The unique multidisciplinarity of diabetes‐related foot disease

Abstract

Few diseases globally require treatment from so many different disciplines as diabetes‐related foot disease. At least 25 different professionals may be involved: casting technicians, dermatologists, diabetes (educator) nurses, diabetologists, dieticians, endocrinologists, general practitioners, human movement scientists, infectious diseases experts, microbiologists, nuclear medicine physicians, orthopaedic surgeons, orthotists, pedorthists, physical therapists, plastic surgeons, podiatric surgeons, podiatrists, prosthetists, psychologists, radiologists, social workers, tissue viability physicians, vascular surgeons, and wound care nurses. A shared vocabulary and shared treatment goals and recommendations are then essential. The International Working Group on the Diabetic Foot (IWGDF) has produced guidelines and supporting documents to stimulate and support shared and multidisciplinary evidence‐based treatment in diabetes‐related foot disease. In this special virtual issue of Diabetes/Metabolism Research and Reviews , all 21 documents of the 2023 update of the IWGDF Guidelines are bundled, added with a further 6 reviews from multidisciplinary experts to drive future research and clinical innovations, based on their contributions to the International Symposium on the Diabetic Foot. We hope the readers will enjoy this special virtual issue, and widely implement the knowledge shared here in their daily clinical practice and research endeavours with the goal to improve the care for people with diabetes‐related foot disease.

Full text

DOI: 10.1002/dmrr.3804
EDITORIAL
The unique multidisciplinarity of diabetes‐related foot
disease
Abstract
Few diseases globally require treatment from so many
different disciplines as diabetes‐related foot disease. At
least 25 different professionals may be involved: casting
technicians, dermatologists, diabetes (educator) nurses,
diabetologists, dieticians, endocrinologists, general prac-
titioners, human movement scientists, infectious diseases
experts, microbiologists, nuclear medicine physicians, or-
thopaedic surgeons, orthotists, pedorthists, physical
therapists, plastic surgeons, podiatric surgeons, podia-
trists, prosthetists, psychologists, radiologists, social
workers, tissue viability physicians, vascular surgeons, and
wound care nurses. A shared vocabulary and shared
treatment goals and recommendations are then essential.
The International Working Group on the Diabetic Foot
(IWGDF) has produced guidelines and supporting docu-
ments to stimulate and support shared and multidisci-
plinary evidence‐based treatment in diabetes‐related foot
disease. In this special virtual issue of Diabetes/Metabolism
Research and Reviews, all 21 documents of the 2023 up-
date of the IWGDF Guidelines are bundled, added with a
further 6 reviews from multidisciplinary experts to drive
future research and clinical innovations, based on their
contributions to the International Symposium on the
Diabetic Foot. We hope the readers will enjoy this special
virtual issue, and widely implement the knowledge shared
here in their daily clinical practice and research endeav-
ours with the goal to improve the care for people with
diabetes‐related foot disease.
Editorial
Few diseases require treatment from so many different disci-
plines as diabetes‐related foot disease. The disease itself consists of
multiple conditions affecting the foot, as outlined in the definition:
‘Disease of the foot of a person with current or previously diagnosed
diabetes mellitus that includes one or more of the following:
peripheral neuropathy, peripheral artery disease, infection, ulcer(s),
neuro‐osteoarthropathy, gangrene, or amputation’.
1
When a person
with diabetes mellitus develops diabetes‐related foot disease, life-
long care and treatments from a plethora of the following medical
professions (listed alphabetically) are required: casting technicians,
dermatologists, diabetes (educator) nurses, diabetologists, dieticians,
endocrinologists, general practitioners, human movement scientists,
infectious diseases experts, microbiologists, nuclear medicine physi-
cians, orthopaedic surgeons, orthotists, pedorthists, physical thera-
pists, plastic surgeons, podiatric surgeons, podiatrists, prosthetists,
psychologists, radiologists, social workers, tissue viability physicians,
vascular surgeons, and wound care nurses. This list of 25 (!) pro-
fessions is likely to be incomplete, with local circumstances some-
times requiring the inclusion of still other professions in addition.
Optimal collaboration both with the person with diabetes‐related
foot disease and informal carers, and between all these professions
requires a shared vocabulary, shared treatment goals and shared
recommendations for diagnosis and treatment.
Since their inaugural practical guidelines in 1999,
2
the Interna-
tional Working Group on the Diabetic Foot (IWGDF) has had this
multidisciplinary communication and collaboration at the heart of its
mission. Aiming to ‘produce evidence‐based guidelines to inform
health care providers all over the world on strategies for the pre-
vention and management of diabetes‐related foot disease’, the
IWGDF has updated and improved its guidelines every 4 years since
1999. In this special virtual issue of Diabetes/Metabolism Research and
Reviews, all guidelines and their supporting documents are bundled,
to provide readers, from all multidisciplinary backgrounds, a com-
plete update on the science and clinical practice of this devastating
disease.
For those with almost no time to read, the practical guidelines
3
provide a key summary for the clinician at the coalface. This is the
minimum that each clinician who treats a person with diabetes‐
related foot disease should know and do. The information in the
practical guidelines is based on the 7 evidence‐based guidelines, each
describing in detail the recommendations on their specific topic, that
is, prevention,
4
classification,
5
infection,
6
peripheral artery disease,
7
offloading,
8
wound healing,
9
and Charcot's neuro‐osteo‐
arthropathy
10
. The evidence underlying these recommendations is
described in 11 systematic reviews of the literature,
11–21
collectively
having screened >100,000 publications. For full transparency, the
methodology is described in even more detail in a separate
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document
22
and, to further ensure a shared language, detailed defi-
nitions and criteria are also provided.
1
In addition to these 21 publications that describe the present‐
day knowledge in diabetes‐related foot disease, we also present 6
reviews from experts in the field in this special virtual issue.
23–28
These reviews aim to help guide the field forward, and discuss
topics where the evidence may be thin, and where research and
clinical practice can together advance the field and drive innovations.
The authors discussed these latest developments during the
quadrennial International Symposium of the Diabetic Foot in the
Hague 2023, the largest meeting in this field ‐also known as the
Olympic Games of the Diabetic Foot – and the meeting where the
IWGDF guidelines were also first publicly presented.
As a result of the ever‐growing burden of both diabetes and
diabetes‐related foot disease,
25,29
continued efforts to improve
remain needed. The unique multidisciplinarity of medical pro-
fessionals involved in diabetes‐related foot disease as shown in the
list of 25 professions provided above requires huge collaborative
efforts. High‐quality multidisciplinary collaboration requires time and
energy from all involved. With the IWGDF, we have managed to
ensure input from experts in all these different fields, either as
working group members or the external experts who reviewed our
guidelines before they were released. In addition, IWGDF is sup-
ported by researchers with expertise in, for example, epidemiology,
guideline and trial methodology, biomechanics, and engineering.
Their collective efforts add up to more than 10 years of one full‐time
equivalent to produce these guidelines, all voluntarily contributed.
These and more stories are described in detail elsewhere.
30
The collaboration of so many different professionals within the
IWGDF is just a start. With the 2023 update of the IWGDF Guide-
lines, two guidelines have taken multidisciplinary collaboration even
further. The infection guideline is a joint effort between the IWGDF
and the Infectious Diseases Society of America (IDSA), published
simultaneously in two journals.
6,31
The peripheral artery disease
guideline is a joint effort between IWGDF, the Society of Vascular
Surgery (SVS) and the European Society of Vascular Surgery (ESVS),
with publication in three journals.
7,32,33
We are using the opportunity of this editorial with the special
virtual issue in Diabetes/Metabolism Research and Reviews to again
thank all experts from all these different and multidisciplinary
backgrounds involved, and the IDSA, SVS and ESVS, for joining us on
our journey. Reducing the high patient and societal burden of
diabetes‐related foot disease is only possible with such unique
multidisciplinary efforts. We hope the readers will enjoy this special
virtual issue, and widely implement the knowledge shared here (with
all publications being freely accessible) in their daily clinical practice
and research endeavours to improve the care for people with
diabetes‐related foot disease.
Jaap J. van Netten
1,2
Jan Apelqvist
3
Sicco A. Bus
1,2
Robert Fitridge
4
Fran Game
5
Matilde Monteiro‐Soares
6,7,8,9
Eric Senneville
10
Nicolaas C. Schaper
11
1
Department of Rehabilitation Medicine, Amsterdam UMC,
University of Amsterdam, Amsterdam, the Netherlands
2
Amsterdam Movement Sciences, Program Rehabilitation,
Amsterdam, the Netherlands
3
Department of Endocrinology, University Hospital of Malmö,
Malmö, Sweden
4
Faculty of Health and Medical Sciences, University of Adelaide,
Adelaide, South Australia, Australia
5
Research and Development Department, University Hospitals of
Derby and Burton NHS Foundation Trust, Derby, UK
6
Portuguese Red Cross School of Health – Lisbon, Lisbon, Portugal
7
Cross I&D, Lisbon, Portugal
8
MEDCIDS – Departamento de Medicina da Comunidade
Informação e Decisão em Saúde, Faculty of Medicine of the
University of Porto, Porto, Portugal
9
RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto,
Portugal
10
Department of Infectious Diseases Gustave Dron Hospital, Univ‐
lille, Tourcoing, France
11
Division Endocrinology, MUMCþ, CARIM and CAPHRI Institute,
Maastricht, the Netherlands
Correspondence
Jaap J. van Netten.
Email: j.j.vannetten@amsterdamumc.nl
ORCID
Jaap J. van Netten
https://orcid.org/0000-0002-6420-6046
Robert Fitridge https://orcid.org/0000-0001-6258-5997
Eric Senneville https://orcid.org/0000-0002-5720-8908
REFERENCES
1. van Netten JJ, Bus SA, Apelqvist J, et al. Definitions and criteria for
diabetes‐related foot disease (IWGDF 2023 update). Diabetes Metab
Res Rev. 2024;40(3):e3654. https://doi.org/10.1002/dmrr.3654
2. Apelqvist J, Bakker K, van Houtum WH, Nabuurs‐Franssen MH,
Schaper NC. International consensus and practical guidelines on the
management and the prevention of the diabetic foot. International
Working Group on the Diabetic Foot. Diabetes Metab Res Rev.
2000;16(Suppl 1):S84‐S92. https://doi.org/10.1002/1520‐7560
(200009/10)16:1þ<::aid‐dmrr113>3.0.co;2‐s
3. 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.
https://doi.org/10.1002/dmrr.3657
4. Bus SA, Sacco ICN, Monteiro‐Soares M, et al. Guidelines on the
prevention of foot ulcers in persons with diabetes (IWGDF 2023
update). Diabetes Metab Res Rev. 2024;40(3):e3651. https://doi.org/
10.1002/dmrr.3651
5. Monteiro‐Soares M, Hamilton EJ, Russell DA, et al. Guidelines on the
classification of foot ulcers in people with diabetes (IWGDF 2023
2 of 3
-
EDITORIAL
15207560, 2024, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/dmrr.3804 by Uva Universiteitsbibliotheek, Wiley Online Library on [19/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

update). Diabetes Metab Res Rev. 2024;40(3):e3648. https://doi.org/
10.1002/dmrr.3648
6. Senneville É, Albalawi Z, Van Asten SA, et al. IWGDF/IDSA guide-
lines on the diagnosis and treatment of diabetes‐related foot in-
fections (IWGDF/IDSA 2023). Diabetes Metab Res Rev. 2024;40(3):
e3687. https://doi.org/10.1002/dmrr.3687
7. Fitridge R, Chuter VH, Mills JL, et al. The intersocietal IWGDF, ESVS,
SVS guidelines on peripheral artery disease in people with diabetes
and a foot ulcer. Diabetes Metab Res Rev. 2024;40(3):e3686. https://
doi.org/10.1002/dmrr.3686
8. Bus SA, Armstrong DG, Crews RT, et al. Guidelines on offloading
foot ulcers in persons with diabetes (IWGDF 2023 update). Diabetes
Metab Res Rev. 2024;40(3):e3647. https://doi.org/10.1002/dmrr.
3647
9. Chen P, Vilorio NC, Dhatariya K, et al. Guidelines on interventions to
enhance healing of foot ulcers in people with diabetes (IWGDF 2023
update). Diabetes Metab Res Rev. 2024;40(3):e3644. https://doi.org/
10.1002/dmrr.3644
10. Wukich DK, Schaper NC, Gooday C, et al. Guidelines on the diag-
nosis and treatment of active Charcot neuro‐osteoarthropathy in
persons with diabetes mellitus (IWGDF 2023). Diabetes Metab Res
Rev. 2024;40(3):e3646. https://doi.org/10.1002/dmrr.3646
11. van Netten JJ, Sacco ICN, Lavery L, et al. Clinical and biomechanical
effectiveness of foot‐ankle exercise programs and weight‐bearing
activity in people with diabetes and neuropathy: a systematic re-
view and meta‐analysis. Diabetes Metab Res Rev. 2024;40(3):e3649.
https://doi.org/10.1002/dmrr.3649
12. Van Netten JJ, Raspovic A, Lavery LA, et al. Prevention of foot ulcers
people with diabetes at risk of ulceration: a systematic review and
meta‐analysis. Diabetes Metab Res Rev. 2024;40(3):e3652. https://
doi.org/10.1002/dmrr.3652
13. Monteiro‐Soares M, Hamilton EJ, Russell DA, et al. Classification of
foot ulcers in people with diabetes: a systematic review. Diabetes
Metab Res Rev. 2024;40(3):e3645. https://doi.org/10.1002/dmrr.
3645
14. Senneville E, Albalawi Z, van Asten SA, et al. Diagnosis of infection in
the foot of patients with diabetes: a systematic review. Diabetes Metab
Res Rev. 2024;40(3):e3723. https://doi.org/10.1002/dmrr.3723
15. Peters EJG, Albalawi Z, van Asten SA, et al. Interventions in the
management of diabetes‐related foot infections: a systematic re-
view. Diabetes Metab Res Rev. 2024;40(3):e3730. https://doi.org/10.
1002/dmrr.3730
16. Chuter V, Schaper N, Mills J, et al. Effectiveness of bedside in-
vestigations to diagnose peripheral artery disease among people
with diabetes mellitus: a systematic review. Diabetes Metab Res Rev.
2024;40(3):e3683. https://doi.org/10.1002/dmrr.3683
17. Chuter VH, Schaper NC, Mills JL, et al. Performance of prognostic
markers in the prediction of wound healing or amputation among
patients with foot ulcers in diabetes: a systematic review. Diabetes
Metab Res Rev. 2024;40(3):e3701. https://doi.org/10.1002/dmrr.
3701
18. Chuter V, Schaper N, Mills J, et al. Effectiveness of revascularisation
for the ulcerated foot in patients with diabetes and peripheral artery
disease: a systematic review. Diabetes Metab Res Rev. 2024;40(3):
e3700. https://doi.org/10.1002/dmrr.3700
19. Lazzarini PA, Armstrong DG, Crews RT, et al. Effectiveness of off-
loading interventions for people with diabetes‐related foot ulcers: a
systematic review and meta‐analysis. Diabetes Metab Res Rev.
2024;40(3):e3650. https://doi.org/10.1002/dmrr.3650
20. Chen P, Vilorio NC, Dhatariya K, et al. Effectiveness of interventions
to enhance healing of chronic foot ulcers in diabetes: a systematic
review. Diabetes Metab Res Rev. 2024;40(3):e3786. https://doi.org/
10.1002/dmrr.3786
21. Raspovic KM, Schaper NC, Gooday C, et al. Diagnosis and treatment
of active charcot neuro‐osteoarthropathy in persons with diabetes
mellitus: a systematic review. Diabetes Metab Res Rev. 2024;40(3):
e3653. https://doi.org/10.1002/dmrr.3653
22. Bus SA, Monteiro‐Soares M, Game F, et al. Standards for the devel-
opment and methodology of the 2023 IWGDF guidelines. Diabetes
Metab Res Rev. 2024;40(3):e3656. https://doi.org/10.1002/dmrr.
3656
23. Golledge J, Thanigaimani S, Barratt KS, Fadini GP. Recent de-
velopments in targets for ischemic foot disease. Diabetes Metab Res
Rev. 2024;40(3):e3703. https://doi.org/10.1002/dmrr.3703
24. Hon K, Nobels F, Senneville É, Uckay I, Maas M, Fitridge R.
Assessment and management of diabetes‐related foot infection
according to the new International Working Group on the Diabetic
Foot guidelines 2023‐Multidisciplinary grand rounds. Diabetes
Metab Res Rev. 2024;40(3):e3737. https://doi.org/10.1002/dmrr.
3737
25. Lazzarini PA, Raspovic KM, Meloni M, van Netten JJ. A new
declaration for feet's sake: halving the global diabetic foot dis-
ease burden from 2% to 1% with next generation care. Diabetes
Metab Res Rev. 2024;40(3):e3747. https://doi.org/10.1002/dmrr.
3747
26. Pouwer F, Perrin B, Lavender A, Najafi B, Ismail K, Vileikyte L. The
quest for wellness: how to optimise self‐care strategies for diabetic
foot management? Diabetes Metab Res Rev. 2024;40(3):e3751.
https://doi.org/10.1002/dmrr.3751
27. Wukich DK, Frykberg RG, Kavarthapu V. Charcot neuroarthropathy
in persons with diabetes: it's time for a paradigm shift in our
thinking. Diabetes Metab Res Rev. 2024;40(3):e3754. https://doi.org/
10.1002/dmrr.3754
28. Bus SA, Reeves ND, Armstrong DG, Najafi B. Offloading and
adherence through technological advancements: modern ap-
proaches for better foot care in diabetes. Diabetes Metab Res Rev.
2024;40(2):e3769. https://doi.org/10.1002/dmrr.3769
29. Zhang Y, Lazzarini PA, McPhail SM, van Netten JJ, Armstrong DG,
Pacella RE. Global disability burdens of diabetes‐related lower‐
extremity complications in 1990 and 2016. Diabetes Care. 2020;
43(5):964‐974. https://doi.org/10.2337/dc19‐1614
30. van Netten JJ, Apelqvist J, Bus SA, et al. The international working
group on the diabetic foot: stories and numbers behind three de-
cades of evidence‐based guidelines for the management of diabetes‐
related foot disease. Diabetes Ther. 2024;15(1):19‐31. https://doi.
org/10.1007/s13300‐023‐01510‐5
31. Senneville É, Albalawi Z, van Asten SA, et al. IWGDF/IDSA guide-
lines on the diagnosis and treatment of diabetes‐related foot in-
fections (IWGDF/IDSA 2023). Clin Infect Dis. 2023. https://doi.org/
10.1093/cid/ciad527
32. Fitridge R, Chuter V, Mills J, et al. The intersocietal IWGDF, ESVS,
SVS guidelines on peripheral artery disease in people with diabetes
mellitus and a foot ulcer. J Vasc Surg. 2023;78(5):1101‐1131. https://
doi.org/10.1016/j.jvs.2023.07.020
33. Fitridge R, Chuter V, Mills J, et al. The intersocietal IWGDF, ESVS, SVS
guidelines on peripheral artery disease in people with diabetes mel-
litus and a foot ulcer. Eur J Vasc Endovasc Surg. 2023;78(5):1101‐1131.
https://doi.org/10.1016/j.jvs.2023.07.020
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