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The purpose of this study was to quantify the impact of an integrated diabetic foot surgical service on outcomes.
We abstracted registry data from 48 consecutive months at a single institution, evaluating all patients with diabetic foot complications requiring foot surgery or vascular intervention. We compared outcomes in the 24 months before and after integrating podiatric surgery with a vascular surgical limb-salvage service.
The service performed 2923 operations; 790 operations (27.0%) were related to the treatment of diabetic foot complications in 374 patients. Of these, 502 operations were classified as nonvascular diabetic foot surgery and 288 were vascular interventions. Overall, one third of patients required vascular intervention, initially endovascular in 86.5% of patients. Conversion to open bypass was required in 29.2% of these patients, more than double the revision rate of those receiving open bypass first (13.1%). After team integration, vascular reconstructions increased 44.2%. This increase held true for both endovascular (26.7% increase) and open interventions (88.2% increase), with a trend toward more infrageniculate vascular procedures (43.2% vs 57.7%; P = .02; odds ratio [OR] = 1.8). After team integration, the percentage of urgent operations was significantly reduced (74.4% vs 51.8%; P < .0001; OR = 2.7), and the high/low amputation ratio decreased from 0.34 to 0.26, (P < .0001) due to an increase in midfoot amputations (6.7% vs 11.6%; P < .08; OR = 1.8). Below knee amputations (BKAs) were reduced 45.7% with a relatively stable above knee/below knee amputation (AKA/BKA) ratio (0.73-0.81).
Creation of an interdisciplinary vascular and podiatric surgical team significantly impacts surgery type and volume. Significantly more nonurgent operations are performed with a decrease in the high/low amputation ratio. Vascular surgery volume is significantly increased, especially with regard to open infrageniculate procedures. While endovascular procedures have become increasingly applicable, open bypass remains critical to success.
Re: The Impact and Outcomes of Establishing an Integrated Interdisciplinary Team to Care for Patients with Diabetic Foot Ulcers
The Impact and Outcomes of Establishing an Integrated Interdisciplinary Surgical Team To Care for The Diabetic Foot.
Armstrong DG, Bharara M, White M, Lepow B, Bhatnagar S, Fisher T, Kimbriel HR, Walters J, Goshima KR, Hughes J, Mills JL. Diabetes Metab Res Rev. 2012 Mar 19.
To quantify the impact of an integrated diabetic foot surgical service on outcomes and changes in surgical volume and focus.
We abstracted registry data from 48 consecutive months at a single institution, evaluating all patients with diabetic foot complications requiring surgery or vascular intervention and compared outcomes in the 24 months before and after integrating podiatric surgery with vascular surgical limb-salvage service.
The service performed 2923 operations; 790 (27.0%) were related to treatment of diabetic foot complications in 374 patients. Of these, 502 were classified as non-vascular diabetic foot surgery and 288 were vascular interventions. Urgent surgery was significantly reduced after team implementation (77.7% vs. 48.5% p <0.0001, OR = 3.7, 95% CI: 2.4 - 5.5). The high/low amputation ratio decreased from 0.35 to 0.27 due to an increase in low-level (midfoot) amputations (8.2% vs. 26.1%, p <0.0001, OR = 4.0, CI: 2.0 to 83.3) A 45.7% reduction in BKAs was realized with a stable above knee/below knee amputation (AKA/BKA) ratio (0.73 to 0.81). One-third of patients required vascular intervention. Vascular reconstructions increased 44.1% following institution of the team. Initial revascularization was endovascular in 70.6% of patients. Repeat endovascular intervention or conversion to open bypass was required in 37.1% of these patients, almost double the reintervention rate of those receiving open bypass first (18.9%).
Interdisciplinary diabetic foot surgery teams may significantly impact surgery type, with greater focus on proactive/preventive rather than reactive/ablative procedures. While endovascular limb-sparing procedures have become increasingly applicable, open bypass remains critical to success