History of the Team Approach to Amputation Prevention

Abstract

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.

Systolic blood pressure variability and lower extremity amputation in a non-elderly population with diabetes

“…In the last quarter century, there has been a steady decrease in the amputation rates in the US (5), UK(6), and other parts of the world (7). The decrease has been rapid at first after the introduction of specialist diabetic foot clinics and multi-disciplinary approaches to diabetic foot care (6; 8; 7). However, the trend has slowed, especially in the US, in the last five to ten years (5).…”

History, Prevalence and Assessment of Limited Joint Mobility, from Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative Review of the Literature

“…The earliest observations of the presence of joint deficits in diabetic patients date back to the middle of the last century [31]. In this period, advances in DM patient therapy and, above all, the discovery of insulin (1923), radically changed routine medical practice [30]. In the middle of the last century, awareness of a progressive increase in chronic complications of severe diabetes became widespread [30].…”

“…In this period, advances in DM patient therapy and, above all, the discovery of insulin (1923), radically changed routine medical practice [30]. In the middle of the last century, awareness of a progressive increase in chronic complications of severe diabetes became widespread [30]. In this same period K. Lundbeack reported the presence of a typical “Hand Syndrome” as a long-term diabetic alteration [31].…”

“…Birke et al . suggested that physical therapists and other clinicians should evaluate how to treat patients with this problem in order to prevent ulceration under the big toe [30, 117, 118]. Therefore, even in these years, the study of the relationship between diabetes and foot ulcers, while considering the role of gait and stiffness of some foot joints, did not consider, as a whole, the role of limited joint mobility.…”

“…Identifying the role of LJM in the development of diabetic foot ulcer, providing a clear definition of its prevalence, explaining the progression of this problem and its effects on diabetes, could help to define better preventive treatments [29, 30].…”