What is a “diabetic foot attack”?

A new commentary paper has called for the world to start calling severe presentations of diabetic foot disease (DFD), “diabetic foot attacks”. The paper, published by Professor Mike Edmonds and his team in the International Journal of Lower Extremity Wounds, argues using such a term aligns with similar terms that have “transformed outcomes in myocardial infarction (“heart attacks”) and stroke”.

If Professor Edmonds sounds familiar, it may well be because he is a true pioneer of diabetic foot research. Thirty years ago he published arguably the world’s first paper showing multi-disciplinary DFD teams reduce amputation rates and just last week we highlighted his recent world first RCT showing particular wound dressings can speed up diabetic foot ulcer healing. So when Prof Edmonds and his team canvas new concepts it’s probably worth listening.

Now “diabetic foot attack” is not a completely new term. Over the last few years many clinicians and even public awareness campaigns across the world have begun using the term to denote a diabetic foot ulcer. They have even extended the “foot attack” concept to health professional education campaigns advocating CPR (“check, protect, refer”) as the first line of treatment for people with diabetic foot attacks. However, this paper appears to be the first time a journal paper has tried to define “diabetic foot attack” and outline management pathways needed to treat it.

So what do the authors define as a “diabetic foot attack”?

They essentially define it as an “acutely inflamed foot with rapidly progressive skin and tissue necrosis”. They go on to state it could also include “critical limb ischaemia with or without tissue loss” or “an acute Charcot foot”. In short, their definition translates to patients with diabetic foot disease presenting with what we currently define as moderate-severe infection, critical ischaemia or acute Charcot foot; or even briefer ‘severe infection, ischaemia or neuropathy’.

So why did the authors go with this definition?

They attribute the term “attack” as conveying a “very powerful sense of urgency … to physicians … podiatrists, nurses and paramedics”, as “heart attack” has done so well for public awareness in this regard for myocardial infarction. Therefore, they specifically included DFD conditions in their definition that “require immediate recognition and urgent aggressive management … to improve limb and life survival”. The authors then nicely highlight the similarity in necessary time to intervention factors for:

  • heart attacks, need intervention within minutes to prevent death (known as the “golden hour” concept); &
  • diabetic foot attacks, need intervention within hours to prevent (limb or life) death (known as the “time is tissue” concept).

Lastly, they suggest the term importantly conveys a powerful message to policymakers to intervene in these devastating health conditions. They state the term “heart attack” has helped to engage policymakers to implement more specialist acute cardiac units across the world that have resulted in significant improvements in myocardial infarction mortality outcomes. The author’s state using “diabetic foot attack” may also provoke similar policymaker engagement to more readily implement the critical specialist acute foot units also needed to significantly improve DFD morbidity and mortality outcomes.

So how do the authors suggest to manage a diabetic foot attack?

As the authors state there are no international guidelines for managing “diabetic foot attacks”, but there are for moderate-severe diabetic foot infections and critical ischaemia and some reviews for acute Charcot joints. The authors borrow from these guidelines to create a basic management pathway for their definition of “diabetic foot attack”. In general, their pathway outlines the following steps:

  1. urgent hospital admission and surgical planning;
  2. urgent surgery for debridement and revascularistation (if needed);
  3. intensive wound management follow-up; and
  4. safe discharge planning.

However, they also rightly state the management of their subtly different diabetic foot attack definitions involve subtly different priorities within the pathway, i.e.:

  1. An “infected diabetic foot attack” should prioritise urgent surgical debridement and antibiotics.
  2. An “ischaemia diabetic foot attack” should prioritise urgent revascularisation
  • An “acute Charcot diabetic foot attack” should prioritise urgent offloading

Whilst this paper should provoke much needed debate on the definition of “diabetic foot attacks”, it does come with the overarching limitations of being a commentary paper which the authors duly highlight, i.e. the definition and management pathways are based on the author’s expert opinions.

So what is the future of the diabetic foot attack?

In conclusion, the authors recommend, “What is now indispensable is wider awareness (is needed) of the diabetic foot attack, (with) clearly described (definitions and) interventions, and referral algorithms, as well as improved organization of urgent health care provision by expert teams”. We agree with the authors that the term “diabetic foot attack” has much merit and the world’s diabetic foot community needs to now debate and decide on a consensus definition in the near future.

Whilst we suggest this paper provides the first formal step towards such a notion of “diabetic foot attacks”, we dare say that in thirty years from now we will reflect back on this paper and see it as another of Prof Edmonds pioneering papers that began a pivotal journey in the world’s appreciation of the severity of DFD; as occurred with heart attacks decades ago.

If the world’s public begins to appreciate the critical nature of a “diabetic foot attack”, hopefully, policymakers will begin to understand the critical need for specialist “foot attack” units as they have done for “heart attack” units. With recommendations on the numbers of needed “inpatient interdisciplinary DFD services” to manage severe DFD already available in Australia, we are sure no-one will mind if they are termed “foot attack units” to ensure these necessary services are implemented. Nation-wide coverage from “diabetic foot attack units”, now that would be a huge step towards us ending avoidable amputations in a generation in this country.