Lower-limb amputation remains one of the most feared complications of diabetes, and most amputations begin with a foot ulcer. Because diabetic foot disease involves nerve damage, arterial disease, infection, deformity and wound biology at the same time, no single specialty can address every driver. This article reviews what systematic reviews and guidelines published since 2015 show about organised, team-based care and its relationship to amputation.
Why Diabetic Foot Ulcers Carry Such High Stakes
Armstrong, Boulton and Bus described the scale of the problem in the New England Journal of Medicine (2017): roughly one in three people with diabetes will develop a foot ulcer during their lifetime, and about 40% of healed ulcers recur within a year, rising to approximately 65% within five years. Ulceration is therefore best understood as a chronic, relapsing condition rather than a single event.
Outcomes after ulceration are sobering. Armstrong and colleagues, in the Journal of Foot and Ankle Research (2020), reported five-year mortality of about 30% after a diabetic foot ulcer and about 57% after a major amputation, figures comparable to several common cancers. These data frame why preventing the first major amputation is a central goal of care.
What Systematic Reviews Show About Multidisciplinary Care
Musuuza and colleagues conducted a systematic review of multidisciplinary teams for patients with diabetic foot ulcers, published in the Journal of Vascular Surgery (2020). The review examined whether coordinated teams were associated with fewer major amputations and concluded that team-based approaches were generally associated with reduced major amputation rates across settings, although the underlying studies were mostly observational and varied in design.
Meza-Torres and colleagues extended this work in Diabetologia (2021) with a systematic review and meta-analysis of health service organisation in people with type 2 diabetes and foot ulcers. Of 57 studies identified, seven were eligible for pooling. Organised care, which included dedicated teams, care pathways and protocols, was associated with a 29% lower odds of any lower-extremity amputation (OR 0.71, 95% CI 0.52–0.96) and a 48% lower odds of major amputation (OR 0.52, 95% CI 0.30–0.91). The authors cautioned that more standardised research is needed on cost-effectiveness and implementation barriers.
Who Is on the Team?
Teams described in this literature typically combine podiatric medicine, vascular surgery, infectious disease, endocrinology, wound nursing, orthotics and offloading expertise, with orthopaedic or plastic surgery and rehabilitation available as needed. The common thread is not a specific job title but timely access: rapid vascular assessment, early infection management, appropriate offloading and glycaemic optimisation occurring in parallel instead of sequentially.
Guideline Recommendations on Organising Care
The International Working Group on the Diabetic Foot (IWGDF) and partner organisations, in their 2023 guideline suite and the accompanying practical guidance (Schaper and colleagues, Diabetes/Metabolism Research and Reviews, 2024), emphasise structured, tiered care. This includes risk stratification of every person with diabetes, regular foot screening, prompt referral of anyone with an active ulcer, and access to a multidisciplinary team for those with infection, ischaemia or a wound that is not progressing. Delays in referral are a recurring and potentially modifiable contributor to poor outcomes.
Interpreting the Evidence
Several caveats apply. Most studies comparing organised care with usual care are observational, so patient selection, healthcare system differences and concurrent improvements in practice may account for part of the benefit. Team structures differ widely, which limits direct comparison. Even so, the direction of effect has been consistent across reviews and settings, and the mechanism is biologically plausible: coordinated care shortens the time to revascularisation assessment, infection control and offloading, each of which independently influences limb outcomes.
Key Takeaways
Diabetic foot ulcers are common, frequently recur and carry substantial mortality. Systematic review evidence from 2020 and 2021 associates multidisciplinary, protocol-driven care with lower rates of both minor and major lower-extremity amputation, with pooled estimates suggesting nearly half the odds of major amputation. Current IWGDF guidance supports tiered screening and early referral to coordinated teams. Higher-quality prospective research is still needed to define optimal team composition and cost-effectiveness.
References
- Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376:2367–2375.
- Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, Padula WV, Bus SA. Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer. J Foot Ankle Res. 2020;13:16.
- Musuuza J, Sutherland BL, Kurter S, Balasubramanian P, Bartels CM, Brennan MB. A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers. J Vasc Surg. 2020;71(4):1433–1446.
- Meza-Torres B, Carinci F, Heiss C, Joy M, de Lusignan S. Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis. Diabetologia. 2021;64:954–966.
- Schaper NC, van Netten JJ, Apelqvist J, et al. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev. 2024;40(3):e3657.
Comments
