Salvaging the Diabetic Limb: An Interdisciplinary Review of the Integrated Foot Clinic Model for Amputation Prevention
Abstract
Background: Diabetic foot complications, driven by a triad of neuropathy, ischemia, and infection, represent a global crisis in diabetes management, culminating in a lower limb amputation every 20 seconds. The traditional siloed approach—where patients navigate disparate specialists—fails to address the complexity of these wounds, leading to preventable morbidity, mortality, and staggering healthcare costs. Aim: This narrative review aims to synthesize contemporary evidence on the multidisciplinary diabetic foot clinic (MDFC) as a paradigmatic model of integrated care. Methods: A systematic search of peer-reviewed literature (2010-2024) was conducted across PubMed, CINAHL, Scopus, and The Cochrane Library. Results: The review establishes that MDFCs significantly reduce major amputation rates (40-60%), hospitalizations, and costs compared to usual care. Key success factors include: 1) Co-location of specialists enabling same-day, collaborative assessment; 2) Protocol-driven workflows for infection control, offloading, and revascularization; 3) Robust data systems for tracking outcomes; and 4) The integration of behavioral and social determinants of health into the treatment plan. Barriers include funding models, workforce shortages, and ensuring equitable access. Conclusion: The MDFC is not merely a clinic but a healthcare delivery system engineered to confront a multifaceted disease process. Its effectiveness validates the principle that amputation is more often a systems failure than an inevitable outcome. Widespread implementation requires policy reform to incentivize integrated, value-based care and a commitment to interdisciplinary education.
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References
Ahmed, M. U., Tannous, W. K., Agho, K. E., Henshaw, F., Turner, D., & Simmons, D. (2021). Social determinants of diabetes-related foot disease among older adults in New South Wales, Australia: evidence from a population-based study. Journal of foot and ankle research, 14(1), 65. https://doi.org/10.1186/s13047-021-00501-8
Almasri, J., Adusumalli, J., Asi, N., Lakis, S., Alsawas, M., Prokop, L. J., ... & Murad, M. H. (2019). A systematic review and meta-analysis of revascularization outcomes of infrainguinal chronic limb-threatening ischemia. Journal of vascular surgery, 69(6), 126S-136S. https://doi.org/10.1016/j.jvs.2018.01.071
Armstrong, D. G., Boulton, A. J., & Bus, S. A. (2017). Diabetic foot ulcers and their recurrence. New England Journal of Medicine, 376(24), 2367-2375. DOI: 10.1056/NEJMra1615439
Berchiolli, R., Bertagna, G., Adami, D., Canovaro, F., Torri, L., & Troisi, N. (2023). Chronic limb-threatening ischemia and the need for revascularization. Journal of clinical medicine, 12(7), 2682. https://doi.org/10.3390/jcm12072682
Bus, S. A., Armstrong, D. G., Crews, R. T., Gooday, C., Jarl, G., Kirketerp‐Moller, K., ... & Lazzarini, P. A. (2024). Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes/metabolism research and reviews, 40(3), e3647. https://doi.org/10.1002/dmrr.3647
Carls, G. S., Gibson, T. B., Driver, V. R., Wrobel, J. S., Garoufalis, M. G., DeFrancis, R. R., ... & Christina, J. R. (2011). The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. Journal of the American Podiatric Medical Association, 101(2), 93-115. https://doi.org/10.7547/1010093
Crawford, F., Nicolson, D. J., Amanna, A. E., & Smith, M. (2022). Reliability of the evidence to guide decision-making in foot ulcer prevention in diabetes: an overview of systematic reviews. BMC Medical Research Methodology, 22(1), 274. https://doi.org/10.1186/s12874-022-01738-y
Dixon, D., & Edmonds, M. (2023). The Diabetic Foot, Its Complications, Role of Technology in Evidence-Based Management. In Chronic Wound Management: The Significance of Evidence and Technology (pp. 45-66). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-031-26110-7_3
Elnour, M. A. A., & Mirghani, H. O. (2023). Periodontitis treatment (surgical and nonsurgical) effects on glycemic control: a review and meta-analysis. Annals of African Medicine, 22(2), 131-135. DOI: 10.4103/aam.aam_53_22
Godavarty, A., Leiva, K., Amadi, N., Klonoff, D. C., & Armstrong, D. G. (2023). Diabetic foot ulcer imaging: an overview and future directions. Journal of Diabetes Science and Technology, 17(6), 1662-1675. https://doi.org/10.1177/19322968231187660
Hamilton, J. E., Blanco, E., Selek, S., Wirfel, K. L., Bernstam, E. V., Velligan, D., ... & Roberts, K. (2022). Patient and provider perspectives on medication non-adherence among patients with depression and/or diabetes in diverse community settings–a qualitative analysis. Patient preference and adherence, 1581-1594. https://doi.org/10.2147/PPA.S328785
Jarl, G., Rusaw, D. F., Terrill, A. J., Barnett, C. T., Woodruff, M. A., & Lazzarini, P. A. (2023). Personalized offloading treatments for healing plantar diabetic foot ulcers. Journal of diabetes science and technology, 17(1), 99-106. https://doi.org/10.1177/19322968221101632
Jodheea-Jutton, A., Hindocha, S., & Bhaw-Luximon, A. (2022). Health economics of diabetic foot ulcer and recent trends to accelerate treatment. The Foot, 52, 101909. https://doi.org/10.1016/j.foot.2022.101909
Lavery, L. A., Ryan, E. C., Ahn, J., Crisologo, P. A., Oz, O. K., La Fontaine, J., & Wukich, D. K. (2020). The infected diabetic foot: re-evaluating the Infectious Diseases Society of America diabetic foot infection classification. Clinical Infectious Diseases, 70(8), 1573-1579. https://doi.org/10.1093/cid/ciz489
Lipsky, B. A., Berendt, A. R., Cornia, P. B., Pile, J. C., Peters, E. J., Armstrong, D. G., ... & Senneville, E. (2012). 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clinical infectious diseases, 54(12), e132-e173. https://doi.org/10.1093/cid/cis346
Maurer, S. M., Hepp, Z. S., McCallin, S., Waibel, F. W., Romero, F. C., Zorman, Y., ... & Uçkay, İ. (2022). Short and oral antimicrobial therapy for diabetic foot infection: a narrative review of current knowledge. Journal of bone and joint infection, 7(2), 61-70. https://doi.org/10.5194/jbji-7-61-2022
Meloni, M., Ahluwalia, R., Bellia, A., Brocco, E., Di Venanzio, M., Andreadi, A., ... & Uccioli, L. (2022). The neuro-ischaemic Charcot foot: prevalence, characteristics and severity of peripheral arterial disease in acute Charcot neuro-arthropathy. Journal of Clinical Medicine, 11(21), 6230. https://doi.org/10.3390/jcm11216230
Monteiro‐Soares, M., Russell, D., Boyko, E. J., Jeffcoate, W., Mills, J. L., Morbach, S., ... & International Working Group on the Diabetic Foot (IWGDF). (2020). Guidelines on the classification of diabetic foot ulcers (IWGDF 2019). Diabetes/metabolism research and reviews, 36, e3273. https://doi.org/10.1002/dmrr.3273
Moore, Z., Avsar, P., Wilson, P., Mairghani, M., O'Connor, T., Nugent, L., & Patton, D. (2021). Diabetic foot ulcers: treatment overview and cost considerations. Journal of wound care, 30(10), 786-791. https://doi.org/10.12968/jowc.2021.30.10.786
Rogers, L. C., Frykberg, R. G., Armstrong, D. G., Boulton, A. J., Edmonds, M., Van, G. H., ... & Uccioli, L. (2011). The Charcot foot in diabetes. Journal of the American Podiatric Medical Association, 101(5), 437-446. https://doi.org/10.7547/1010437
Rogers, L. C., Lavery, L. A., Joseph, W. S., & Armstrong, D. G. (2023). All feet on deck: the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened health-care system, reducing amputation and death in people with diabetes. Journal of the American Podiatric Medical Association, 113(2). https://doi.org/10.7547/20-051
Roy, J. F., Lozano del Hoyo, M. L., Urcola-Pardo, F., Monreal-Bartolome, A., Gracia Ruiz, D. C., Gomez Borao, M. M., ... & Fernandez Rodrigo, M. T. (2021). The TELE-DD project on treatment nonadherence in the population with type 2 diabetes and comorbid depression. Scientific Reports, 11(1), 8889. https://doi.org/10.1038/s41598-021-87410-9
Shapoval, S. D., Tribushniy, O. V., Savon, I. L., Sophylkanych, M. M., Shidlovskyi, V. O., Vasilevska, L. A., & Sheremet, M. I. (2021). Complex treatment of patients with complicated syndrome of diabetic foot and sepsis. Romanian Journal of Diabetes Nutrition and Metabolic Diseases, 28(2), 131-136. https://www.rjdnmd.org/index.php/RJDNMD/article/view/917.
Simons, J. P., Schanzer, A., Flahive, J. M., Osborne, N. H., Mills Sr, J. L., Bradbury, A. W., & Conte, M. S. (2019). Survival prediction in patients with chronic limb-threatening ischemia who undergo infrainguinal revascularization. European Journal of Vascular and Endovascular Surgery, 58(1), S120-S134. https://doi.org/10.1016/j.ejvs.2019.04.009
Simpson, T. C., Clarkson, J. E., Worthington, H. V., MacDonald, L., Weldon, J. C., Needleman, I., ... & Twigg, J. (2022). Treatment of periodontitis for glycaemic control in people with diabetes mellitus. Cochrane Database of Systematic Reviews, (4). https://doi.org/10.1002/14651858.CD004714.pub4
Sorber, R., & Abularrage, C. J. (2021, March). Diabetic foot ulcers: Epidemiology and the role of multidisciplinary care teams. In Seminars in Vascular Surgery (Vol. 34, No. 1, pp. 47-53). WB Saunders. https://doi.org/10.1053/j.semvascsurg.2021.02.006
Syed, M. H., Salata, K., Hussain, M. A., Zamzam, A., de Mestral, C., Wheatcroft, M., ... & Al-Omran, M. (2020). The economic burden of inpatient diabetic foot ulcers in Toronto, Canada. Vascular, 28(5), 520-529. https://doi.org/10.1177/1708538120923420
Tansley, J., Collings, R., Williams, J., & Paton, J. (2023). Off-loading and compression therapy strategies to treat diabetic foot ulcers complicated by lower limb oedema: a scoping review. Journal of foot and ankle research, 16(1), 56. https://doi.org/10.1186/s13047-023-00659-3
Vossen, L. E., van Netten, J. J., Bakker, C. D., Berendsen, H. A., Busch-Westbroek, T. E., Peters, E. J., ... & Bus, S. A. (2023). An integrated personalized assistive devices approach to reduce the risk of foot ulcer recurrence in diabetes (DIASSIST): study protocol for a multicenter randomized controlled trial. Trials, 24(1), 663. https://doi.org/10.1186/s13063-023-07635-z
Wang, A., Lv, G., Cheng, X., Ma, X., Wang, W., Gui, J., ... & Hu, Y. (2020). Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition). Burns & trauma, 8, tkaa017. https://doi.org/10.1093/burnst/tkaa017
Zhang, Y., Leveille, S. G., Camhi, S. M., & Shi, L. (2023). Association of oral care with periodontitis and glycemic control among US adults with diabetes. BMC oral health, 23(1), 903. https://doi.org/10.1186/s12903-023-03580-0
Authors
Copyright (c) 2024 Abdulrahman Hadi Muhammed Hakami, Abdullah Read Abdullah Alruaydan, Abdullah Sultan ALdawsari, Abdulrahman Adnan Salah Abuljadael, Manar Mohammed Abuattiyh, Hanan Obid Aldawsari, Fahad Ali Nageef Alqhtani, Mohammed Ayed Al-Rumayh, Ibrahim Dhaher Humaidan Alsharari, Salem Owald Daldhafeeri, Sultan Atallha Sbeel Alharbi, Asma Mohammed Ishaq
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