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Complacency is not warranted: Teamwork is needed

"The number of lower leg amputations is still too high" is a rarely disputed statement
among medical professionals who treat leg/foot tissue loss. The debate over how many
legs are lost in each country is a difficult one, as different countries rely on different
approaches to record the number of lower limb amputations.


I have noticed over the last year that all involved medical disciplines are aware of the
deficiencies in the care that patients with leg/foot tissue loss receive in Europe. Although
statistics are reliable regarding the total number of amputations, they do not give information
about the quality of medical treatment. Furthermore, information about the quality of medical
treatment and about the underlying diseases is sparse.

The good news is that with well-organised, interdisciplinary care and education for patients to
enable them to control their diabetes and encourage good self-management, more than 70% of
amputations are preventable. However, there is no one single approach to improving patient
outcomes as there are many aspects to consider - such as early referral, early intervention,
infection control and removing healthcare system hurdles - when solving the puzzle of
preventing amputations.

Early referral

Patients should be referred to an interdisciplinary team of specialists as soon as possible. The
aetiologies of leg tissue loss are more complex and hence challenging than previously
recognised, which may be a consequence of both increasing ulcer chronicity and age.
An interdisciplinary team of specialists needs to work together to establish an all-
encompassing diagnosis, breaking down traditional silos of responsibility and attacking the
challenge from a patient-centred view where all involved share responsibility for all aspects
of patient care (see case study).

Early intervention and infection control

Early intervention can help save limbs both in securing flow and also in avoiding chronicity
of wounds. When problems with wounds are identified early, appropriate interventions should
avoid complications and facilitate healing.

Infection control is of course crucial to preventing amputation. However, it is not always
identified early. As Michael Edmonds highlights in the article on page 2, "All healthcare
professionals looking after diabetic patients should understand that the white blood count and
body temperature may be normal even in severe infections. A normal white blood count or
temperature does not rule out infection in diabetes." Removing healthcare system hurdles is
another part of the puzzle. A partnership between efficient professional networks and
competent insurers has been able to eradicate the majority of the structural problems when
treating the diabetic foot, as shown in the diabetic foot network Cologne (see case study).

Preventing amputations requires professionals to change the way they treat patients with leg/
foot tissue loss and healthcare systems need to be changed to incentivise medical
professionals to roll out the current best approach in their daily practice. Some centres of
excellence are showing that it is possible to almost eradicate the number of leg amputations,
but the word needs to be spread, professionals need to be educated to understand both the
complexity of treating leg/foot tissue loss and ways to prevent amputation. At this time of
ageing populations and given the significant impact of leg/foot tissue loss on the lives of
patients, the emphasis must now be on innovating to reach the objectives of the St Vincent
Declaration agreed in October 1989, which set out general goals for people with diabetes.
This should not be limited to diabetic patients, all patients with leg/foot tissue loss should
benefit from optimal care. One discipline alone cannot make a difference, only together can
we eradicate the disease and improve patient outcomes. The ilegx symposium, which will be
held in Munich, Germany, on 13-14 October 2009, will focus on these issues. A diverse
attendance from all specialties involved in foot and leg care will facilitate the sharing of
knowledge and experience to keep an interdisciplinary approach at the heart of caring for
patients with foot/leg tissue loss.