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There have been major improvements seen in the care of these patients following recommendations from the NCEPOD report on major amputations with in-hospital mortality reported at just under 5% for below-knee amputations and under 10% for above-knee amputations compared to an overall mortality at nearly 13% in the 2014 NCEPOD publication [4].

Since its establishment in 2014 The National Diabetic Foot Care Audit (NFDA) measures the volumes outcomes and treatment structures/processes for newly occurring foot ulcers affecting diabetic patients. The NDFA aims to record every new foot ulcer, measure healing rates and record the numbers amputations in patients with diabetic foot ulceration Their aim was to determine the variation in clinical outcomes across England and Wales and the extent to which the differences could be explained by differences in patient care. NFDA consistently found a strong link between ulcer severity and worse outcomes in diabetic patients. Early referral meant better outcomes [7].

Patient education presented in a structured and repeated manner plays an impor­tant in the role in diabetic foot ulcer prevention. A well-educated patient will have proper foot self-care knowledge and is able to ag up any abnormalities to their GP, practice nurse or podiatrist. Patients need to learn how to identify foot ulcers and signs of infection before problems arise. Likewise, healthcare professionals should periodically be improving their skills on how to identify and manage high risk dia­betic foot patients (see Fig.16.1).

Individualised planning for ongoing care should also be developed at this stage, including negotiated goals and expectations. Secondary prevention to prevent com­plications of macrovascular disease in the form of smoking cessation, appropriate antiplatelet, statin and antihypertensive therapy and ACE (Angiotensin converting enzyme) inhibitors/ARB’s (Angiotensin Receptor Blockers) to prevent renal com­plications and nephropathy requires to be initiated early in the disease [10–12]. In the ideal scenario diabetic patients should have all their co-morbidities well con­trolled, have proper foot wear and advice to prevent them from developing foot ulcers/ischaemia in the rst place (Fig.16.2). However, we know that this is virtu­ally impossible as patients slip through the system. Patients with diabetic foot ulcers should be referred to and followed up by the local podiatry team on a regular basis

Diabetic patients with severe foot problems should be admitted to hospital under the medical or vascular teams and cared for in an MDT approach. Vascular special­ists, in particular interventional radiologists, can then guide the teams appropriately with required imaging such as pre-operative magnetic resonance angiography (MRA), computerised tomographic angiography (CTA), or catheter angiography when surgical intervention is required or intervene endovascularly. A 24h on call service for accepting referrals of patients with diabetic feet, whether urgent or chronic is important in that it helps avoid missing or delaying treatment [14].

The report further recommended that trusts should work towards providing a seven-day service with at least one MDT team member, such as a specialist diabetes inpatient nurse, available for part of the day on weekends so that urgent cases can be seen by a diabetes specialist within hours.

biologist, orthopaedic foot and ankle surgeon, vascular scientist, vascular sur-

To determine the number and epidemiology of diabetic foot amputations (in the UK), data is available from two sources: published peer reviewed journals and freely available national/local databases. This data can then be used to compare outcomes across both geographic areas and individual services.