title: The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine.
abstract: BACKGROUND
  Diabetes mellitus continues to grow in global prevalence and to consume an increasing amount of health care resources. One of the key areas of morbidity associated with diabetes is the diabetic foot. To improve the care of patients with diabetic foot and to provide an evidence-based multidisciplinary management approach, the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine developed this clinical practice guideline.
  
  
  METHODS
  The committee made specific practice recommendations using the Grades of Recommendation Assessment, Development, and Evaluation system. This was based on five systematic reviews of the literature. Specific areas of focus included (1) prevention of diabetic foot ulceration, (2) off-loading, (3) diagnosis of osteomyelitis, (4) wound care, and (5) peripheral arterial disease.
  
  
  RESULTS
  Although we identified only limited high-quality evidence for many of the critical questions, we used the best available evidence and considered the patients' values and preferences and the clinical context to develop these guidelines. We include preventive recommendations such as those for adequate glycemic control, periodic foot inspection, and patient and family education. We recommend using custom therapeutic footwear in high-risk diabetic patients, including those with significant neuropathy, foot deformities, or previous amputation. In patients with plantar diabetic foot ulcer (DFU), we recommend off-loading with a total contact cast or irremovable fixed ankle walking boot. In patients with a new DFU, we recommend probe to bone test and plain films to be followed by magnetic resonance imaging if a soft tissue abscess or osteomyelitis is suspected. We provide recommendations on comprehensive wound care and various débridement methods. For DFUs that fail to improve (>50% wound area reduction) after a minimum of 4 weeks of standard wound therapy, we recommend adjunctive wound therapy options. In patients with DFU who have peripheral arterial disease, we recommend revascularization by either surgical bypass or endovascular therapy.
  
  
  CONCLUSIONS
  Whereas these guidelines have addressed five key areas in the care of DFUs, they do not cover all the aspects of this complex condition. Going forward as future evidence accumulates, we plan to update our recommendations accordingly.
authors.affiliation: NYU Lutheran Medical Center, Brooklyn, NY. Electronic address: ahingorani67@gmail.com.
authors.forename: Anil
authors.initials: A
authors.lastname: Hingorani
authors.affiliation: Massachusetts General Hospital and Harvard Medical School, Boston, Mass.
authors.forename: Glenn M
authors.initials: GM
authors.lastname: LaMuraglia
authors.affiliation: University of Michigan, Ann Arbor, Mich.
authors.forename: Peter
authors.initials: P
authors.lastname: Henke
authors.affiliation: University of Washington, Seattle, Wash.
authors.forename: Mark H
authors.initials: MH
authors.lastname: Meissner
authors.affiliation: UMass Memorial, Worcester, Mass.
authors.forename: Lorraine
authors.initials: L
authors.lastname: Loretz
authors.affiliation: Geisinger Health System, Danville, Pa.
authors.forename: Kathya M
authors.initials: KM
authors.lastname: Zinszer
authors.affiliation: Brown University, Alpert Medical School, Providence, RI.
authors.forename: Vickie R
authors.initials: VR
authors.lastname: Driver
authors.affiliation: Carl T. Hayden Veterans Affairs Medical Center, Phoenix, Ariz.
authors.forename: Robert
authors.initials: R
authors.lastname: Frykberg
authors.affiliation: University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Teresa L
authors.initials: TL
authors.lastname: Carman
authors.affiliation: University of North Carolina School of Medicine, Chapel Hill, NC.
authors.forename: William
authors.initials: W
authors.lastname: Marston
authors.affiliation: Baylor College of Medicine in Houston, Houston, Tex.
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Mills
authors.affiliation: Mayo Clinic, Rochester, Minn.
authors.forename: Mohammad Hassan
authors.initials: MH
authors.lastname: Murad
mesh_terms: D017719:Diabetic Foot / Q000628:therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D011032:Podiatry; D012955:Societies, Medical; D014481:United States; D014656:Vascular Surgical Procedures