The diabetic foot has become a major area of interest, and insight has been gained into the reasons why diabetic feet go wrong and the ways in which patients can be helped. Of all the complications of diabetes, the diabetic foot is probably the easiest to prevent and treat.
The groundswell of interest in the diabetic foot surged in the 1980s, and developments in foot care included the setting up of multidisciplinary diabetic foot clinics (Fig. 6) and the pioneering educational work of Jean Philippe Assal in Geneva, Switzerland. Paul Brand, Frank Tovey and Grace Warren worked in India as medical missionaries with leprosy patients and subsequently applied their knowledge to the management of diabetic neuropathic
Fig. 6 International visitors at the King's Diabetic Foot Clinic: left to right, Dr Kamenov (Bulgaria), the Authors, Dr Harkless (USA) and Dr Plamen (Bulgaria).
If key members of the team, such as podiatrists, are not available in certain countries, then doctors or nurses can take on many aspects of the role of the podiatrist. Indeed, we have learnt from the work of Dr Grace Warren with Hansen's disease patients that neuropathic patients and their families can be taught safe self-care techniques for removing callus to prevent ulceration if no other help is available.
One of the most important messages from these workers is that successful interventions in the real world do not depend on the possession of high-technology
equipment and vast financial budgets. Barriers to care which at first glance appear to be insurmountable can usually be overcome if we learn lessons from our own and other people's experiences, and, in the words of E. M. Forster, 'only connect' with each other.
'Experts' are sometimes called in to help to set up systems for managing the diabetic foot. However, experts are often outsiders from other regions or countries, who may lack information about local conditions and should refrain from being too dictatorial to local practitioners who may have expert and first-hand knowledge of local conditions and problems. While we always welcome visitors from abroad to our foot clinics, we try to avoid being too dogmatic about how they should manage feet back home: they observe what we do and extract what is relevant to their own situation but should not regard our messages as being cast in stone.
There is a dearth of evidence for treatments applied to the diabetic feet. One of the problems encountered in developing guidelines for management of the diabetic foot is that evidence is often lacking, and rarely comes from large, properly conducted, randomized controlled trials. Our recommendations are based either upon firsthand experience gained over the past 22 years working in the outpatient diabetic foot clinic and on the wards or on the published work of other groups, throughout the world.
In the spirit of the International Consensus on the Diabetic Foot (Fig. 10), we have tried to make this book relevant to all practitioners who want to set up a diabetic foot service, no matter where or under whatever conditions they labour: we hope that there is something here for everybody.
These are heady times for devotees of the diabetic foot, and we hope and believe that a new generation of young and enthusiastic practitioners will be there to take up the baton for the diabetic foot in the future. We hope that they will find this book useful and practical.
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