Benefits of Multi-Disciplinary Limb Preservation Teams

INTRODUCTION

Diabetes mellitus presents a significant global health burden, with more than half a billion adults living with the condition in 2024.¹ There are many long-term complications of diabetes, including foot deformities and ulceration. Foot ulcers and infections precede approximately 80% of major lower-extremity amputations.² The physical, psychological, and socioeconomic impacts associated with diabetes-related amputations emphasize the importance of robust clinical pathways for limb preservation.³ Studies show that multidisciplinary teams, comprising specialties such as family or hospital medicine, endocrinology, infectious disease, wound care, podiatry, and vascular surgery, reduce major amputations.^3,4 This collaborative model is not just about managing a complex disease; it is a vital strategy that actively improves patient outcomes and prevents irreversible limb loss that is predicted to affect 783 million people by 2045.¹

DEFINITION AND STRUCTURE OF A MULTIDISCIPLINARY LIMB-PRESERVATION TEAM

People with diabetic foot ulcers (DFUs) often face fragmented clinical care, despite a coordinated multidisciplinary approach being known to improve limb amputation rates by up to 60%.⁵ Multidisciplinary teams benefit from the involvement of numerous specialists, with the podiatrist and vascular surgeon (ie, the “toe and flow”) anchoring teams owing to their ability to rapidly diagnose and address structural deficits, wounds, and ischemia.⁶

Podiatry

Podiatrists play an essential role in treating foot deformities and soft tissue complications linked to diabetes to prevent amputations. The prevention strategy includes regular foot examinations, consistent wound debridement, and an evaluation of how to offload the wound.^7,8 Surgical offloading methods, such as exostectomy or reconstruction, can be powerful tools that treat the wounds, prevent reoccurrence, and also keep Charcot neuroarthropathy at bay. Nonsurgical methods and collaboration with a prosthetic/orthotic team ensure the patient consistently uses assistive devices to achieve consistent wound pressure relief. In addition, stagnant wounds may benefit from aggressive and frequent wound debridement or the application of skin substitutes. These options are continuously reevaluated, and podiatrists must have a watchful eye and be willing to find new strategies when needed for offloading, effective wound healing, and surveillance to prevent reulcerations.

Vascular Surgery

Approximately half of all patients with a DFU will also suffer from peripheral artery disease (PAD), often manifesting in the most severe form: chronic limb-threatening ischemia (CLTI). The vascular surgeon’s role is to establish the severity of the arterial occlusive disease and determine when revascularization is required for healing a neuroischemic wound. Strong physical examination skills and access to noninvasive imaging using arterial duplex and ankle/brachial indices with toe pressures are the bedrock of this approach, and a peripheral vascular laboratory is an essential component for the vascular surgeon in the limb-preservation setting. Angiography is often the next step in patients with CLTI, depending on the extent of their ischemia and the size of their wound. These determinations are guided by the Society for Vascular Surgery (SVS) wound, ischemia, foot infection (WIfI) classification system, which is focused on WIfI categories to best determine the risk of limb amputation and potential benefit of revascularization (Fig. 1).⁹

Fig. 1.

SVS WIfI Classification System predicts major amputation risk and benefit of revascularization. TCPO2, transcutaneous partial pressure of oxygen. (**Reprinted with permission from Dr. David Armstrong from https://diabeticfootonline.com/2015/04/02/visualizing-and-using-wifi-everyday-wound-ischemia-foot-infection-three-dynamic-rings-of-risk/.)

The vascular surgeon must communicate regularly with the podiatrist to discuss what revascularization options are possible and to determine the timeline of definitive foot reconstruction status post revascularization. This is because not all target arteries can be revascularized, and there are certain revascularizations that are at higher risk for earlier failures than others. This is especially important when considering complex revascularization procedures, such as deep venous arterialization, which often require frequent reinterventions and intensive wound care. Finally, when the podiatrist identifies that a wound, or a reconstruction, is showing signs of delayed healing or worsening ischemia, they should immediately be in contact with their vascular surgery partner to allow them to reassess the blood flow and determine if additional interventions are possible.

Infectious Disease

Although not co-captains of the espoused toe and flow model, infectious disease clinicians serve a vital role on the multidisciplinary team.^10–12 Their expertise is especially impactful for cases involving osteomyelitis or deep space abscess. In these instances, infectious disease clinicians excel at providing information about the potential success of medical therapy alone, or in conjunction with a more proximal amputation. Because of their training in internal medicine, they are often the best team members to explain how factors like glycemic control, smoking cessation, and other medical comorbidities contribute to the risk of amputation. This is an important preamble to the role of a hospitalist or endocrinologist, gauging patient readiness and priming them for further discussions.

Hospitalist Medicine

Although limb-preservation teams were originally formed around surgical subspecialties, given the significant comorbidities that often accompany diabetes mellitus and PAD, there are increasing recommendations for general internist participation during the inpatient care received in the perioperative periods around vascular and/or podiatric surgery. A systematic review of multidisciplinary limb-preservation teams from 2020 demonstrated that general internists were present on 30% of teams at that time, and it is reasonable to expect this number to grow given increasing medical complexity of inpatients and emphasis on care coordination and quality improvement.¹²

PATIENT-CENTERED BENEFITS OF A MULTIDISCIPLINARY TEAM

The patient is the central focus of any multidisciplinary limb-preservation program. Although professional collaboration is vital, the ultimate success of these efforts is determined by patient understanding, engagement, and well-being. A team-based approach offers significant benefits in three interconnected domains: treatment adherence, health education, and quality of life.

Adherence to treatment is a frequent barrier, particularly for patients facing mobility, transportation, or financial challenges. In this setting, alignment of appointments and comprehensive follow-up can meaningfully affect outcomes. For example, a multidisciplinary foot clinic in England with co-scheduled appointments with multiple specialists reduced major amputations (2.5% vs 11%; P=.04) compared with podiatry-only care.¹³ Meta-analyses of randomized and observational studies report marked reductions in major and minor amputations, shorter time to heal, and improved survival when compared with nonteam models.¹⁴ This suggests that aligned messaging across specialties, where podiatrists, vascular surgeons, and infectious disease specialists reinforce key care principles, can directly impact clinical outcomes.

There is a significant gap in the understanding of the quality of life experienced by people at risk of limb loss, and very few studies report on this outcome.¹³ There is ongoing work being done by professional organizations to develop disease-specific core outcome sets that include patient-reported outcomes.¹⁵ Validated instruments like the recently developed diabetic foot patient–reported outcome scale demonstrate acceptable reliability and validity in capturing patient perspectives.¹⁶ The multicenter Diabetes-Related Extremity Amputation Depression and Distress study highlights the profound emotional impact of limb-threatening disease and amputation risk; greater than 40% of patients with diabetes facing major amputation reported clinically significant depressive symptoms, and greater than 50% experienced diabetes-specific distress directly tied to fear of limb loss.¹⁷ Broader quality-of-life measures show that coordinated care improves functional outcomes and satisfaction among patients with diabetic foot pathologic condition.¹⁸ Multidisciplinary care teams that incorporate quality-of-life measures and mental health support are likely better positioned to improve engagement, reduce anxiety, and ultimately strengthen adherence and outcomes.

CLINICAL BENEFITS OF A MULTIDISCIPLINARY TEAM

Podiatry

Podiatry occupies a central role in multidisciplinary limb-preservation programs, often serving as the first point of contact for patients with foot complications and as a continuous thread throughout care. This integrative role bridges care between disciplines and ensures patients receive a seamless and unified treatment plan.^6,19

Core responsibilities include wound care, surgical and nonsurgical debridement, application of skin substitutes, biomechanical assessment, pressure offloading, and prescription of orthotic devices.^19,20 Sharp debridement remains the standard of care and should be repeated frequently as needed.²¹ Coupled with advanced dressings, these techniques promote optimal healing environments. To maintain that environment, offloading is arguably the most critical intervention for healing, especially for plantar ulcers.⁶ The 2023 International Working Group on the Diabetic Foot strongly recommends nonremovable knee-high offloading devices as the first-line option.²² Meta-analyses demonstrate that total contact casting (a nonremovable device) yields faster healing and higher closure rates compared with removable devices.²³

Beyond wound care, podiatrists assess structural and biomechanical contributors to recurrent ulceration. Identification of deformities, gait abnormalities, and focal pressure points enables targeted interventions that reduce the risk of future breakdown. Surgical contributions range from tendon lengthening to partial foot reconstruction, each undertaken with the goal of maintaining limb function.²⁰

Vascular Surgery

PAD is present in up to 50% of patients with DFUs and is strongly associated with delayed healing, infection, and above-ankle amputation.^20,24 In CLTI, revascularization restores pulsatile arterial flow, improves tissue perfusion, and reduces the risk of both amputation and mortality.^25,26 Neuroischemic DFU represents the most severe presentation, and outcomes are closely related to the timeliness of revascularization.^27,28 The Vascular Society for Great Britain and Ireland published best-practices guidelines for PAD management in March 2019, updated in 2022.^29,30 The Peripheral Arterial Disease Quality Improvement Framework set time targets of no more than two days from referral to admission, no more than twelve hours from admission to cross-sectional imaging, no more than fourteen hours to vascular evaluation, and no more than five days to revascularization after admission.³⁰ Although meeting these benchmarks can be challenging, particularly in systems without existing multidisciplinary teams or regions with limited vascular specialist availability, these recommendations highlight the critical importance of minimizing delays to revascularization.^28,29 Coordinated planning between podiatrists and vascular specialists aligns the timing and durability of revascularization with wound management and foot procedures, while also expediting referrals, streamlining diagnostic imaging, and ensuring rapid treatment of patients with CLTI. Beyond limb-related outcomes, this integrated model can improve wound healing, enhance quality of life, and reduce hospitalizations and overall costs of care.

Infectious Disease

Infectious disease clinicians are experts in interpreting the results of deep tissue and bone cultures, especially when there is concern that prior antibiotics might impact culture yield.³¹ A second important contribution is the determination of whether an infection can be managed with antibiotics alone, or by surgical removal of bone (with or without postoperative antibiotics). There is no single, best answer to this question, and decision-making is highly nuanced.³² Surgeons provide expertise on the feasibility of complete resection and its impact on function,^33,34 while infectious disease clinicians offer opinions about the probability of a cure with medical management alone. Together, a medical-surgical approach might lead to a more distal amputation with subsequent antibiotics for residual infection and a better long-term, functional outcome.^35,36

Hospitalist Medicine

Patients with CLTI often also have clinically significant cardiovascular disease and, thus, have a ten- to fifteen-fold increased risk of cardiovascular death compared with patients without PAD, as well as an increased risk of major adverse limb events after revascularization.³⁷ These comorbidities, deemed risk amplifiers, include diabetes mellitus, chronic kidney disease/end-stage renal disease, polyvascular disease (defined as the presence of atherosclerosis in two or more vascular beds), tobacco abuse, and depression.³⁸

Unfortunately, more than two-thirds of patients with CLTI do not have medically controlled comorbidities, resulting in up to an eight-fold risk of major amputation and/or death.³⁹ Given this, inpatient admissions are an opportune time to ensure patients are on appropriate, guideline-directed medical therapy. This includes inpatient monitoring of lipids, hemoglobin A1c, and smoking as well as initiation and titration of lipid-lowering, antihypertensive, and smoking cessation medications as appropriate. Antiplatelet and antithrombotic medication decisions are often left to the vascular specialists.

Poor glycemic control has an exponential effect on risk of major adverse cardiac events with the EUCLID trial noting a 14.2% increased risk for every 1% increase in hemoglobin A1c.⁴⁰ Teams should have a low threshold to involve endocrinology providers for patients with uncontrolled diabetes to help manage inpatient hyperglycemia and to develop comprehensive, individualized patient care plans that include not only pharmacotherapy but also diet and exercise in order to help patients achieve long-term improved glucose control.

SYSTEMS-LEVEL BENEFITS

Multidisciplinary limb teams consistently demonstrate value by decreasing the rate of major amputations, which are very financially burdensome to health systems, by 39% - 56%.^11,12,41 In addition, care pathways containing stepwise protocols ensure expedited, evidenced-based care that can shift care to less costly outpatient offices and avoid emergency department visits and urgent inpatient hospitalizations.⁴¹

Once admitted to a hospital, the effects of multidisciplinary care on length of stay and readmission rates are less well defined, but some small studies indicate that it is possible to have a decrease in hospital days and decrease in time to definitive, surgical management.^42–44 Given that 30-day readmission rates for patients with DFU and/or CLTI are as high as 30%, this is a prime area to focus quality- and value-based care initiatives.^45–47

There is currently a paucity of data on whether multidisciplinary limb-preservation teams result in direct cost savings for US health care organizations; however, hospitalizations for nontraumatic major amputations cost $53,700 per hospitalization (2010 data).⁴⁸ Measuring the financial benefits of multidisciplinary limb-preservation teams by predicting the “number of limbs saved” is both a patient-centered and cost-effective approach.

CASE STUDY

An 82-year-old woman with PAD, aortic dissection treated with thoracic endograft, diabetes controlled with oral medications, and tobacco abuse presented to the emergency department with a posterior ankle wound that had worsened over 2 months (Fig. 2). Vascular surgery consult noted that she did not have a femoral pulse nor did she have adequate perfusion to heal her wound (Fig. 3; Ankle-brachial index, 0; toe pressure, 33 mm Hg). The patient underwent computed tomographic angiography, and an iliac occlusion was identified with moderate multifocal tibial stenosis. Podiatric examination revealed that the wound involved the Achilles tendon, which helped frame the complexity of the patient’s issue. Based on SVS WIfI classification, the patient was a W 2, I 3, fI 0—clinical stage 4 disease, with a high risk of amputation and high potential benefit for revascularization. At this point, the patient was admitted to the authors’ hospitalist-run threatened limb service for rapid risk stratification and medical optimization for blood pressure control before proceeding to the operating room for a joint vascular and podiatry case. The patient underwent a femoral-to-femoral bypass, wound debridement, bilayer skin substitute placement (Fig. 4), ankle immobilization and off-loading. The hospitalist service continued to adjust antihypertensive medications and her statin; assessed nutritional status and added relevant dietary supplements; coordinated with the infectious disease specialist to determine that a 2-week course of oral antibiotics would be sufficient based on intraoperative data; and ensured a smooth transition to a skilled nursing facility, as the patient could not be safely discharged home with her non-weight-bearing status. One month post procedure, she had joint vascular and podiatry clinic visits. Noninvasive vascular studies were obtained, which demonstrated a significant improvement in perfusion (ABI, 0.9; toe pressure, 61), and the top layer of the skin substitute was removed, revealing granulation tissue forming over the remaining scaffold layer (Fig. 5). Two weeks later, a split-thickness skin graft was applied, and at three months, she was fully healed and starting physical therapy (Fig. 6).

Fig. 2.

Right posterior distal leg wound. (A) Wound appearance at initial urgent care presentation. (B) Wound appearance 2 months later in the threatened limb clinic.

Fig. 3.

Baseline noninvasive vascular assessment. BP, blood pressure; Dor. Pedis (DP), dorsalis pedis; L, left; Post Tibial (PT), posterior tibial; R, right; TBI, toe-brachial index.

Fig. 4.

Right posterior leg wound after debridement and skin substitute placement.

Fig. 5.

Right leg wound healing after 1 month. (A) Bilayer skin substitute in place. (B) Silicone layer of skin substitute removed.

Fig. 6.

Right posterior leg wound healed after split-thickness skin grafting.

Some key elements of this case are the importance of communication between vascular and podiatry colleagues. Achilles wounds are very challenging, and the insight that the podiatry partner provided was extremely helpful for avoiding a lag between her revascularization and debridement and immobilization, which were vital to her healing. Regarding her perfusion, the femoral-femoral bypass provided adequate perfusion for wound healing; however, given that the patient did have disease at multiple levels, if wound healing stalled at any point, additional revascularization would have been done. The team was particularly watchful for adequate perfusion before her final skin grafting. The hospitalist team ensured that the patient’s overall medical stability and coordinated discharge planning. Finally, the multidisciplinary outpatient clinic and weekly threatened limb clinical conferences allowed the authors to use a team approach, with the ability to communicate quickly and respond efficiently throughout the limb-preservation process.

BARRIERS TO MULTIDISCIPLINARY TEAM IMPLEMENTATION

Despite their clear benefits, multidisciplinary teams are challenging to implement, as they often require culture change and realignment of services to keep clinicians from multiple departments and practice settings united. Most multidisciplinary teams are based in urban, tertiary centers where vascular surgeons and infectious disease specialists are typically located^10,49,50; however, informal alliances of clinicians outside of these settings can be formed to target geographic areas with health care access challenges. Transportation can be a problem for both rural patients and those in urban, disadvantaged neighborhoods.^51–53 Telehealth can be useful but is not a viable option when hands-on care is necessary. Insurance coverage, disjointed electronic medical records, and poor triage pathways threaten to widen disparity gaps if equitable triage is not part of the implementation plan.^54–56 With thoughtful design, however, these teams may be one of the best tools to combat disparities in limb salvage and improve outcomes for all.^51,57

Once key clinicians are identified, multidisciplinary teams often can be established with existing resources.^44,58,59 Many begin in either the inpatient or outpatient setting and then mature to span both, providing continuity of care.¹² Implementation should focus on supporting collaboration within team members and between the team and referring clinicians; care algorithms that delineate clinicians’ roles are particularly useful.⁶⁰ Clinicians within and outside the team benefit from stable partnerships and face-to-face interactions.^61,62 For referring clinicians, an in-person introduction to a multidisciplinary team member and exchange of contact information may be all that is necessary to develop trusting, impactful partnerships.^61,63 Clear and rapid triage systems, especially for those outside the team’s immediate health care system, should be a top priority.^64–67

THE FUTURE

The approach to diabetic limb salvage is evolving from reactive to proactive, multidisciplinary care teams with the constant goals of prevention, avoiding disease progression and the worst complications. Proactive, coordinated models are making a noticeable difference by lowering the rates of major amputations and improving the overall well-being of patients.²⁰ More professionals—including clinical pharmacists, therapists, and dietitians—are being brought in to strengthen both inpatient and outpatient services for patients facing limb threat.

Telehealth has emerged as an effective approach for managing DFUs, particularly in rural and underserved communities, where a significant number of people struggle to travel long distances for specialty care. In a study of 232 people examined over a twelve-week period, nurse-led telemedicine in rural hospitals achieved comparable rates of ulcer healing and amputations to those observed with traditional in-person wound and podiatric care.^68,69

Custom-made offloading devices—such as tailored insoles and shoes—have shown greater effectiveness in reducing or preventing ulcer recurrence compared with standard, prefabricated alternatives.^70–72 Emerging technologies, including smart insoles, wearable pressure sensors, and telemonitoring systems, offer promising avenues for enhancing offloading adherence.^24,25 These advances to existing patient monitoring systems can provide regular data on wound healing, vital signs, and medical communication, enabling health care providers to address complications and intervene at earlier stages.^68,69

Artificial intelligence (AI) and machine learning are playing a bigger role in managing DFUs and are bringing new possibilities for patient care.⁷³ Predictive analytics can even use large patient data sets to identify high-risk patients, which may help prevent DFUs before they start.⁷³ Additionally, these tools can help clinicians diagnose, treat, and predict how ulcers will heal on an individualized level based on each patient’s own longitudinal history.⁷³ Thermogram-based classifiers and personalized offloading prescriptions support early detection and tailored treatment.^73,74

Although these technological advances are already being used to improve outcomes, the basics will be as important as ever. Education and advocacy are still needed for raising awareness and focusing on prevention of diabetes and its complications. Strong patient education about daily foot checks, proper shoes, and keeping blood sugar under control will always be a cornerstone of care. A strong multidisciplinary limb-preservation team (whether in person, remote, or AI-assisted) to treat people with diabetes and foot deformities or ulcers will be the key to good outcomes.^75,76

SUMMARY

The implementation of multidisciplinary limb-preservation teams represents a critical advancement in the management of diabetic foot disease and related complex pathologic conditions. By integrating the specialized expertise of podiatry, vascular surgery, infectious disease, endocrinology, and hospital medicine within coordinated care pathways, these models demonstrate measurable improvements in limb preservation, functional outcomes, and overall survival. Sustained commitment to interdisciplinary collaboration, standardized protocols, and longitudinal follow-up is essential to further optimize outcomes and establish multidisciplinary limb-preservation programs, which can even be enhanced as the world moves closer to integrating many fields with AI-generated tools.

CLINICS CARE POINTS.

• Assess and address real-world barriers to offloading.

• Expedite vascular assessment starting with ankle- and toe-brachial indices.

• When managing osteomyelitis complicating diabetic foot ulcers, consider both medical and surgical options, tailoring treatment to what maximizes function and quality of life for the patient in front of you.

• Don’t forget to address factors proximal to the ankle: glycemic control, blood pressure, lipids, and smoking.

KEY POINTS.

• Multidisciplinary limb-preservation teams integrate podiatry, vascular surgery, infectious disease, endocrinology, and family and hospital medicine to optimize care.

• Coordinated inpatient and outpatient pathways with standardized protocols to promote early, proactive interventions, improve wound healing, reduce amputation risk, and enhance survival.

• Patient-centered care models, with or without artificial intelligence–assisted devices, promote functional recovery, quality of life, and long-term disease management.

Abbreviations

AI

artificial intelligence

CLTI

chronic limb-threatening ischemia

DFU

diabetic foot ulcer

PAD

peripheral artery disease

SVS

Society for Vascular Surgery

WIfI

wound, ischemia, foot infection