectiveness of Total Contact Orthosis for Plantar Pressure Redistribution in Neuropathic Diabetic Patients During Different Walking Activities

BACKGROUND

Using a total contact orthosis (TCO) is an effective method to offload in diabetic patients with foot neuropathy. However, the redistribution of peak plantar pressure is mostly observed during level walking, which may differ from other walking activities. The aim of this study was to investigate the plantar pressure from 4 regions of the foot during different walking activities (level walking, ramp ascending, ramp descending, stair ascending, and stair descending) in neuropathic diabetic patients with and without a TCO.

METHODS

Sixteen neuropathic diabetic patients aged 40 to 60 years with calluses and hallux valgus were included in this study and were provided with TCOs made up of multifoam, Plastazote, and microcellular rubber. The plantar pressure and contact area with the TCO and without the TCO were recorded using the Pedar X system during different walking activities.

RESULTS

A significant reduction of plantar pressure during different walking activities at the toes and forefoot regions was observed while walking with the TCO compared with walking without the TCO (control condition). Plantar pressure increased at the midfoot region when walking with the TCO, and no significant difference was observed at the hindfoot region between the control and TCO conditions. Furthermore, maximum contact area was observed during level walking with the TCO compared with other walking activities.

CONCLUSION

The TCO significantly reduced and redistributed the peak plantar pressure from the sites where the ulceration rate is higher at the toes and forefoot compared with the other regions of the foot.

LEVEL OF EVIDENCE

Therapeutic level II, lesser quality randomized controlled trial.

The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers: a systematic review

OBJECTIVE

To assess the impact of the multidisciplinary team in the management of the diabetic foot compared with those who did not receive multidisciplinary care.

METHOD

A systematic review of the literature was conducted using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Embase and Cochrane Library. The following search terms were used: diabetic foot, multidisciplinary team, patient care team, multidisciplinary care team. Data were extracted using a bespoke data extraction tool and quality appraisal of the studies was undertaken using the EBL Critical Appraisal checklist. Data analysis was undertaken using RevMan with results presented as odds ratio for dichotomous data, or mean difference for continuous data, all with the associated 95% confidence intervals.

RESULTS

The search identified 19 eligible studies. Severity of amputation, death rates and length of hospital stay of clients receiving multidisciplinary team care were improved when compared with those who did not receive multidisciplinary team care. Ulcer healing and quality of life showed an improvement but not all studies explored these outcomes. Only 7 of the 19 articles appraised were found to be of acceptable quality, questioning the generalisability of the results.

CONCLUSION

From the currently available evidence a positive impact of the multidisciplinary team on diabetic foot outcomes can be seen, but due to the lack of high-quality evidence and substantial heterogeneity in the studies, these results should be interpreted with caution.

Building a Multidisciplinary Hospital-Based Wound Care Center: Nuts and Bolts

BACKGROUND

A hospital-based wound care center provides an important platform for the multidisciplinary approach to wound care. The colocation of specialists is an ideal working environment for the efficient delivery of quality care of the complex wound through daily communication and shared resources.

METHODS

We describe the critical components necessary in building a hospital-based wound care center. Furthermore, the experience at the authors' institution in developing the multidisciplinary approach is discussed.

RESULTS

Readily available ancillary services, specially trained personnel, continuum of care from the outpatient clinic to admission to surgery, and inpatient and outpatient post operative care all contribute to a process that is especially amenable to the care of the complex wound.

CONCLUSIONS

The final goal is to return the patient to the best quality of life achievable given his or her wound or disability. The aim of this study is to present the authors' experiences and provide insight for others who may want to build this model within their institutions.

Intensive versus conventional glycaemic control for treating diabetic foot ulcers

BACKGROUND

The estimated likelihood of lower limb amputation is 10 to 30 times higher amongst people with diabetes compared to those without diabetes. Of all non-traumatic amputations in people with diabetes, 85% are preceded by a foot ulcer. Foot ulceration associated with diabetes (diabetic foot ulcers) is caused by the interplay of several factors, most notably diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD) and changes in foot structure. These factors have been linked to chronic hyperglycaemia (high levels of glucose in the blood) and the altered metabolic state of diabetes. Control of hyperglycaemia may be important in the healing of ulcers.

OBJECTIVES

To assess the effects of intensive glycaemic control compared to conventional control on the outcome of foot ulcers in people with type 1 and type 2 diabetes.

SEARCH METHODS

In December 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; Elsevier SCOPUS; ISI Web of Knowledge Web of Science; BioMed Central and LILACS. We also searched clinical trial databases, pharmaceutical trial databases and current international and national clinical guidelines on diabetes foot management for relevant published, non-published, ongoing and terminated clinical trials. There were no restrictions based on language or date of publication or study setting.

SELECTION CRITERIA

Published, unpublished and ongoing randomised controlled trials (RCTs) were considered for inclusion where they investigated the effects of intensive glycaemic control on the outcome of active foot ulcers in people with diabetes. Non randomised and quasi-randomised trials were excluded. In order to be included the trial had to have: 1) attempted to maintain or control blood glucose levels and measured changes in markers of glycaemic control (HbA1c or fasting, random, mean, home capillary or urine glucose), and 2) documented the effect of these interventions on active foot ulcer outcomes. Glycaemic interventions included subcutaneous insulin administration, continuous insulin infusion, oral anti-diabetes agents, lifestyle interventions or a combination of these interventions. The definition of the interventional (intensive) group was that it should have a lower glycaemic target than the comparison (conventional) group.

DATA COLLECTION AND ANALYSIS

All review authors independently evaluated the papers identified by the search strategy against the inclusion criteria. Two review authors then independently reviewed all potential full-text articles and trials registry results for inclusion.

MAIN RESULTS

We only identified one trial that met the inclusion criteria but this trial did not have any results so we could not perform the planned subgroup and sensitivity analyses in the absence of data. Two ongoing trials were identified which may provide data for analyses in a later version of this review. The completion date of these trials is currently unknown.

AUTHORS' CONCLUSIONS

The current review failed to find any completed randomised clinical trials with results. Therefore we are unable to conclude whether intensive glycaemic control when compared to conventional glycaemic control has a positive or detrimental effect on the treatment of foot ulcers in people with diabetes. Previous evidence has however highlighted a reduction in risk of limb amputation (from various causes) in people with type 2 diabetes with intensive glycaemic control. Whether this applies to people with foot ulcers in particular is unknown. The exact role that intensive glycaemic control has in treating foot ulcers in multidisciplinary care (alongside other interventions targeted at treating foot ulcers) requires further investigation.

What's new in the literature: an update of new research since the original WHS diabetic foot ulcer guidelines in 2006

The objective of the paper was to update the diabetic foot ulcer guidelines that were previously published in 2006. We performed a key word search using MEDLINE and Cochrane reviews for publication between January 2006 and January 2012. Articles that fit the inclusion criteria were reviewed and the previous guidelines were updated.

Subsequent ischemic events associated with lower extremity amputations in patients with type 2 diabetes: a population-based cohort study

AIMS

To explore the risk of subsequent ischemic events in type 2 diabetes mellitus (DM) patients who had lower extremity amputations (LEAs) were compared with DM patients without LEAs.

METHODS

A population-based cohort study was conducted utilizing the data of 2011 patients with newly diagnosed DM with and without LEAs sourced from the Longitudinal Health Insurance Database 2000 (LHID 2000) of the Taiwan National Health Insurance (NHI) program between 1996 and 2008.

MAIN OUTCOME MEASURES

Relative risks (RRs), hazard ratios (HRs), and disease-free rates for various ischemic events.

RESULTS

In contrast with the comparison group, subjects with LEAs were more likely to reside in less urbanized areas, be white collar workers, and have higher DM-related costs (p<0.05). Subjects with LEAs also had significantly higher risks of developing ischemic diseases, except intestinal ischemia. In the multivariate Cox proportional hazards regression model analysis, the HR of end-stage renal disease (ESRD) was highest (HR=3.91, 95% CI=2.38-6.42), followed by embolism and thrombosis (HR=3.47, 95% CI=2.12-5.67), other peripheral vascular diseases (HR=3.11, 95% CI=2.11-4.57), atherosclerosis (HR=2.64, 95% CI=1.60-4.35), retinopathy (HR=2.24, 95% CI=1.79-2.80), cerebral ischemia (HR=1.61, 95% CI=1.25-2.06), and coronary artery disease (HR=1.44, 95% CI=1.18-1.74).

CONCLUSIONS

DM patients with LEAs had significantly higher risks for subsequent ischemic events, particularly among men. The greatest risk detected among DM patients with LEA's was for end-stage renal disease. Disease free survival rates also indicated that the course of generalized DM ischemia proceeded despite treatment.

Predictive factors for successful limb salvage surgery in diabetic foot patients

Background

The goal of salvage surgery in the diabetic foot is maximal preservation of the limb, but it is also important to resect unviable tissue sufficiently to avoid reamputation. This study aims to provide information on determining the optimal amputation level that allows preservation of as much limb length as possible without the risk of further reamputation by analyzing several predictive factors.

Methods

Between April 2004 and July 2013, 154 patients underwent limb salvage surgery for distal diabetic foot gangrene. According to the final level of amputation, the patients were divided into two groups: Patients with primary success of the limb salvage, and patients that failed to heal after the primary limb salvage surgery. The factors predictive of success, including comorbidity, laboratory findings, and radiologic findings were evaluated by a retrospective chart review.

Results

The mean age of the study population was 63.9 years, with a male-to-female ratio of approximately 2:1. The mean follow-up duration was 30 months. Statistical analysis showed that underlying renal disease, limited activity before surgery, a low hemoglobin level, a high white blood cell count, a high C-reactive protein level, and damage to two or more vessels on preoperative computed tomography (CT) angiogram were significantly associated with the success or failure of limb salvage. The five-year survival rate was 81.6% for the limb salvage success group and 36.4% for the limb salvage failure group.

Conclusion

This study evaluated the factors predictive of the success of limb salvage surgery and identified indicators for preserving as much as possible of the leg of a patient with diabetic foot. This should help surgeons to establish the appropriate amputation level for a case of diabetic foot and help prevent consecutive operations.

Pre-hospital delay in patients with diabetic foot problems: influencing factors and subsequent quality of care

AIMS

To assess pre-hospital patient delay and its associated variables in patients with diabetic foot problems.

METHODS

We classified 270 patients with diabetic foot problems retrospectively based on the distribution of pre-hospital delay. Clinical, demographic and socio-economic data were collected. Logistic regression analysis was performed to examine independent associations with patient delay.

RESULTS

The median pre-hospital delay time was 46.49 days. Patients reported short (≤ 1 week; 77 patients, 28.5%), moderate (> 1 week and ≤ 1 month; 106 patients, 39.3%) and long delays (> 1 month; 87 patients, 32.2%). In a univariate analysis, nine variables were associated with a longer delay (P < 0.05): (1) no previous ulcer; (2) no health insurance; (3) poor housing conditions; (4) low income level; (5) low educational level; (6) infrequent foot inspection; (7) few follow-up medical visits; (8) absence of diabetic foot education; (9) lack of knowledge of foot lesion warning signals. A multivariate analysis showed that absence of diabetic foot education (odds ratio 2.70, 95% CI 1.03-7.06, P = 0.043) and lack of knowledge of foot lesion warning signals (odds ratio 2.14, 95% CI 1.16-3.94, P = 0.015) were independent predictors of long patient delay. Long delay increased the risk of amputation (odds ratio 2.22, 95% CI 1.36-3.64, P = 0.002) and mortality (odds ratio 2.69, 95% CI 1.35-5.33, P = 0.005).

CONCLUSIONS

A number of factors were involved in pre-hospital delay among patients with diabetic foot problems and contributed to poor outcomes. We recommend developing a community intervention programme that targets at-risk communities to encourage earlier multidisciplinary team assessment to reduce disparities and improve foot outcomes in patients with diabetes.

Exploring the concept of a team approach to wound care: Managing wounds as a team

Background

The growing prevalence and incidence of nonhealing acute and chronic wounds is a worrying concern. A major challenge is the lack of united services aimed at addressing the complex needs of individuals with wounds. However, the WHO argues that interprofessional collaboration in education and practice is key to providing the best patient care, enhancing clinical and health-related outcomes and strengthening the health system. It is based on this background that the team approach to wound care project was conceptualised. The project was jointly initiated and realised by the Association for the Advancement of Wound Care (AAWC-USA), the Australian Wound Management Association (AWMA) and the European Wound Management Association (EWMA).

Aim

The aim of this project was to develop a universal model for the adoption of a team approach to wound care.

Objective

The overarching objective of this project was to provide recommendations for implementing a team approach to wound care within all clinical settings and through this to develop a model for advocating the team approach toward decision makers in national government levels.

Method

An integrative literature review was conducted. Using this knowledge, the authors arrived at a consensus on the most appropriate model to adopt and realise a team approach to wound care.

Results

Eighty four articles met the inclusion criteria. Following data extraction, it was evident that none of the articles provided a definition for the terms multidisciplinary, interdisciplinary or transdisciplinary in the context of wound care. Given this lack of clarity within the wound care literature, the authors have here developed a Universal Model for the Team Approach to Wound Care to fill this gap in our current understanding.

Conclusion

We advocate that the patient should be at the heart of all decision-making, as working with the Universal Model for the Team Approach to Wound Care begins with the needs of the patient. To facilitate this, we suggest use of a wound navigator who acts as an advocate for the patient. Overall, we feel that the guidance provided within this document serves to illuminate the importance of a team approach to wound care, in addition to providing a clear model on how to achieve such an approach to care. We look forward to gathering evidence of the impact of this model of care on clinical and financial outcomes and will continue to share updates over time.

Reducing length of stay for acute diabetic foot episodes: employing an extended scope of practice podiatric high-risk foot coordinator in an acute foundation trust hospital

BACKGROUND

To enhance the acute management of people with diabetic foot disease requiring admission, an extended scope of practice, podiatric high-risk foot coordinator position, was established at the Great Western Hospital, Swindon in 2010. The focus of this new role was to facilitate more efficient and timely management of people with complex diabetic foot disease. The aim of this project was to investigate the impact of the podiatric high-risk foot coordinator role on length of stay, rate of re-admission and bed cost.

METHOD

This study evaluated the difference in length of stay and rate of re-admission between an 11- month pre-pilot period (November 2008 to October 2009) and a 10-month pilot period (August 2010 to June 2011). The estimated difference in bed cost between the pre-pilot and pilot audits was also calculated. Inclusion criteria were restricted to inpatients admitted with a diabetic foot ulcer, gangrene, cellulitis or infection as the primary cause for admission. Eligible records were retrieved using ICD-10 (V9) coding via the hospital clinical audit department for the pre-pilot period and a unique database was used to source records for the pilot phase.

RESULTS

Following the introduction of the podiatric high-risk foot coordinator, the average length of stay reduced from 33.7 days to 23.3 days (mean difference 10.4 days, 95% CI 0.0 to 20.8, p = 0.050). There was no statistically significant difference in re-admission rate between the two study periods, 17.2% (95% CI 12.2% to 23.9%) in the pre-pilot phase and 15.4% (95% CI 12.0% to 19.5%) in the pilot phase (p = 0.820). The extrapolated annual cost saving following the implementation of the new coordinator role was calculated to be £234,000 for the 2010/2011 year.

CONCLUSIONS

This audit found that the extended scope of practice coordinator role may have a positive impact on reducing length of stay for diabetic foot admissions. This paper advocates the role of a podiatric high-risk foot coordinator utilising an extended scope of practice model, although further research is needed.

Complications of the diabetic foot

The diabetic foot is at high risk for complications because of its role in ambulation. Peripheral neuropathy and peripheral vascular disease can lead to chronic foot ulcers, which are at high risk for infection, in part attributable to areas of high pressure caused by lack of tolerance of the soft tissue and bone and joint deformity. If left untreated, infection and ischemia lead to tissue death, culminating in amputation. Treatment strategies include antibiosis, topical therapies, offloading, debridement, and surgery. A multidisciplinary team approach is necessary in the prevention and treatment of complications of the diabetic foot.

Epidemiology of foot ulceration and amputation: can global variation be explained?

Amputation is a treatment, and not simply part of the natural history of foot disease. However, assessment of amputation incidence is the measure most frequently used to document an outcome reflecting the management of diabetic foot disease, mainly because the data are already captured in most health care systems. Nevertheless, interpretation of the results requires great care. Many centers have recorded decreases in the incidence of amputation in recent years and have concluded that this reflects improvement in clinical care. Although improvement in clinical care is clearly of a priority, it is important not to underestimate the extent to which the at-risk population (those with diabetes) may have changed as a result of changing criteria for the diagnosis of diabetes, as well as the increasing implementation of systematic and opportunistic screening. The incidence of amputation can be calculated and expressed in many ways, with different groups using different criteria for deciding both the numerator and the denominator, and studying populations that may differ in several different ways. Given that the incidence of amputation can also be influenced by a wide variety of clinical and social factors, it is not surprising that considerable variation exists between published studies from different countries. For these reasons it is currently difficult to make meaningful comparisons between data from different countries. On the other hand, the demonstration of wide variation within a single country or between countries or communities that have very similar populations, health care systems, and procedures for documenting amputation incidence is of greater interest. When 8- to 10-fold variation exists within similar health care systems, a risk as large as any published risk factor for amputation, it is essential that the reasons are explored. While race and social deprivation both make an important contribution to variation, another is likely to relate to aspects of the structure of care, including the training and beliefs of individual clinicians, patients’ access to care, preferences of patients, and the ability of a patient to understand the need for care and execute a care plan. This area of study requires further investigation.