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Horm Metab Res 2005; 37: 69-75
DOI: 10.1055/s-2005-861377
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© Georg Thieme Verlag KG Stuttgart · New York

Management of the Diabetic Foot: Surgical and Organisational Aspects

F.  Gottrup1
  • 1 The University Center of Wound Healing, Odense University Hospital, Odense, Denmark
Further Information

Publication History

Received 6 December 2004

Accepted after Revision 26 February 2005

Publication Date:
30 June 2005 (online)

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Abstract

Most patients are older, but increasing numbers of young patients also develop diabetic foot ulcer (DFU) [1]. A third of the patients are under 50 years of age [2]. The prevalence in the Western countries is 4-10 % and the incidence 2-6 % [3]. Only 10-60 % of patients are healed after the first three months [4] and the recurrence rate is 44 %, 61 % and 70 % after one, two and three years, respectively [5]. DFU results in extensive treatment costs, and the hospital treatment cost of DFU counts towards 25-30 % of the total hospital expenses of treatment of patients suffering of diabetes [6].

Recent progress in the treatment of patients with DFU has reduced the number of low-extremity amputation (LEA) cases. These improvements have been achieved through an increasing understanding of the importance of the multifactorial background of DFU, and that there should be a multidisciplinary organ„ised structure behind the treatment of DFU. This used to be a topic of interest, but especially focused on in the International Consensus on the Diabetic Foot from 1999 [3]. Our understanding of the importance of surgery in DFU has increased over the last 30 years [7 17]. A simple classification based on presents or absents of neuropathy, open wound or infection has been suggested [16]. Treatment is dependable of the type and classification group of the wound. Various surgical correction techniques are available [18] [19].

The team approach and collaboration between all healthcare professionals is required to facilitate good quality holistic care [20 23]. Recognition of the talent and creativity of all employees in the multidisciplinary team will increase the chance of success in establishment of the concept [24].

This article is based on a presentation focusing on the surgical and organisational aspects in the treatment of DFU.

Key words

Diabetic foot - Surgery - Organisation - Wound centres - Multidisciplinary collaboration

References

  • 1 Holstein P E, Lohmann M, Gottrup F. Forbedret behandling af diabetiske fodproblemer.  Ugeskr Læg. 2001;  163 3212-3717
    PubMedGoogle Scholar
  • 2 Larsen K, Holstein P, Deckert T. Limb salvage in diabetes with foot ulcers.  Prosthet Orthot Int. 1989;  13 100-103
    PubMedGoogle Scholar
  • 3 International Working Group on the Diabetic Foot .International Consensus on the Diabeteic Foot. Maastricht; 1999
    Google Scholar
  • 4 Margolis D J, Kantor J, Berlin J A. Healing of diabetic neuropathic foot ulcers receiving standard treatment.  Diabetic care. 1999;  22 692-695
    PubMedGoogle Scholar
  • 5 Apelqvist J, Larsson J, Agardh C D. Long term prognosis for diabetic patients with foot ulcers.  J Intern Med. 1993;  233 485-491
    CrossrefPubMedGoogle Scholar
  • 6 Apelqvist J. Wound healing in diabetes. Outcome and costs.  Clin Podiatr Med Surg. 1998;  15 21-39
    PubMedGoogle Scholar
  • 7 Wagner F W. The dysvascular foot: a system for diagnosis and treatment.  Foot Ankle. 1981;  2 64-122
    PubMedGoogle Scholar
  • 8 Armstrong D G, Lavery L A, Stern S, Harkless L B. Is prophylactic diabetic foot surgery dangerous?.  J Foot Ankle Surg. 1996;  35 585-589
    CrossrefPubMedGoogle Scholar
  • 9 Armstrong D G, Stacpoole-Shea S, Nguyen H C, Harkless L B. Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot.  J Bone Joint Surg (Am). 1999;  81A 535-538
    PubMedGoogle Scholar
  • 10 Gudas C J. Prophylactic surgery in the diabetic foot.  Clin Podiatr Med Surg. 1987;  4 445-458
    PubMedGoogle Scholar
  • 11 Frykberg R, Giurini J, Habershaw G, Rosenblum B, Chrzan J. Prophylactic surgery in the diabetid foot. In: Kominsky SJ (ed) Medical and surgical management of the diabetic foot. Mosby, St. Louis; 1993
    Google Scholar
  • 12 Blume P A, Paragas L K, Sumpio B E, Attinger C E. Single-stage surgical treatment of non-infected diabetic foot ulcers.  Plast Reconstr Surg. 2002;  109 601-609
    PubMedGoogle Scholar
  • 13 Frykberg R G, Armstrong D G, Giurini J M. et al . Diabetic foot disorders: a clinical practice guideline.  J Foot Ankle Surg. 2000;  39 S2-S60
    PubMedGoogle Scholar
  • 14 Laing P. Prophylactic orthopaedic surgery - is there a role?. In: Boulton AJM, Connor H, Cavanagh PR (eds) The foot in diabetes, 3rd edn. Chichester; John Wiley & Sons 2002
    Google Scholar
  • 15 Ha Van G, Siney H, Danan J P, Sachon C, Grimaldi A. Treatment of osteomyelitis in the diabetic foot: contribution of conservative surgery.  Diabetes Care. 1996;  19 1257-1260
    CrossrefPubMedGoogle Scholar
  • 16 Armstrong D G, Frykberg R G. Classification of diabetic foot surgery: toward a rational definition.  Diabet Med. 2003;  20 329-331
    CrossrefPubMedGoogle Scholar
  • 17 Armstrong D G. Diabetic Foot Surgery. In: Teot L, Ban Well PE, Ziegler KE (eds) Surgery in Wounds. Berlin; Springer 2004: 361-366
    Google Scholar
  • 18 Holstein P. Polyneuropathic ulcer surgery. In: Teot L, Ban Well PE, Ziegler KE (eds) Surgery in Wounds. Berlin; Springer 2004: 367-373
    Google Scholar
  • 19 Piaggesi A, Schipani E, Campi F. et al . Conservative surgical approach versus non-surgical management for diabetic neuropathic foot ulcers: a randomized trial.  Diab Med. 1998;  15 412-417
    CrossrefPubMedGoogle Scholar
  • 20 Gray B L. Developing a model for clinical practice.  J Wound Care. 1996;  5 428-432
    PubMedGoogle Scholar
  • 21 Doan-Johnson S. The growing influnce of wound care teams (editorial).  Adv Wound Care. 1998;  11 54
    PubMedGoogle Scholar
  • 22 Frykberg R G. The team approach in diabetic foot management.  Adv Wound Care. 1998;  11 71-77
    PubMedGoogle Scholar
  • 23 Granick M S, Ladin D A. The multidisciplinary In-hospital wound care team: Two models.  Adv Wound Care. 1998;  11 80-83
    PubMedGoogle Scholar
  • 24 Reich R B. Entrepreneurship reconsidered: the team as hero.  Harvard Busines review. 1987;  65 77-78
    PubMedGoogle Scholar
  • 25 Jeffcoate W J, Harding K G. Diabetic foot ulcers.  Lancet. 2003;  361 1545-1551
    CrossrefPubMedGoogle Scholar
  • 26 Strandness D E, Priest R E, Gibbons G R. Combined clinical and pathological study of diabetic and non diabetic peripheral arterial disease.  Diabetes. 1964;  13 366-372
    CrossrefPubMedGoogle Scholar
  • 27 LoGerfo F W, Coffman J D. Vascular and microvascular disease of the foot in diabetes.  N Engl J Med. 1984;  311 1615-1619
    Google Scholar
  • 28 Akbari C M, LoGerfo F W. Diabetes and peripheral vascular disease.  J Vasc Surg. 1999;  30 373-384
    CrossrefPubMedGoogle Scholar
  • 29 Eneroth M, Apelqvist J. Clinical characteristics and outcome in diabetic patients with deep foot infections.  Foot Ankle. 1997;  18 716-722
    PubMedGoogle Scholar
  • 30 Kumar S, Fernando D JS, Veves A, Knowles E A, Young M J, Boulton A JM. Semmes-Weinstein monofilaments: a simple, effective and inexpensive streening device for identifying diabetic patients.  Diabetic Res Clin Pract. 1991;  13 63-68
    CrossrefPubMedGoogle Scholar
  • 31 Holstein P, Lassen N A. Healing of ulcers on the feet correlated with distal blood pressure measurements in occlusive arterial disease.  Acta Orthop Scand. 1980;  51 995-1006
    PubMedGoogle Scholar
  • 32 Gottrup F. Oxygen. Wound healing and the development of infection. Present status.  Eur J Surg. 2002;  168 260-263
    CrossrefPubMedGoogle Scholar
  • 33 Gottrup F. Oxygen in Wound Healing and infection.  World J Surg. 2004;  28 312-315
    CrossrefPubMedGoogle Scholar
  • 34 Tateishi-Yuyama E, Matsubara H, Murohara T. et al . Therapeutic angiogenesis for patients with limb ischaemia by autologous transplantation of bone-marrow cells: a pilot study and a randomised controlled trial.  Lancet. 2002;  360 427-435
    CrossrefPubMedGoogle Scholar
  • 35 Giurini J M, Basile P, Chrzan J S, Habershaw G M, Rosenblum B I. Panmetatarsal head resection. A viable alternative to the transmetatarsal amputation.  J Am Podiatr Med Assoc. 1993;  83 101-107
    PubMedGoogle Scholar
  • 36 Cohen M, Roman A, Malcom W G. Pan-metatarsal head resection and transmetatarsal amputation versus solitary partial ray resection in the neuropathic foot.  J Foot Surg. 1991;  30 29-33
    PubMedGoogle Scholar
  • 37 Rosenblum B I, Pomposelli F B Jr, Giurini J M, Gibbons G W, Freeman D V, Chrzan J S, Campell D R, Habershaw G M, LoGerfo F W. Maximizing foot salvage by a combined approach to foot ischemia and neuropathic ulceration in patients with diabetes. A 5-year experience.  Diabetes Care. 1994;  17 983-987
    PubMedGoogle Scholar
  • 38 Lin S S, Lee T H, Wapner K L. Plantar forefoot ulceration with equines deformity of the ankle in diabetic patients: the effect of tendo-achilles lengthening and total contact casting.  Orthopaedics. 1996;  19 465-475
    PubMedGoogle Scholar
  • 39 Armstrong D G, Lavery L A, Vazques J R. et al . Clinical efficacy of the first metatarsophalangeal joint arthroplasty as a curative procedure for hallux interphalangeal joint wounds in persons with diabetes.  Diabetes Care. 2003;  26 3284-3287
    PubMedGoogle Scholar
  • 40 Mueller M J, Sinacore D R, Hastings M K, Strube M J, Johnson J E. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial.  J Bone Joint Surg. 2003;  85A 1436-1445
    PubMedGoogle Scholar
  • 41 Gottrup F. Wound Debridement.  In: The Oxford European Wound Healing Course Handbook. Oxford; Positif Press 2002: 116-120
    Google Scholar
  • 42 Baharestani M. The clinical relevance of debridement. In: Baharestani M, Gottrup F, Holstein P, Vanscheidt W (eds) The clinical relevance of debridement. Berlin; Springer-Verlag 1999: 1-13
    Google Scholar
  • 43 Wolff H, Hansson C. Larval therapy - an effective method of ulcer debridement.  Clin Exp Dermatol. 2003;  28 134-137
    CrossrefPubMedGoogle Scholar
  • 44 Wolff H. Studies of chronic ulcers & larval therapy. Gotenborg, Sweden; Theis 2004
    Google Scholar
  • 45 McGee S R, Boyko E J. Physical examination, chronic lower-extremity ischaemia: a critical review.  Arch Intern Med. 1998;  158 1357-1364
    CrossrefPubMedGoogle Scholar
  • 46 Holstein P E, Sorensen S. Limb salvage experience in a multidisciplinary diabetic foot clinic.  Diab Care. 1999;  22 (suppl 2) B97-B103
    PubMedGoogle Scholar
  • 47 Taylor R S, Belli A M, Jacob S. Distal venous arterialisation for salvage of critically ischaemic inoperable limbs.  Lancet. 1999;  354 1962-1965
    CrossrefPubMedGoogle Scholar
  • 48 Akbari C M, Pomposelli F B Jr, Gibbons G W. et al . Lower extremity revascularisation in diabetes: late observations.  Arch Surg. 2000;  135 452-456
    PubMedGoogle Scholar
  • 49 Holstein P, Ellitsgaard N, Olsen B B. et al . Decreasing incidence of major amputations in people with diabetes.  Diabetologia. 2000;  43 844-847
    CrossrefPubMedGoogle Scholar
  • 50 Bradbury A W, Ruckley C V. Angioplasty for lower-limb ischaemia: time for randomised controlled trials.  Lancet. 1996;  347 277-278
    CrossrefPubMedGoogle Scholar
  • 51 Gottrup F, Holstein P, Jørgensen B, Lohmann M, Karlsmark T. A new concept of a multidisciplinary wound healing center and a national expert function of wound healing.  Arch Surg,. 2001;  136 765-772
    CrossrefPubMedGoogle Scholar
  • 52 Knighton D R, Ciresi K, Fiegel V D, Schumerth S, Butler E, Cerra F. Stimulation of repair in chronic nonhealing cutaneous ulcers using Platelet-derived Wound Healing Formula.  Surg Gynecol Obstet. 1990;  170 56-60
    PubMedGoogle Scholar
  • 53 Steed D L. Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. Diabetic Study Group.  J Vasc Surg. 1995;  21 71-78
    PubMedGoogle Scholar
  • 54 Gibbons G W, Marcaccio E J, Burgess A M, Pomposelli F B, Freeman D, Campbeli D, Miller A, LoGerfo F. Improved quality of diabetic foot care, 1984 vs 1990; reduced length of stay and costs, insufficient reimbursement.  Arch Surg. 1993;  128 576-581
    PubMedGoogle Scholar
  • 55 Agency for Health Care Policy and Research .Pressure ulcers in adults: prediction and prevention. Rockville, Md; USDHHS, AHCPR Pub. No. 92-0047 1992
    Google Scholar
  • 56 Miller H, Delozier J. Cost implications of the pressure ulcer treatment guideline. Columbia, Md; Center for Health Policy Studies, Contract No. 282-91-0070 (Sponsored by the AHCPR) 1994: 17
    Google Scholar
  • 57 Motta G J, Thimsen-Whitaker K, Demoor M A. Documenting outcomes of wound care.  Contin Care. 1995;  14(8) 16
    PubMedGoogle Scholar
  • 58 Baharestani M. Clinical decision making in wound care management: the need for a paradigmatic shift.  Wounds: A Compendium of Clinical Research and Practice. 1995;  7(suppl A) 84A
    PubMedGoogle Scholar
  • 59 Hunter S M. et al . The effectiveness of skin care protocols for pressure ulcers.  Rehabil Nurs. 1995;  20(5) 250
    PubMedGoogle Scholar
  • 60 Kresevic D, Naylor M. Preventing pressure ulcers through the use of protocols in a mentoring nursing model.  Geriatr Nurs. 1995;  16(5) 225
    PubMedGoogle Scholar
  • 61 Turnbull G. The international committee on wound management (ICWM) statement on cost-effective wound care: evaluating your supply use to prepare for managed care.  Ostomy Wound Manage. 1996;  42(2) 72
    PubMedGoogle Scholar
  • 62 Gates J. Total quality management: pressure ulcer prevention.  Nurs Manage. 1996;  27(4) 48E
    PubMedGoogle Scholar
  • 63 Lessner W. Small but successful changes prepare MDs for advent of decubitus protocol.  Quality Improvement/Total Quality Management. 1996;  6(1) 1
    PubMedGoogle Scholar
  • 64 Tomaselli N, Oxler K. Thomas Jefferson University Hospital comprehensive skin care program. Philadelphia; Thomas Jefferson University Hospital 1997
    Google Scholar
  • 65 Thomson F J, Veves A, Ashe H. A team approach to diabetic foot care - the Manchester experience.  The Foot. 1991;  2 75-82
    PubMedGoogle Scholar
  • 66 Bentkover J D, Champion A H. Economical evaluation of alternative methods of treatment for diabetic foot ulcer patients: cost-effectiveness of platelet releasate and wound care clinics.  Wounds. 1993;  5 207-215
    PubMedGoogle Scholar
  • 67 Sibbald R G, Kensholme A, Carter L. Special foot clinics for patients with diabetes.  J Wound Care. 1996;  5 238-243
    PubMedGoogle Scholar
  • 68 Gottrup F. Organization of wound healing services: The Danish experience and the importance of surgery.  Wound Rep Reg. 2003;  11 452-457
    PubMedGoogle Scholar
  • 69 Gottrup F. Optimizing wound treatment through health care structuring and professional education.  Wound Rep Reg. 2004;  12 129-133
    CrossrefPubMedGoogle Scholar
  • 70 Gottrup F. Multidisciplinary Wound Healing Concepts.  EWMA Journal. 2003;  3(1) 5-11
    PubMedGoogle Scholar
  • 71 Holstein P, Ellitsgaard N, Olsen B B, Ellitsgaard V. Decreasing incidence of major amputations in people with diabetes.  Diabetologia. 2000;  43 844-847
    CrossrefPubMedGoogle Scholar
  • 72 Holstein P, Lohmann M, Wallø N. Surgical decompression of recalcitrant neuropathic foot ulcerations in patients with diabetes. Abstract in proceedings: 2. joint meeting of the Diabetic Neuropathy Study Group and the Diabetic Foot Study Group of the Eupean Association for the Study of Diabetes (EASD). Balatonfured, Hungary; August-September 2002
    Google Scholar
  • 73 Holstein P, Lohmann M, Bitsch M, Jørgensen B. Achilles tendon lengthening, the panacea for plantar forefoot ulceration?.  Diabetes Metab Res Rev. 2004;  20(suppl 1) S37-S40
    CrossrefPubMedGoogle Scholar

F. Gottrup, M.D., DMSci.

The University Center of Wound Healing

Odense University Hospital · 5000 Odense C · Denmark

Phone: + 45 65413904

Email: finn.gottrup@ouh.fyns-amt.dk

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