At the end of an anatomical peninsula, the foot in diabetes is prone to short- and long-term complications involving neuropathy, vasculopathy, and infection. Effective management requires an interdisciplinary effort focusing on this triad. Herein, we describe the key factors leading to foot complications and the critical skill sets required to assemble a team to care for them. Although specific attention is given to a conjoined model involving podiatric medicine and vascular surgery, the so-called toe and flow model, we further outline three separate programmatic models of care—basic, intermediate, and center of excellence—that can be implemented in the developed and developing world. (J Am Podiatr Med Assoc 100(5): 342–348, 2010)
This historical perspective highlights some of the pioneers, milestones, teams, and system changes that have had a major impact on management of the diabetic foot during the past 100 years. In 1934, American diabetologist Elliott P. Joslin noted that mortality from diabetic coma had fallen from 60% to 5% after the introduction of insulin, yet deaths from diabetic gangrene of the lower extremity had risen significantly. He believed that diabetic gangrene was preventable. His remedy was a team approach that included foot care, diet, exercise, prompt treatment of foot infections, and specialized surgical care.
The history of the team approach to management of the diabetic foot chronicles the rise of a new health profession—podiatric medicine and surgery—and emergence of the specialty of vascular surgery. The partnership among the diabetologist, vascular surgeon, and podiatric surgeon is a natural one. The complementary skills and knowledge of each can improve limb salvage and functional outcomes. Comprehensive multidisciplinary foot-care programs have been shown to increase quality of care and reduce amputation rates by 36% to 86%. Development of distal revascularization techniques to restore pulsatile blood flow to the foot has also been a major advancement.
Patients with diabetic foot complications are among the most complex and vulnerable of all patient populations. Specialized diabetic foot clinics of the 21st century should be multidisciplinary and equipped to coordinate diagnosis, off-loading, and preventive care; to perform revascularization procedures; to aggressively treat infections; and to manage medical comorbidities. (J Am Podiatr Med Assoc 100(5): 317–334, 2010)