SLR - November 2020 - Ameer Matariyeh

Impact of Multidisciplinary Foot Care Team on Outcome of Diabetic Foot Ulcer in Term of Lower Extremity Amputation at a Tertiary Care Unit in Karachi, Pakistan

Reference: Riaz M, Miyan Z, Waris N, et al. Impact of Multidisciplinary Foot Care Team on Outcome of Diabetic Foot Ulcer in Term of Lower Extremity Amputation at a Tertiary Care Unit in Karachi, Pakistan. Int Wound J. 2019;16(3):768-772. doi:10.1111/iwj.13095

Level of Evidence: Level IV

Reviewed By: Ameer Matariyeh, DPM 
Residency Program: Southern Arizona VA Health Care System – Tucson, AZ

Podiatric Relevance: Diabetes Mellitus is a disease recognized on a global platform with diabetic foot ulcers resulting in lower extremity amputations listed as a leading complication. Within the United States, about a quarter of diabetics will encounter a foot ulcer over the course of the disease; while Pakistan mimics similar outcomes with seventy percent lower extremity amputations preceded by foot ulcers. Previous studies list multidisciplinary medicine as the leading reduction in diabetic limb amputations. This study compares outcomes of diabetic foot ulcers and lower extremity amputation rates in cohorts before and after implementing multidisciplinary foot care teams at a Pakistani tertiary care unit.

Methods: Retrospective cross-sectional study of 7994 cases over the course of 20 years with diabetic foot ulcers subjects split into two groups. Group A subjects (888 feet) were treated prior to Multidisciplinary Foot Care Team (MFCT) approach and Group B subjects (7106 feet) received MFCT service. MFCT included physicians trained in diabetic foot surgery, standard operating procedures dictated by vascular and orthopedic surgeons, neurothesiometer and vascular doppler evaluation, wound care assistants, footwear technicians, access to interventional radiologists, and a twenty-four-hour helpline to advance compliance. Patient demographics, duration of diabetes, hemoglobin A1c, ulcer types and history. Amputation vs. epithelialization outcomes recorded utilizing Statistical Package for Social Science (SPSS) with p-value significance <0.05. 

Results: Upon initial review in clinic, both groups had similar average HbA1c values with 9.79 in Group A and 10.17 in Group B. Group A had 51.7 percent neuropathic ulcers and 48.3 percent neuroischemic ulcers. Group B showed 87.4 percent neuropathic and 12.6 percent neuroischemic. Statistically significant (p<0.0001) improvement in epithelialization revealed in Group B with overall 89.1 percent of subjects completely healed while Group A had a 78.8 percent healed rate. Group A had 13.8 percent of subjects requiring toe amputations while Group B had a 8.11 percent toe amputation rate. Group A yielded 5.26 percent below knee amputation rate while Group B had a mere 1.82 percent (p<0.03).  

Conclusions: Rate of amputation was significantly decreased due to a MFCT application in treating diabetic ulcers. The collected data identified the most influential factors of delayed wound healing leading to amputations. The authors and MFCT practitioners were able to delegate focus and resources to the most detrimental aspects of wound healing. The study’s limitation resides in application of this specific MFCT to a single Pakistani tertiatry care unit. The authors encourage researchers to apply and document multifactorial care in varying wound care settings. 

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