title: The impact and outcomes of establishing an integrated interdisciplinary surgical team to care for the diabetic foot.
abstract: OBJECTIVE
  This study aimed to quantify the impact of an integrated diabetic foot surgical service on outcomes and changes in surgical volume and focus.
  
  
  METHODS
  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.
  
  
  RESULTS
  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, 95% CI: 2.0-83.3). A 45.7% reduction in below-knee amputations was realized with a stable above-knee/below-knee amputation ratio (0.73-0.81). 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%).
  
  
  CONCLUSIONS
  Interdisciplinary diabetic foot surgery teams may significantly impact surgery type, with greater focus on proactive and preventive, rather than reactive and ablative, procedures. Although endovascular limb-sparing procedures have become increasingly applicable, open bypass remains critical to success.
authors.affiliation: University of Arizona, Department of Surgery, Tucson, AZ 85724, USA. armstrong@usa.net
authors.forename: David G
authors.initials: DG
authors.lastname: Armstrong
authors.forename: Manish
authors.initials: M
authors.lastname: Bharara
authors.forename: Matthew
authors.initials: M
authors.lastname: White
authors.forename: Brian
authors.initials: B
authors.lastname: Lepow
authors.forename: Sugam
authors.initials: S
authors.lastname: Bhatnagar
authors.forename: Timothy
authors.initials: T
authors.lastname: Fisher
authors.forename: Heather R
authors.initials: HR
authors.lastname: Kimbriel
authors.forename: Jodi
authors.initials: J
authors.lastname: Walters
authors.forename: Kaoru R
authors.initials: KR
authors.lastname: Goshima
authors.forename: John
authors.initials: J
authors.lastname: Hughes
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Mills
mesh_terms: D000671:Amputation, Surgical; D048909:Diabetes Complications / Q000601:surgery; D017719:Diabetic Foot / Q000601:surgery*; D057510:Endovascular Procedures; D005528:Foot / Q000601:surgery; D006801:Humans; D023821:Limb Salvage; D010043:Outcome and Process Assessment, Health Care; D010348:Patient Care Team; D011032:Podiatry; D012086:Reoperation; D014656:Vascular Surgical Procedures / Q000706:statistics & numerical data