Editorial

Since the November 2000 issue of Foot and Ankle International, which was dedicated to the diabetic foot, over 100,000 Americans with diabetes have undergone lower extremity amputation as a consequence of foot infection or associated peripheral vascular disease. Diabetes 2000 was the focal point of a year-long effort by the American Orthopaedic Foot and Ankle Society (AOFAS) to highlight the worldwide epidemic associated with diabetic foot morbidity and concentrate on the current strategies of treatment. Unlike other resource-consuming morbidities, the appreciable morbidity associated with the diabetic foot can be significantly diminished without the consumption of vast sums of high-tech resources. The simple triad of identification of those at risk, foot-specific patient education, and prophylactic skin, nail, and footwear care has been shown to significantly affect the quality of life of diabetic individuals. These successes have been accomplished in a cost-effective manner.

We know that prophylactic proactive foot care decreases the morbidity associated with the diabetic foot. Established programs combine risk assessment, foot-specific patient education, skin and nail care, and therapeutic footwear. ² How can an interested physician institute this type of care in their local “health system”? Can the same techniques successful in large urban managed medical environments be employed in small rural communities?

The first step is risk stratification. One in four diabetics has loss of protective sensation, as measured by insensitivity to the Semmes-Weinstein 5.07 (10 g) monofilament. One in four has a deformity, and one in three has asymptomatic peripheral vascular disease. Better than half wear improper footwear.^1,3 Virtually every diabetic patient visits a diabetic nurse educator. The foot screen/risk assessment can be performed during periodic patient education sessions, when risk level-specific, foot-specific patient education can be incorporated. It is imperative that this be performed one-on-one, as these individuals are not capable of retaining the information when it is provided in a group session or by written material alone. Lower risk individuals can be advised on reasonable footwear, and higher risk individuals can be referred to an orthopaedic foot and ankle surgeon, podiatrist, or supervised nurse practitioner.

The second step in the process is scheduled periodic prophylactic skin and nail care. This can be accomplished by a supervised nurse or physical therapist, physician, podiatrist, or orthopaedic surgeon, depending on the specific needs of the individual patient and the resources of the local “health system.” Medicare has appreciated that these Evaluation and Management services can be performed by a supervised nurse or physical therapist, with reimbursement at 60% to 80% the rate of a trained physician. Most American healthcare benefit providers have followed the lead of Medicare and offer similar benefits. Dennis Janisse has outlined the benefits of the Medicare Therapeutic Shoe Bill, passed in 1993, which provides therapeutic footwear for individuals with diabetes at risk for the development of foot ulcers. This information can be used to develop local critical pathways that trigger referral to consultant specialists. ⁴ The final step in the process is the development of a comprehensive multispecialty wound care team. Michael Strauss and Susan Seaman have outlined how this process can be developed in a cost-effective manner. Coordination of care has been well shown to decrease morbidity and resource consumption over a period of time.

Those of us committed to the epidemic of diabetic foot associated morbidity, owe a great deal of gratitude to Dr. Hap Lutter. Dr. Lutter has been instrumental in the development of this special issue of Foot and Ankle International. His editorial support to the improvement of the quality of our work will always be remembered.

The goal of Diabetes 2000 was to highlight the continued dedication of the American Orthopaedic Foot and Ankle Society to educate physicians who deal with patients “attached” to their diabetic feet. The project was initiated by Dr. Elly Trepman, who solicited translations of the AOFAS patient care instructions, appreciating their value in allowing the patient to participate in his/her care. From the patient education material, the members of the Diabetes Committee of the American Orthopaedic Foot and Ankle Society decided to provide a current summary of issues important to those who care for the diabetic patient population. Whether you practice in a small rural community, or at the hub of a large tertiary care medical center, these principles can be applied to lessen the burden of the diabetic foot.