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GUIDELINE TITLE
INTENDED USERS
Advanced Practice Nurses
Nurses
Physician Assistants
Physicians
Podiatrists
GUIDELINE OBJECTIVE(S)
SCOPE
DISEASE/CONDITION(S)
GUIDELINE CATEGORY
TARGET POPULATION
Patients with diabetes mellitus who have or who are at risk of
developing diabetic foot disorders
INTERVENTIONS AND PRACTICES CONSIDERED
Diagnosis
Evaluation
Management
Prevention
Treatment
CLINICAL SPECIALTY
3.
Cardiology
Endocrinology
Family Practice
Infectious Diseases
Internal Medicine
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4.
(Primary
Sources)
Prevention
Not stated
1.
2.
3.
4.
5.
6.
Management of comorbidities
Evaluation of vascular status
Assessment of lifestyle/psychosocial factors
Ulcer assessment and evaluation
Tissue management/wound bed preparation
Debridement (surgical/sharp), including control of
moisture
balance,
wound
dressing,
and
assessment of inflammation and infection
Pressure relief/off-loading
Management of wounds that fail to heal
2.
Immobilization/stress reduction
Progression to weightbearing
Special footwear
Reconstructive surgery
Expert Consensus
RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE
Not applicable
METHODS USED TO ANALYZE THE EVIDENCE
Review
DESCRIPTION OF THE METHODS USED TO ANALYZE THE
EVIDENCE
Not stated
METHODS USED TO FORMULATE THE RECOMMENDATIONS
Expert Consensus
DESCRIPTION OF METHODS USED TO FORMULATE THE
RECOMMENDATIONS
This clinical practice guideline is based on the consensus of
current clinical practice and review of the clinical literature.
RATING
SCHEME
FOR
RECOMMENDATIONS
THE
STRENGTH
OF
THE
Podiatric care
Protective shoes
Pressure reduction
Prophylactic surgery
Preventive education
COST ANALYSIS
A formal cost analysis was not performed and published cost
analyses were not reviewed.
METHOD OF GUIDELINE VALIDATION
Peer Review
DESCRIPTION OF METHOD OF GUIDELINE VALIDATION
METHODOLOGY
METHODS USED TO COLLECT/SELECT EVIDENCE
Not stated
RECOMMENDATIONS
MAJOR RECOMMENDATIONS
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Diabetes - duration
Glycemic management/control
Cardiovascular,
renal,
and
ophthalmic evaluations
Other comorbidities
Treating physicians
Nutritional status
Social habits: alcohol, tobacco, drugs
Current medications
Allergies
Previous hospitalizations/surgery
Wound/Ulcer History
Physical Examination
All patients with diabetes require a pedal inspection whenever
they present to any health care practitioner, and they should
receive a thorough lower extremity examination at least once
annually. Patients with complaints relating to the diabetic foot
require more frequent detailed evaluations. The examination
should be performed systematically so that important aspects
are not overlooked. It begins with a gross evaluation of the
patient and extremities. Any obvious problem can then receive
closer scrutiny.
Key components of the foot examination are presented in Table
3 of the original guideline document. Although not specifically
mentioned, it is assumed that a general medical assessment
(including vital sign measurements) will be obtained.
Diagnostic Procedures
Diagnostic procedures may be indicated in the assessment and
care of the diabetic foot. Consideration should be given to the
following tests in concert with members of the consulting team.
It should be noted that many of the following tests lack the
ability to impart a definitive diagnosis, necessitating clinical
correlation.
Location
Duration
Inciting event or trauma
Recurrences
Infection
Hospitalization
Wound care
Off-loading techniques
Wound response
Patient compliance
Interference with wound care (Family or social
problems for patient)
Previous foot trauma or surgery
Presence of edema-unilateral vs. bilateral
Charcot foot previous or active
Charcot treatment
Laboratory Tests
Plain radiographs should be the initial imaging study in diabetic
patients with signs and symptoms of a diabetic foot disorder.
Radiographs can detect osteomyelitis, osteolysis, fractures,
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require
prompt
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of
Acute
Charcot
Neuropathic
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Acute
Charcot
Neuropathic
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IMPLEMENTING
THE
GUIDELINE
POTENTIAL BENEFITS
Foot care programs emphasizing preventive management can
reduce the incidence of foot ulceration through modification of
self-care practices, appropriate evaluation of risk factors, and
formulation of treatment protocols aimed at early intervention,
limb preservation, and prevention of new lesions. The foot and
ankle surgeon should play an integral role in this scheme,
providing ongoing surveillance, education, and management of
new or impending lesions. A significant reduction in both major
and minor diabetic limb amputations is certainly attainable if
clinicians embrace these principles and incorporate them into
daily patient care.
POTENTIAL HARMS
CONTRAINDICATIONS
CONTRAINDICATIONS
#1:
#2:
#3:
#4:
#5:
#6:
Pathway
Pathway
Pathway
Pathway
Pathway
Pathway
QUALIFYING STATEMENTS
QUALIFYING STATEMENTS
CLINICAL ALGORITHM(S)
Algorithms are provided in the original guideline document for:
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While these guidelines cannot and should not dictate the care of
all affected patients, they provide evidence-based guidance for
general patterns of practice.
COMPOSITION
GUIDELINE
GROUP
THAT
AUTHORED
THE
OF
Documentation/Checklists/Forms
For information about availability, see the "Availability of Companion Documents" and
"Patient Resources" fields below.
GUIDELINE STATUS
INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE
QUALITY REPORT CATEGORIES
with
Illness
IOM DOMAIN
GUIDELINE AVAILABILITY
Effectiveness
Patient-centeredness
BIBLIOGRAPHIC SOURCE(S)
Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM,
Kravitz SR, Landsman AS, Lavery LA, Moore C, Schuberth JM,
Wukick DK, Andersen C, Vanore JV. Diabetic foot disorders: a
clinical practice guideline. J Foot Ankle Surg 2006 SepOct;45(5):S2-66. [579 references]
ADAPTATION
DATE RELEASED
PATIENT RESOURCES
None available
GUIDELINE DEVELOPER(S)
American College of Foot and Ankle Surgeons - Medical
Specialty Society
NGC STATUS
This NGC summary was completed by ECRI on October 31,
2001. It was reviewed by the guideline developers as of March
11, 2002. This NGC summary was updated by ECRI on
December 29, 2006. The updated information was verified by
the guideline developer on January 8, 2007.
SOURCE(S) OF FUNDING
Development and publication of this Clinical Practice Guideline
was made possible by an educational grant co-sponsored by
Johnson & Johnson Wound Management, a division of ETHICON,
INC. and KCI USA, Inc.
COPYRIGHT STATEMENT
Please contact the American College of Foot and Ankle Surgeons
(ACFAS) for permission to reproduce.
GUIDELINE COMMITTEE
Clinical Practice Guideline Diabetes Panel
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DISCLAIMER
NGC DISCLAIMER
The National Guideline Clearinghouse (NGC) does not develop,
produce, approve, or endorse the guidelines represented on this
site.
All guidelines summarized by NGC and hosted on our site are
produced under the auspices of medical specialty societies,
relevant
professional
associations,
public
or
private
organizations, other government agencies, health care
organizations or plans, and similar entities.
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