Reduction of Major Amputations after Starting a Multidisciplinary Diabetic Foot Care Team: Single Centre Experience from Turkey

Effect of a multidisciplinary team approach in patients with diabetic foot ulcers on major adverse limb events (MALEs): systematic review and meta-analysis for the development of the Italian guidelines for the treatment of diabetic foot syndrome

The treatment of patients with diabetic foot ulcers (DFUs) is extremely complex, requiring a comprehensive approach that involves a variety of different healthcare professionals. Several studies have shown that a multidisciplinary team (MDT) approach is useful to achieve good clinical outcomes, reducing major and minor amputation and increasing the chance of healing. Despite this, the multidisciplinary approach is not always a recognized treatment strategy. The aim of this meta-analysis was to assess the effects of an MDT approach on major adverse limb events, healing, time-to-heal, all-cause mortality, and other clinical outcomes in patients with active DFUs. The present meta-analysis was performed for the purpose of developing Italian guidelines for the treatment of diabetic foot with the support of the Italian Society of Diabetology (Società Italiana di Diabetologia, SID) and the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD). The study was performed using the Grading of Recommendations Assessment, Development, and Evaluation approach. All randomized clinical trials and observational studies, with a duration of at least 26 weeks, which compared the MDT approach with any other organizational strategy in the management of patients with DFUs were considered. Animal studies were excluded. A search of Medline and Embase databases was performed up until the May 1st, 2023. Patients managed by an MDT were reported to have better outcomes in terms of healing, minor and major amputation, and survival in comparison with those managed using other approaches. No data were found on quality of life, returning-to-walking, and emergency admission. Authors concluded that the MDT may be effective in improving outcomes in patients with DFUs.

Development of the Italian clinical practice guidelines for the treatment of diabetic foot syndrome: design and methodological aspects

AIMS

Diabetic foot syndrome (DFS) and its complications are a growing public health concern. The Italian Society of Diabetology (SID) and the Italian Association of Clinical Diabetologists (AMD), in collaboration with other scientific societies, will develop the first Italian guidelines for the treatment of DFS.

METHODS

The creation of SID/AMD Guidelines is based on an extended work made by 19 panelists and 12 members of the Evidence Review Team. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide aims, reference population, and target health professionals. Clinical questions have been created using PICO (Patient, Intervention, Comparison, Outcome) conceptual framework. The definition of questions has been performed using a two-step web-based Delphi methodology, a structured technique aimed at obtaining by repeated rounds of questionnaires a consensus opinion from a panel of experts in areas wherein evidence is scarce or conflicting, and opinion is important.

RESULTS

The mean age of panelists (26.3% women) was 53.7 ± 10.6 years. The panel proposed 34 questions. A consensus was immediately reached for all the proposed questions, 32 were approved and 2 were rejected.

CONCLUSIONS

The areas covered by clinical questions included diagnosis of ischemia and infection, treatment of ischemic, neuropathic, and infected ulcers, prevention of foot ulceration, organization and education issues, and surgical management. The PICO presented in this paper are designed to provide indications for healthcare professionals in charge of diabetic foot treatment and prevention, primarily based on clinical needs of people with diabetic foot syndrome and considering the existing organization of health care.

The Opportunity for Impactful Integration of Vascular and Podiatric Care

BACKGROUND

The importance of collaboration between vascular and podiatric surgeons has been well-established. High-level partnerships are integral to the development of multidisciplinary programs and wound care centers, ultimately resulting in improved patient outcomes. This vascular-podiatric integration is not universal, however, and podiatric surgery may not be aligned within a vascular surgery division at many institutions. As one such institution, we reviewed our single-center experience in order to identify opportunities for the impactful integration of vascular-podiatric patient care.

METHODS

Institutional electronic medical records were retrospectively reviewed for all procedures performed by vascular surgeons at a high volume, safety-net academic medical center. Data were collected on all primary and additional procedures, current procedural terminology (CPT) codes, case type (elective, urgent, emergent), surgeon specialty, and date/time of the procedures performed. CPT codes were linked to the Centers for Medicare & Medicaid Services' Physician Fee Schedule to estimate the work relative value unit (wRVU) per procedure.

RESULTS

From 2018 to 2022, vascular surgeons performed a total of 12,206 operations, of which 1102 (9.9%) involved podiatric procedures. The most common vascular-performed podiatry procedures performed were toe amputations (38.1%, n = 420), transmetatarsal foot amputations (20.1%, n = 222), and ankle/foot debridement (16.2%, n = 178). Foot/ankle-specific procedures were identified as the primary procedure in 726 (65.9%) cases and as the adjunct procedure in 376 (34.1%) cases. A substantial proportion of podiatric procedures occurred on an urgent (n = 278, 25.2%) or emergent (n = 28, 2.5%) basis. A total of 163 (14.8%) cases occurred after hours (either before 0600 or after 1800), and 133 (12.1%) cases were performed on a holiday or weekend. Procedure-specific revenue included 4243.39 wRVU for primary procedures and 2108.08 wRVU for additional procedures performed.

CONCLUSIONS

We report our single-center experience in which vascular surgeons provide a significant proportion of podiatric procedures. Our study underscores the potential for integrating podiatric surgeons within a vascular surgical division and presents opportunities for collaboration and enhanced patient care.

Future Projections of Diabetes-Related Amputations in Eastern Saudi Arabia During 2022-2045 Using a Validated Epidemiological Model

INTRODUCTION

Diabetes-related amputations (DRA) are associated with significant morbidity and mortality. There are limited studies on the burden of this condition and its future projections in Saudi Arabia.

OBJECTIVES

To estimate future forecasts in the burden of DRA (number of cases and mortalities) among adult diabetics (aged ≥20 years) in Al-Ahsa, Eastern Region of Saudi Arabia from 2022 to 2045.

METHODS

A simulation epidemiological model was designed and validated. It is a simple discrete-state model composed of multiple states, in which diabetics make annual transitions to either 'Major Amputations', 'Minor Amputations', or 'No Amputations' states, and then to two states of mortalities. The data inputs required are minimal, including the total diagnosed cases of diabetes for 2022 and transition parameters obtained from recent published literature. The model used some reasonable assumptions and scenarios for testing potential uncertainties around the model outputs. Model validation was conducted by comparing its estimates with the observed local data from two main hospitals in Al-Ahsa for 2022.

RESULTS

The model projected that the total number of DRA among diabetics in Al-Ahsa will increase from 129 (uncertainty interval (UI): 103-154) in 2022 to 169 (UI: 136-203) in 2030 and 227 (UI: 182-272) in 2045, assuming that the incidence rates of major and minor amputations among diabetics will remain constant. However, assuming that these incidence rates will show a gradual decline of 20% every three years, the model predicted the total number of DRA to decrease from 103 (UI: 82-124) in 2022 to 91 (UI: 73-110) in 2030 and 61 (UI: 49-74) in 2045.

CONCLUSION

DRA impose a considerable burden on patients and the healthcare system, despite the possibility of a potential decrease in incidence rates.

Will Multidisciplinary Collaboration Reduce the Disability Rate of Diabetic Foot (2009-2019)?-A Study Based on the Perspective of Organizational Reform

Objectives: Discuss the experience and practice of multidisciplinary cooperation of diabetic foot in China and analyze its impact on the quality of care.

Methods: This study observed the medical procedure by interviewing 12 key personnel in-depth. We extracted data from medical records and assessed the effect of MDT in three dimensions: quality, efficiency, and cost, to eventually achieve a final conclusion.

Results: The studied reform includes the following three aspects: the adjustment of hospital buildings layout and disciplines, one-stop outpatient, and one-stop inpatient service. After the multidisciplinary collaboration, the rate of above-knee amputation is reduced by 3.63%, the disability score per 100 diabetic foot patients decreases by 6.12, the average length of stay decreases significantly, and the cost of hospitalization shows an increasing trend.

Conclusions: Multidisciplinary collaboration is performed based on spatial layout adjustment and clinical pathway optimization, which provide more comprehensive and integrated care than a general medical team or a single specialist, thereby reducing the rate of disability, shortening the length of hospitalization. Besides, the new measurable indicator called disability score per 100 diabetic foot patients has been verified to evaluate the living ability of patients after surgery. This paper provides a reference for organizational reform of multidisciplinary diseases to support treatment and management of other multiorgan diseases.

Structure, processes, and initial outcomes of The Ottawa Hospital Multi-Specialist Limb-Preservation Clinic and Programme: A unique-in-Canada quality improvement initiative

In 2017, The Ottawa Hospital initiated a unique-in-Canada quality improvement initiative by opening a novel, multi-specialist limb-preservation clinic. We sought to describe the structure, processes, and initial outcomes of the clinic and evaluate whether it is achieving its mandate of providing high-quality wound clinical care, education, and research. We conducted a descriptive prospective cohort study alongside a nested study of 162 clinic patients requiring serial assessments. There have been 1623 visits, mostly (72.2%) from outpatients. During 17.8% of visits, patients were evaluated by >1 specialist. Therapies provided most often included negative-pressure wound therapy (32.7%), biological wound dressings (21.6%), and total contact casting (18.5%). Furthermore, 1.2% underwent toe/ray amputations or skin grafting in clinic and 22.8% were initiated on antimicrobials. Mixed-effects models suggested that mean wound volumes for those requiring serial assessments decreased by 1.6 (95% confidence interval = -0.86 to -2.27) cm³ between visits. The clinic provided seven rotations to vascular surgery, infectious diseases, dermatology, and palliative care physicians; three nursing preceptorships; and two educational workshops. It also initiated provincial and national vascular health and wound care research initiatives. This study may be used to guide development of other limb-preservation clinics and programmes. Findings support that our programme is achieving its mandate.

Demographics and outcomes of inpatients with diabetic foot ulcers treated conservatively and surgically in a metropolitan hospital network

AIMS

To describe the demographics of patients with diabetic foot ulcers (DFU) and their impact on inpatient management. Secondary outcomes identified relationships of treatment modality with mortality, length of hospital admission, readmissions and post-admission care.

METHODS

Retrospective cohort study including patients with DFU admitted to a hospital network in Melbourne, Australia from 2016 to 2018. Medical records were manually reviewed for acute admission with DFU as a major presenting diagnosis; incidental ulcers and traumatic amputations were excluded. Amputations distal and proximal to the ankle were labelled 'minor' and 'major' respectively. Patients were followed until October 31, 2019.

RESULTS

Of 338 patients, 21 and 148 had major and minor amputations, and 169 were managed conservatively. 94% had ≥1 microvascular and/or macrovascular complication. Conservative management (7 days) was associated with a shorter length of stay (major 18, minor 10 days, p < 0.001). Readmission rates were not significantly different. Mortality was greatest (38%) and survival time shortest (999 days) after major amputation than after either other treatment. Other factors associated with mortality were age and a history of coronary artery disease.

CONCLUSIONS

Early identification and multi-disciplinary management of DFU is essential to reduce the significant morbidity and mortality associated with amputation in these complex patients.

A systematic review with meta-analysis of the impact of access and quality of diabetic foot care delivery in preventing lower extremity amputation

AIMS

To assess the impact of diabetic foot care delivery in preventing lower extremity amputation (LEA).

METHODS

We systematically searched the MEDLINE database for research evaluating the association between any aspect of diabetic foot care delivery and risk of LEA. Meta-analysis was conducted by calculating a pooled odds ratio through a random effects model.

RESULTS

Our search retrieved 5093 articles. In total, 58 articles were included: 9 addressing healthcare access, 4 educating health professionals, 2 implementing guidelines, 6 receiving chiropody/podiatry care services and 37 implementing structured diabetic foot care services (SDFC). All of these aspects of diabetic foot care seemed to have a positive impact on preventing LEA. Only SDFC literature met criteria for performing a meta-analysis. For SDFC impact on preventing overall and major LEA but not for minor LEA compelling evidence was observed [aggregated odds ratio (OR) of 0.45 (95% CI 0.37-0.57), 0.40 (95% CI 0.32-0.51), and 0.87 (95% CI 0.67-1.14), respectively]. However, high heterogeneity (superior to 60%) was observed for all outcomes.

CONCLUSIONS

Results support a reduction in diabetic LEA frequency in association with structured diabetic foot care, and, in particular, major LEA. Less evidence is available for the remaining aspects of diabetic foot care delivery.

Effectiveness of multidisciplinary care teams in reducing major amputation rate in adults with diabetes: A systematic review & meta-analysis

AIMS

To determine the pooled effectiveness of multidiscipinary care teams (MCTs) in reducing major amputation rates in adults with diabetes.

METHODS

A systematic review and meta-analysis was performed, searching databases MEDLINE, EMBASE, Google Scholar, Cochrane Library, and Clinicaltrials.gov thru October 2018. We included only before-after studies comparing amputation rates before and after the implementation of a MCT for the prevention of major amputation in adults with diabetes. Our primary outcome was relative risk of major amputation. Risk ratios and 95% confidence intervals were calculated using a fixed effects model.

RESULTS

Twenty studies met the inclusion criteria. Nine studies were included in the meta-analysis, and eleven were included in a qualitative analysis. Exposure to a MCT resulted in a protective effect ranging from a RR of 0.44 [p-value < 0.00001 (95% CI 0.38, 0.51) I² = 67%] to a RR of 0.61 [p-value < 0.0001, (95% CI 0.50, 0.75) I² = 0%] after sensitivity analysis, and remained robust in qualitative analysis.

CONCLUSIONS

Healthcare systems can expect a 39-56% amputation rate reduction after implementing an MCT amputation prevention program. These findings may justify the use of additional resources needed for program implementation by helping healthcare systems predict the anticipated benefit these teams have on "possible limbs saved".

FUNDING

None.

Current Wound Care Education in Entry-Level Doctor of Physical Therapy Curricula

OBJECTIVE

To investigate how wound care instruction is currently delivered within entry-level doctor of physical therapy (DPT) educational curricula.

METHODS

An electronic survey was distributed to 226 DPT programs in the US. The questionnaire contained 27 questions about the characteristics of the wound care instruction as well as the credentials, clinical experience, and teaching experience of the instructors. Descriptive statistics were analyzed for each questionnaire item response.

MAIN RESULTS

The response rate was 22.1% (n = 50). The majority of respondents reported 10 to 29 contact hours of wound care instruction throughout the curriculum. More than half of the programs reported that their students completed a wound care observation in clinical settings. Forty-four percent of programs stated that their students had the opportunity to participate in a clinical rotation focused solely on wound care. All respondents reported that their wound care instructors were physical therapists. Of those instructors, most were seasoned clinicians, and 46% held a wound care-related certification.

CONCLUSIONS

Current entry-level DPT curricula provide physical therapy students with adequate contact hours in wound care and the opportunity for clinical experiences. The instructors are seasoned physical therapists, and nearly half of them hold advanced certification in the content area. Further studies are warranted to investigate how physical therapists practice in wound management in various clinical settings.

A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers

OBJECTIVE

Multiple single-center studies have reported significant reductions in major amputations among patients with diabetic foot ulcers after initiation of multidisciplinary teams. The purpose of this study was to assess the association between multidisciplinary teams (ie, two or more types of clinicians working together) and the risk of major amputation and to compile descriptions of these diverse teams.

METHODS

We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials from inception through May 24, 2019 for studies reporting the association between multidisciplinary teams and major amputation rates for patients with diabetic foot ulcers. We included original studies if ≥50% of the patients seen by the multidisciplinary team had diabetes, they included a control group, and they reported the effect of a multidisciplinary team on major amputation rates. Studies were excluded if they were non-English language, abstracts only, or unpublished. We used the five-domain Systems Engineering Initiative for Patient Safety Model to describe team composition and function and summarized changes in major amputation rates associated with multidisciplinary team care. A meta-analysis was not performed because of heterogeneity across studies, their observational designs, and the potential for uncontrolled confounding (PROSPERO No. 2017: CRD42017067915).

RESULTS

We included 33 studies, none of which were randomized trials. Multidisciplinary team composition and functions were highly diverse. However, four elements were common across teams: teams were composed of medical and surgical disciplines; larger teams benefitted from having a "captain" and a nuclear and ancillary team member structure; clear referral pathways and care algorithms supported timely, comprehensive care; and multidisciplinary teams addressed four key tasks: glycemic control, local wound management, vascular disease, and infection. Ninety-four percent (31/33) of studies reported a reduction in major amputations after institution of a multidisciplinary team.

CONCLUSIONS

Multidisciplinary team composition was variable but reduced major amputations in 94% of studies. Teams consistently addressed glycemic control, local wound management, vascular disease, and infection in a timely and coordinated manner to reduce major amputation for patients with diabetic foot ulcerations. Care algorithms and referral pathways were key tools to their success.

Inpatient Management of Diabetic Foot Infections: A Review of the Guidelines for Hospitalists

Diabetic foot infections (DFIs) are common and represent the leading cause for hospitalization among diabetic complications. Without proper management, DFIs may lead to amputation, which is associated with a decreased quality of life and increased mortality. However, there is currently significant variation in the management of DFIs, and many providers fail to perform critical prevention and assessment measures. In this review, we will provide an overview of the diagnosis, management, and discharge planning of hospitalized patients with DFIs to guide hospitalists in the optimal inpatient care of patients with this condition.

Building a Multidisciplinary Hospital-Based Wound Care Center: Nuts and Bolts

BACKGROUND

A hospital-based wound care center provides an important platform for the multidisciplinary approach to wound care. The colocation of specialists is an ideal working environment for the efficient delivery of quality care of the complex wound through daily communication and shared resources.

METHODS

We describe the critical components necessary in building a hospital-based wound care center. Furthermore, the experience at the authors' institution in developing the multidisciplinary approach is discussed.

RESULTS

Readily available ancillary services, specially trained personnel, continuum of care from the outpatient clinic to admission to surgery, and inpatient and outpatient post operative care all contribute to a process that is especially amenable to the care of the complex wound.

CONCLUSIONS

The final goal is to return the patient to the best quality of life achievable given his or her wound or disability. The aim of this study is to present the authors' experiences and provide insight for others who may want to build this model within their institutions.

The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios

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Interdisciplinary teams (IDTs) should aim to implement a patient-centred approach.

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IDTs can enable improved glycaemic control and reduced cardiometabolic risk.

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Successful IDTs require strong leadership, good communication and shared goals.

The Global Partnership for Effective Diabetes Management has previously recommended the implementation of an interdisciplinary team (IDT) approach to type 2 diabetes (T2DM) management as one of 10 practical steps for health care professionals to help more people achieve their glycaemic goal. This article discusses some of the key contributors to success and also the challenges faced when applying IDT care, by examining case studies and examples from around the world. The real-world practices discussed show that implementing successful interdisciplinary care in diabetes is possible despite significant barriers such as established hierarchal structures and financial resource constraints. Instituting collaborative, integrated working relationships among multiple disciplines under strong leadership, together with enhanced and active communication and improved patient access to appropriate specialties is essential. Patients have a crucial role in the management of their own disease and including them as part of the treatment team is also critical. IDTs in diabetes care improve patient outcomes in terms of control of glycaemia and cardiometabolic risk factors, and decreased risk of diabetes complications. Ensuring access to an appropriate IDT, in whatever form, is paramount to enable the best care to be delivered.

A Critical Evaluation of Existing Diabetic Foot Screening Guidelines

AIM

To evaluate critically the current guidelines for foot screening in patients with diabetes, and to examine their relevance in terms of advancement in clinical practice, improvement in technology, and change in socio-cultural structure.

METHODS

A structured literature search was conducted in Pubmed/Medline, CINAHL, Cochrane Register of Controlled Trials, and Google between January 2011 and January 2015 using the keywords '(Diabetes) AND (Foot Screening) AND (Guidelines)'.

RESULTS

Ten complete diabetes foot screening guidelines were identified and selected for analysis. Six of them included the full-process guidelines recommended by the International Diabetes Federation. Evaluation of the existing diabetes foot screening guidelines showed substantial variability in terms of different evidence-based methods and grading systems to achieve targets, making it difficult to compare the guidelines. In some of the guidelines, it is unclear how the authors have derived the recommendations, i.e. on which study results they are based, making it difficult for the users to understand them.

CONCLUSIONS

Limitations of currently available guidelines and lack of evidence on which the guidelines are based are responsible for the current gaps between guidelines, standard clinical practice, and development of complications. For the development of standard recommendations and everyday clinical practice, it will be necessary to pay more attention to both the limitations of guidelines and the underlying evidence.

Complications of the diabetic foot

The diabetic foot is at high risk for complications because of its role in ambulation. Peripheral neuropathy and peripheral vascular disease can lead to chronic foot ulcers, which are at high risk for infection, in part attributable to areas of high pressure caused by lack of tolerance of the soft tissue and bone and joint deformity. If left untreated, infection and ischemia lead to tissue death, culminating in amputation. Treatment strategies include antibiosis, topical therapies, offloading, debridement, and surgery. A multidisciplinary team approach is necessary in the prevention and treatment of complications of the diabetic foot.

Treatments for diabetic neuropathy

Diabetic neuropathy comprises disorders of peripheral nerve in diabetes patients after exclusion of other disorders and can be focal or diffuse. The focal diabetic neuropathies tend to resolve spontaneously and are treated by reassurance, physiotherapy and analgesia for painful symptoms. Diabetic sensorimotor polyneuropathy (DSP) is the most frequent form of diabetic neuropathy and effective disease-modifying treatment is not available beyond the interventions of optimal glycemic control, and possibly lifestyle and risk factor modification. In contrast, a recent evidence-based guideline shows that effective treatments for painful DSP include: pregabalin, amitriptyline, duloxetine, venlafaxine, gabapentin, opioids, nitrate sprays, capsaicin, and transcutaneous electrical nerve stimulation. The choice of treatment is guided by the clinical status of the individual patient.

Angiotensin-converting enzyme gene single polymorphism as a genetic biomarker of diabetic peripheral neuropathy: longitudinal prospective study

BACKGROUND

Identifying patients at risk of developing diabetic peripheral neuropathy (DPN) is of paramount importance in those with type 2 diabetes mellitus (T2DM) to provide and anticipate secondary prevention measures as well as intensify action on risk factors, particularly so in primary care. Noteworthy, the incidence of DPN remains unknown in our environment.

AIMS

(i) To analyze a single angiotensin-converting enzyme (ACE) gene polymorphism (D/I) as a genetic marker of risk of developing DPN, and (ii) to determine the incidence of DPN in our environment.

RESEARCH DESIGN AND METHODS

Longitudinal study with annual follow-up for 3years involving a group of T2DM (N=283) randomly selected. ACE gene polymorphism distribution (I=insertion; D=deletion) was determined. DPN was diagnosed using clinical and neurophysiology evaluation.

RESULTS

Baseline DPN prevalence was 28.97% (95% CI, 23.65-34.20). ACE polymorphism heterozygous genotype D/I presence was 60.77% (95% CI, 55.05-66.5) and was independently associated with a decreased risk of DPN (RR, 0.51; 95% CI, 0.30-0.86). DPN correlated with age (P<0.001) but not with gender (P=0.466) or time of evolution of T2DM (P=0.555). Regarding end point, DPN prevalence was 36.4% (95% CI, 30.76-42.04), and accumulated incidence was 10.4% 3years thereafter. In the final Poisson regression analysis, the presence of heterozygous genotype remained independently associated with a decreased risk of DPN (RR, 0.71; (95% CI, 0.53-0.96). DPN presence remained correlated with age (P=0.002), but not with gender (P=0.490) or time of evolution (P=0.630).

CONCLUSIONS

In our series, heterozygous ACE polymorphism (D/I) stands as a protective factor for DPN development. Accumulated incidence of DPN was relevant. Further prospective studies are warranted.

Change in amputation predictors in diabetic foot disease: effect of multidisciplinary approach

Diabetic foot disease causes important morbidity in diabetic population, and amputation due to diabetic foot disease occurs more often than in general population. We have been evaluating patients with diabetic foot disease in a multidisciplinary approach since year 2000. In the current study, we sought to investigate the change in amputation rate and its predictors in diabetic foot with a multidisciplinary team approach. Seventy-four patients (52 male, 22 female) hospitalised between January 2002 and December 2007 were retrospectively analysed. Sixteen out of 74 have undergone amputation. We found overall amputation rate as 21.6%, which is lower than previously reported from our institution (36.7 and 39.4%, respectively). Major amputations (syme, below-knee, above-knee) were applied to 11 patients (14.9%). A logistic regression model including osteomyelitis, peripheral neuropathy, peripheral vascular disease, hypertension, gangrene and age revealed that gangrene is now the only significant predictor for amputation. Our observations confirm that amputation rate has declined after implementation of a multidisciplinary team work, and risk factors apart from presence of gangrene are no longer amputation predictors in our centre.