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

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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
lesion, 10% had ulcer recurrence at the primary site, 4% at a different site and 5% hadosteomyelitis at other locations (Ghirlanda et al, 1997).A Swedish retrospective study reported the changes in diabetes related amputationfollowing the implementation in 1983 of a multi-disciplinary footcare teamprogramme for prevention and treatment of diabetic foot ulcers (Larsson et al, 1995).The team consisted of a diabetologist, orthopaedic surgeon, diabetes nurse, podiatristand orthotist. From 1982 to 1993, 294 people with diabetes (mean age 77 years) had387 major (above the ankle) or minor (through or below ankle) amputations whichrepresented 48% of all lower extremity amputations. During this period the annualnumber of amputations at all levels decreased from 38 to 21, equalling a decrease inincidence from 19.1 to 9.4/100,000 people (p=0.001); and the incidence of majoramputations decreased by 78% from 16 to 3.6/100,000 inhabitants (p
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National Evidence Based Guidelinesf
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Research OfficersMs Linda SmithPodi
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2.2 Issues for Foot Problems in Typ
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• Aim to achieve the best possibl
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Background - Peripheral Neuropathy
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proportion of subjects with a durat
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and an OR 1.1-7.8. This study also
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Summary - Peripheral Neuropathy as
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Section 2: Diabetes Foot ProblemsIs
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predicting risk of amputation, 2.9
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Summary - Peripheral Vascular Disea
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Section 3: Diabetes Foot ProblemsIs
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Evidence - Foot Deformity and Previ
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people with both LJM and neuropathy
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Summary - Foot Deformity and Previo
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Page 76 and 77: period. In addition people without
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Page 80 and 81: The rate of plantar callus formatio
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Page 104 and 105: Jannink MJ, van Dijk H, de Vries J,
Page 106 and 107: Moss SE, Klein R, Klein BE. The 14-
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Page 110 and 111: Diabetes Foot Problems: General Ref
Page 112 and 113: McNeely MJ, Boyko EJ, Ahroni JH, St
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QUESTIONS KEY WORDS NO.ARTICLESIDEN
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Part 6: Detection and Prevention of Foot Problems in Type 2 Diabetes

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