Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes

Background - Foot Clinics and Multi-disciplinary TeamsRecommendations to prevent amputation in people with diabetes and high risk feetinclude regular foot examination, education, suitable footwear and orthotics, podiatryservices, and early ulcer treatment including surgery where indicated (Mason et al,1999). Implementation of these recommendations cannot be achieved easily by onecategory of health provider and are best achieved with a multi-disciplinary teamapproach. Providing this recommended care requires the services of a physician,podiatrist, diabetes educator and vascular or orthopaedic surgeon (Bild et al, 1989).Unfortunately multi-disciplinary diabetes foot clinics are not common in Australiaand most people receive their care in different sites and some have geographicaldifficulty in accessing a complete range of services.Because of cost implications and geographic considerations it is important to evaluatewhether a multi-disciplinary team approach can reduce amputation in high riskpeople. Even if this can be demonstrated, the provision of such services will stillremain a challenge in many parts of Australia.Evidence - Foot Clinics and Multi-disciplinary TeamsA multi-disciplinary specialist footcare team can reduce ulceration andamputation in people with high risk feetThe studies identified are difficult to compare because there is no universal definitionof multi-disciplinary care and the settings in which such care is offered vary fromprimary care to hospital specialist referral clinics. Studies have been eitherretrospective or prospective cohort studies and true randomisation of high risksubjects to routine care or specialised clinic is virtually impossible and probablyunethical.In Manchester, UK, a weekly diabetic foot clinic with a multi-disciplinary team wasestablished at the district hospital to which people with diabetes and foot lesions werereferred from a wide range of sources (Thomson et al, 1991). The diabetic foot clinicwas staffed by a diabetologist, chiropodist, specialist foot nurse and orthotist. Subjectswere discharged from the clinic once adequate provision for follow up podiatry carehad been made. Of 260 subjects who were referred to the clinic, 112 (73%) had Type2 diabetes, and 153 (59%) had a new foot ulcer. Ulcer healing was obtained in 96cases among 119 subjects available for follow-up. The annual amputations in peoplewith diabetes in the subsequent 3 years were reduced by 42% compared to prior years(Thomson et al, 1991).A predominantly descriptive report from Italy detailed the effects of setting up of amulti-disciplinary hospital foot clinic which provided intensive management of ulcerswith patient education, surgery and detailed follow up of foot lesions (Ghirlanda et al,1997). People attending the clinic had underlying neuropathy and presented withplantar ulcers (66%), soft tissue infections (30%), necrosis of at least one toe (24%)and osteomyelitis (10%). In the 250 people evaluated over the initial 3-year period, noamputation were performed. 98% of people with neuropathy had healing of their84