Dear Editor,
We read with great interest the article entitled “Plastic surgery involvement in diabetic foot care: A national survey in National Health Service England” by Enright et al.1 This study is the first to systematically reveal, through a nationwide survey, that despite the critical role of plastic surgery in complex soft tissue reconstruction for diabetic foot conditions, its involvement in Multidisciplinary Diabetic Foot Teams (MDFTs) across England remains markedly insufficient. This finding provides a significant evidence base for improving the systematic integration of diabetic foot care. We believe that further elaboration in the following areas would enhance the article’s clinical relevance and policy impact.
Firstly, the survey indicates a lack of routine plastic surgery participation in 70% of MDFTs. However, 84% of plastic surgery units receive at least one diabetic foot-related referral annually, and 59% manage at least one case per year of failed soft tissue reconstruction initially performed by non-plastic surgeons. This paradoxical phenomenon of “low involvement, high demand, and high revision rate” suggests potential delays and passivity within the current referral mechanism, which may subject patients to prolonged healing periods, increased infection risks, and greater challenges in limb salvage. By integrating clinical pathway data to analyze the specific impact of referral delays on ulcer healing time, reoperation rates, and limb salvage rates, the necessity for early and systematic integration of plastic surgery could be more compellingly demonstrated. Analysis in this area could reference higher-level evidence in diabetic foot management supporting the value of early intervention.2
Secondly, the study notes that referrals originate primarily from orthopedic and vascular surgery departments rather than from the MDFT itself, reflecting potential “information silos” within multidisciplinary collaboration. We suggest that future research could explore the establishment of structured communication mechanisms within MDFTs, such as introducing a joint assessment checklist or holding regular interdisciplinary case conferences, to facilitate the early involvement of plastic surgery in wound assessment, infection control, and reconstruction planning. The International Working Group on the Diabetic Foot (IWGDF) guidelines also emphasize that structured multidisciplinary collaboration is central to improving outcomes.3 Similar “orthoplastic” collaborative models have proven successful in complex trauma management and merit further validation in the context of diabetic foot care.
Furthermore, the article mentions that most units lack dedicated job planning and resource support. We propose that further discussion could explore how to promote the standardized integration of plastic surgery in diabetic foot care through updates to professional society guidelines (e.g., a joint position statement by BAPRAS and Diabetes UK, referencing the IWGDF framework ), the development of specialized training curricula (incorporating diabetic foot reconstruction into plastic surgery training systems, including principles based on the angiosome concept,4 and performance-based resource allocation models.
Finally, this study provides important benchmark data for the UK healthcare system. The global burden of diabetic foot disease has been well-established.5 Incorporating a brief international comparative perspective into the discussion (such as the integrated care pathway in the Netherlands or the interdisciplinary podiatry clinic model in the United States) would help promote the formation of global best practices and provide a valuable reference for service integration across different healthcare systems.
We thank the authors for their important work and believe that incorporating the above suggestions into subsequent research or policy initiatives will further promote the standardized and systematic integration of plastic surgery within multidisciplinary diabetic foot care.
Author contributions
Xin Yuan: Conceptualization, Writing – original draft. Guobin Liu: Review & editing.
Funding
National Natural Science Foundation of China (82274528).
Declaration of competing interest
None declared.
References
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