Diabetes is increasingly common, probably due to Western lifestyles and diet. Diabetics develop a number of problems with their feet
- Stiff deformities
- Peripheral neuropathy
- Peripheral vascular disease
- Charcot neuropathic arthropathy
These are serious complications which seriously affect quality of life (Pakarinen 2009, Hogg 2012). Patients with diabetic ulcers often feel hopeless and unable to influence their health (Beattie 2012). Winkley (2009) found that quality of life was most affected in patients with recurrent ulcers or ulcers that did not heal.
Diabetic foot problems lead to restricted mobility, systemic ill-health, hospitalisation and reduced lifespan. van Baal (2010) calculated that diabetics with foot ulcers or Chrcot arthropathy lost approximately 14 years of life expectancy.
Sixty percent of lower limb amputations occur in diabetics. Diabetics are seven times more likely to have a major lower limb amputation than the general population, and when osteomyelitis is present, amputation is 22 time more likely. Overall, patients who have major lower limb amputations have higher mortality and lower mobility than those who keep at least part of their feet (Evans 2011). The costs of caring for people with diabetic foot disease are substantial.
Prevention, early treatment and good aftercare can reduce the burden of diabetic foot disease for diabetics themselves and for the community. This requires good teamworking, bringing together:
- orthopaedic and podiatric foot and ankle surgeons
- non-surgical podiatrists
- vascular surgeons
- wound care specialists
- orthotists and bioengineers
NICE (2011) recommended that "A multidisciplinary foot care team should manage the care pathway of patients with diabetic foot problems" and that this team should include:
- a diabetologist
- a surgeon with the relevant expertise in managing diabetic foot problems
- a diabetes nurse specialist
- a podiatrist and a tissue viability nurse
and "the team should have access to other specialist services". While these recommendations were directed at the care of inpatients, there seems no good reason why outpatients, who constitute the majority of diabetcs with foot problem, should not expect the same standards of care.
Studies across many clinical contexts, in Western and developing countries, find that the multidisciplinary team approach has been associated with a reduction of 40-80% in amputations for diabetic foot problems (Sanders 2009, Dooresteijn 2010, Schaper 2012). Prevention of mortality is mainly achieved by attention to cardiovascular risk factors (Firestone 2010, Brownrigg 2012).
Diabetics have many other potentially serious problems:
- cardiovascular disease, including periperal arterial disease
- renal disease
- eye disease
- increased susceptibility to infection
which may influence the feasibility, success and risks of surgery and which call for the involvement of many specialists. The diabetic patient can contribute a lot to their own treatment and may find organisations like the British Diabetic Association helpful.