The aim in managing diabetic foot problems is always to keep the patient at as low a stage as possible. At each stage of the diabetic foot it is necessary to take control of the foot to prevent further progression and management will be considered under the headings shown in Table 1.3.
Table 1.3 Multidisciplinary management
Mechanical control Wound control Microbiological control Vascular control Metabolic control Educational control
When the examination reveals a foot at stage 3, 4 or 5 there is a need for a great sense of urgency: treatment should begin without delay. No one person can take control of the diabetic foot. Successful management needs the expertise of a multidisciplinary team including the following:
It is helpful if the multidisciplinary team works closely together, within the focus of a diabetic foot clinic, which ideally is situated in a hospital. The team should meet regularly for ward rounds and X-ray conferences. Each team member should be available quickly in an emergency. Some roles may overlap, depending on local expertise and interest. Patients in stage 3-5 are best seen in the multi-disciplinary foot service, which takes early referrals from a primary care service. Patients in stages 1 and 2 can be seen in primary care: however, there should be very rapid referral pathways between the primary care service and the hospital multidisciplinary foot service. There should be defined pathways and timescales for the treatment and follow-up of all patients after the feet have been classified and staged.
• Stage 1—Annual review with basic foot education
• Stage 2—It is difficult to stratify the risk of ulceration within this group. Any patient with one or more of the following—neuropathy, ischaemia, deformity, callus, swelling—should be referred for education and podiatry, receiving 3-monthly or more frequent treatment. Patients with specific problems will need the following referrals:
Severe chronic ischaemia to diabetic foot clinic or vascular clinic within 1 week Acute ischaemia to diabetic foot clinic or vascular clinic same day Any neuropathic fracture/Charcot's osteoarthropathy to diabetic foot clinic within 24 h Painful neuropathy to diabetic foot clinic within 2 weeks
• Stage 3—to diabetic foot clinic within 1 week. Maximum follow-up period 2 weeks
• Stage 4—to diabetic foot clinic same day (may need admission for intravenous antibiotics or outpatient treatment with oral or intramuscular antibiotics). Maximum follow-up period 1 week
• Stage 5—to diabetic foot clinic same day for admission: after discharge, maximum follow-up period 1 week until any remaining necrosis is dry and well demarcated, then 2-weekly until fully healed
• Stage 6—to diabetic foot clinic same day for admission. Remaining foot should be inspected daily during perioperative and rehabilitation period. After discharge from hospital, should be followed up with maximum interval between treatments of 6 weeks.
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