Dr. Alastair Younger, M.D., MB ChB FRCSC
Head, BC's Foot and Ankle Clinic,
Providence Health Care,
And Clinical Associate Professor,
Division of Lower Limb Reconstruction and Oncology,
Department of Orthopaedics,
University of British Columbia,
Vancouver, BC

Diabetic foot disease usually sends an orthopaedic surgeon running. The usual response to a consult is "Call me when they need a below-knee amputation" as the surgeon disappears back to a busy and safe practice of joint replacements, arthroscopy and trauma. Diabetic feet are messy and infected, and the patients non-compliant with a multitude of other me-dical complaints. These problems are often saddled on the orthopaedic surgeon as the medicine service transfers the care after any procedure.  

Recent events in Saskatchewan highlight the issues. The go-vernment has a high bill to pay with approximately 5% of all hospital beds occupied with these patients, and with an increasing cost and incidence of the disease¹. Twenty-seven percent of the cost of diabetes is related to the treatment of peripheral neur-opathy and its complications², and one in seven health care dollars are spent on diabetes³. This amounts to 4% of total health care dollars spent being allocated to treating diabetic foot and ankle complications. Foot pathology is the most common cause of admission to hospital for patients with diabetes⁴, and results in the longest hospital stays for diabetic patients⁵. The economic impact on health care is similar to all of orthopaedic trauma. A multidisciplinary clinic can reduce the admission rate by 30% and the amputation rate by 43%⁶. Many studies show multidisciplinary clinics are effective in reducing cost^7-12. However, an orthopaedic surgeon is an essential part of the team, and very few Canadian orthopaedic surgeons are involved. As a result, the legislature in Saskatchewan had little option to approve applications from podiatrists to treat this disease, as podiatry will take ownership and manage the problem.

The costs of diabetes are high and are rising. Vascular disease itself is only rarely the cause of the foot problem in isolation. Within every hospital in Canada, there are patients with end- stage diabetic foot complications requiring surgical management. The diabetic patient is very different from the trauma patient and may not tolerate a below-knee amputation (BKA) well. A below-knee amputation in this population has a high rate of admission to long-term care, a major psychological effect on the patient, and a long recovery time. Amputations account for 80% of the costs of treatment¹³. A below-knee amputation is often refused by the patient, so other viable treatment alternatives need to be explored by the consulting orthopaedic surgeon. These alternatives may allow the patient to be discharged home. As life expectancy is short for these patients (50% mortality in five years) treatment is always symptomatic and aimed at preserving ambulation and quality of life rather than being curative4.

If your orthopaedic department takes responsibility for these patients and manages them well, then your medical colleagues and hospital will see your service in much better light as you assist them in managing a difficult problem. As orthopaedic surgeons, we may have to spearhead multidisciplinary clinics to manage these patients. Much of our role may be to organize care, as well as provide it. Such actions will improve bed utilization, as these patients can receive limb-sparing surgery, be discharged and reviewed in the clinic. Our experience is that 75% of these patients can be successfully salvaged with a transmetatarsal amputation¹⁴.

No one can be expected to take on diabetic feet full time. However if we each do a little bit - learn alternatives to BKA, learn how to treat the problems of diabetes, as well as help the government and hospitals manage these problems by setting up clinics, and take responsibility for the consults, then we will all be seen with much more respect by our patients, our hospitals, provinces and country. Canada needs us to take responsibility for this epidemic of major proportions. Are we up to the challenge?

References

1. Leichter S.B., Hernandez C., Fisher A., Collins P., et al. Diabetes in Kentucky. Diabetes Care, 1982. 5(2): p. 126-34.
   
   
2. Gordois A., Scuffham P., Shearer A., Oglesby A., et al. The health care costs of diabetic peripheral neuropathy in the U.S. Diabetes Care, 2003. 26(6): p. 1790-5.
   
   
3. Syler J. Diabetes mellitus: Old assumptions and new realities, in The Diabetic Foot, J.a.P. Bowker, MA, Editor. 2001, Mosby: St. Louis. p. 3-12.
   
   
4. Reiber G.E. Diabetic foot care. Financial implications and practice guidelines. Diabetes Care, 1992. 15 Suppl 1: p. 29-31.
   
   
5. Thompson C., McWilliams T., Scott D., and Simmons D. Importance of diabetic foot admissions at Middlemore Hospital. N Z Med J, 1993. 106(955): p. 178-80.
   
   
6. Bakker K. and Dooren J. [A specialized outpatient foot clinic for diabetic patients decreases the number of amputations and is cost saving]. Ned Tijdschr Geneeskd, 1994. 138(11): p. 565-9.
   
   
7. O'Rourke I., Heard S., Treacy J., Gruen R., et al. Risks to feet in the top end: outcomes of diabetic foot complications. ANZ J Surg, 2002. 72(4): p. 282-6.
   
   
8. Green M.F., Aliabadi Z., and Green B.T. Diabetic foot: evaluation and management. South Med J, 2002. 95(1): p. 95-101.
   
   
9. Pinzur M.S., Kernan-Schroeder D., Emanuele N.V., and Emanuel M. Development of a nurse-provided health system strategy for diabetic foot care. Foot Ankle Int, 2001. 22(9): p. 744-6.
   
   
10. Fontana E., Bulliard C., and Ruiz J. [Diabetic foot: a public health problem too often underestimated. Consequences and therapeutic possibilities]. Schweiz Rundsch Med Prax, 2001. 90(51-52): p. 2261-5.
    
    
11. Harrington C., Zagari M.J., Corea J., and Klitenic J. A cost analysis of diabetic lower-extremity ulcers. Diabetes Care, 2000. 23(9): p. 1333-8.
    
    
12. Apelqvist J. and Larsson J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes Metab Res Rev, 2000. 16 Suppl 1: p. S75-83.
    
    
13. Apelqvist J., Ragnarson-Tennvall G., Persson U., and Larsson J. Diabetic foot ulcers in a multidisciplinary setting. An economic analysis of primary healing and healing with amputation. J Intern Med, 1994. 235(5): p. 463-71.
    
    
14. Younger A., K.T., Veri J., De Vries G. Outcome Review of Transmetatarsal Amputation in Diabetic Patients as a Single Stage Procedure Using Antibiotic Pellets in the Wound. in Canadian Orthopaedic Association. 2003. Winnipeg.