Blanchette et al.

Journal of Foot and Ankle Research (2020) 13:15

https://doi.org/10.1186/s13047-020-0380-8

RESEARCH Open Access

Effect of contact with podiatry in a team

approach context on diabetic foot ulcer
and lower extremity amputation:
systematic review and meta-analysis
Virginie Blanchette1* , Magali Brousseau-Foley1,2 and Lyne Cloutier3

Abstract
Multidisciplinary team (MDT) approach has been shown to reduce diabetic foot ulcerations (DFUs) and lower
extremity amputations (LEAs), but there is heterogeneity between team members and interventions.
Podiatrists have been suggested as “gatekeepers” for the prevention and management of DFUs. The purpose
of our study is to review the effect of podiatric interventions in MDTs on DFUs and LEAs. We conducted a
systematic review of available literature. Data’s heterogeneity about DFU outcomes made it impossible for us
to include it in a meta-analysis, but we identified 12 studies fulfilling inclusion criteria that allowed for them
to be included for LEA outcomes. With the exception of one study, all reported favourable outcomes for
MDTs that include podiatry. We found statistical significance in favour of an MDT approach including
podiatrists for our primary outcome (total LEAs (RR: 0.69, 95% CI 0.54–0.89, I2 = 64%, P = 0.002)) and major
LEAs (RR: 0.45, 95% CI 0.23–0.90, I2 = 67%, P < 0.02). Our systematic review, with a standard search strategy, is
the first to specifically address the relevant role of podiatrists and their interventions in an MDT approach for
DFU management. Our observations support the literature that MDTs including podiatrists have a positive
effect on patient outcomes but there is insufficient evidence that MDTs with podiatry management can
reduce the risk of LEAs. Our study highlights the necessity for intervention descriptions and role definition in
team approach in daily practice and in published literature.
Keywords: Systematic review, Diabetes, Multidisciplinary team, Podiatry, Foot ulceration, Amputation

Introduction with a lower-extremity amputation (LEA) [4, 5].

Diabetes is a worldwide health issue and of its many Consequently, DFUs in diabetes patients should be
complications, diabetic foot ulceration (DFU) is a perceived as a major warning sign for morbidity and
prominent problem [1]. Up to 25% of people with mortality, and as such, they require close monitoring,
diabetes will experience a DFU in their lifetime, and medical follow-up, and integrated foot care [6, 7].
about 85% of lower limb amputations are preceded by Integrated foot care is a pathway of care management
a DFU [2, 3]. The 5-year mortality rate exceeds 70% with rapid and appropriate access to a multidisciplin-
ary team (MDT) for coordinated care between hos-
pital and community services [8]. An MDT in which
* Correspondence: [email protected]
1
Department of Human Kinetic and Podiatric Medicine, Université du health professionals work together to achieve the best
Québec à Trois-Rivières, 3351, boul. des Forges, C.P. 500, Trois-Rivières, outcomes for patients with an at-risk diabetic foot
Québec G9A 5H7, Canada
has been developed in response to the need for
Full list of author information is available at the end of the article

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Blanchette et al. Journal of Foot and Ankle Research (2020) 13:15 Page 2 of 12

improved methods of service delivery. A number of Method

health disciplines can be involved such as medicine exclusion criteria/exclusion criteria
(general medicine, endocrinology, infectious diseases The research question was “What is the effect of con-
medicine, and vascular, plastic and orthopaedic sur- tact with a podiatrist and their interventions in an
geries), podiatry, nursing, nutrition, orthotics and MDT context, on LEAs and DFUs, in individuals with
prosthetics, physiotherapy, and psychology. Each disci- diabetes?” [26]. Results for the effect of podiatric in-
pline’s implication in the MDT depends on the stage terventions without an MDT with a similar methodo-
of the DFU, but podiatry has a central role through- logical approach will be presented in a different
out [9–11]. The first foot care MDTs were established article. Inclusion criteria were studies that included
in the United Kingdom in the late 1980s and participants 18 years of age or older and having a
highlighted the role of chiropody (former designation diagnosis of either type 1 or 2 diabetes. There were
for podiatry). no restrictions regarding the date of publication, geo-
Previous systematic reviews have linked MDTs to graphical location, or study setting. Randomised con-
lower LEA rates following a DFU, noting the high trolled trials (RCTs), cohorts, either prospective or
heterogeneity of MDTs composition and interventions retrospective, and comparative cohorts before and
[12–15]. Neither of these reviews, however, looked after for which a reported effect on LEAs or on DFUs
specifically at a specific member and its interventions. was available were included. The targeted interven-
International guidelines recommend at least 3 levels tions (presented in Table 1) were educational preven-
of foot care management based on foot risk, and po- tion, foot cares, offloading, infection control, wound
diatrists are included at each level [16]. Many studies cares and surgical strategies that had to be specifically
about multidisciplinary healthcare centres in Europe delivered by a podiatrist in a multidisciplinary context
and in the United States reported that this approach or in an MDT program. The participation of the po-
helped reduce amputation rates by 36 to 86% [17, diatrist had to be clearly identified in the article. To
18]. However, the structures and delivery of these be included, articles had to use a comparison group
MDTs vary across settings and countries [19–22]. As including interventions or treatments without an
part of an MDT approach, podiatrists have been sug- MDT context. Potential measured outcomes that were
gested to serve as “gatekeepers” for the prevention deemed relevant for this study are presented in
and management of diabetes-related foot complica- Table 2. The exclusion criteria for the articles were:
tions [11, 23]. Podiatric management of an at-risk patients with gestational diabetes, language other than
diabetic foot has an underlying focus on preventive
screening, education, offloading, and foot care [2]. It
is usually assumed that podiatry prevents LEA; how- Table 1 Podiatric interventions
ever there is insufficient evidence to demonstrate the Categories Examples of podiatric interventions
[16, 27]
effect of patient contact with a podiatrist in a system-
Preventive strategies - Stratification of the population risk
atic review and meta-analysis [24]. So far, the effects - Program for vulnerable populations
of MDTs including podiatry and its interventions - Pedorthic evaluation
have not been demonstrated [12, 13, 24]. The part- Educational strategies - Program for self-management and
nership with podiatrists for DFU management in support for self-management
MDTs is a logical one, and the expertise and skills of - Personal hygiene education
each team member can improve outcomes and limb Foot cares strategies - Callus management
- Nail management
salvage [25]. It is well known that podiatry is limited
and is a variable resource (in terms of accessibility, fi- Offloading strategies - Orthoses
- Management with shoes
nancial coverage and scope of practice) in several - Walking aids
healthcare systems. In that context, it is sensible to - Immobilisation
question whether or the podiatrist is a resource that Infection control and wound - Specialised wound dressing
makes a difference for patient outcomes. There is care strategies - Infection algorithm
therefore a need to look for the effectiveness of - Biofilm-based wound care
- Advanced adjuvant therapies such as
MDTs which specifically include contact with podiatry hyperbaric oxygen therapy, negative
(from different scope of practice around the world) pressure therapy, etc.
on DFUs and LEAs in people with diabetes. The ob- Surgical strategies - Surgical debridement
jective of this study is to examine the effect of pa- - Correction of bone deformities
- Tissue engineering and grafts
tients’ contact with podiatry in MDTs and highlight
its specific role and, if possible, determine which po- Other strategies from podiatric - Pharmacology
expertise - Radiology
diatric interventions play a key role in MDTs.
Blanchette et al. Journal of Foot and Ankle Research (2020) 13:15 Page 3 of 12

Table 2 List of potential outcomes measured consensus could not be reached, a third reviewer was
Outcomes consulted (LC). Following the selection, the Cohen’s
Primary DFUs Prevent • Rate kappa was calculated to measure the agreement between
• Frequency the two independent authors.
Improve
• Prevalence Data from included articles was extracted and re-
Cure • Incidence
• Data about wound corded independently by two review authors (VB and
healing MBF) using a standardised extraction sheet adapted
LEAs Prevent • Limb salvage for the data of this review [26]. Data sheets were
Improve • Rates compared and discrepancies were discussed between
• Level of LEAs the two investigators (VB and MBF). Risk of foot dis-
• Ratio (high-low) ease at baseline was assessed using the Diabetic foot
• Frequency
• Prevalence risk stratification and triage system from the SIGN
• Incidence (Scottish Intercollegiate Guidelines Network) system
• Time to amputation guidelines because this system showed higher diagnos-
Secondary Mortality/survival tic accuracy values [30, 31]. If the data required was
Recurrence • DFUs missing from the published article, we tried to reach
• LEAs the authors.
• Reamputation
Other • Infection Assessment of risk of bias in included studies
complications • Other foot problems
Assessment of risk of bias was dependent on each
Healthcare Utilization of • Hospitalisation (number
data resources of admissions)
study’s design. For cohort and pre and post cohorts, The
• Length of hospital stay Joanna Briggs Institute Critical Appraisal Tools for Sys-
• Cost-effectiveness tematic Reviews were performed through a qualitative
Patient satisfaction evaluation checklist specifically elaborated for these de-
Bold characters: Outcomes included in meta-analysis signs [32]. Results are expressed by the frequency of
each classification. Risk of bias assessment was per-
formed for within and across studies independently by
French and English, and type of publications such as
the two authors (VB and MBF). A third reviewer (LC)
case-control studies, cross-sectional studies, audit, re-
was involved to resolve disagreements. Excel (Microsoft
view articles, charts reviews, cases series, and case
Corporation, Redmond, WA, USA) was used to repre-
studies, as well as conference and communication pa-
sent the potential risk of bias.
pers. Finally, a predefined review protocol was regis-
tered at the PROSPERO international prospective
register of systematic reviews, registration number Measures of treatment effects and synthesis
CRD42017057851 [28]. When appropriate, meta-analysis was performed in
order to pool outcome data with Review Manager ver-
Search strategy sion 5.3 (RevMan, The Cochrane Collaboration, Oxford,
CENTRAL, CINAHL, EMBASE and MEDLINE data- United Kingdom) for statistical analysis for suitable stud-
bases were searched to identify relevant studies pub- ies [33]. We also assessed the heterogeneity by using the
lished up to February 1, 2020. The strategy was adapted Cochrane’s Q statistic (I2 index). Quantitative synthesis
as per database requirements, and we combined the re- using the Mantel-Haenszel method with fixed effect
sults from the different databases and are available in models (I2 index inferior or equal to 50%) or random ef-
Additional file 1. We also searched for other potential fect models (I2 index between 50 and 75%) were used.
publications identified through search strategy from grey We considered an I2 index greater than 75% indicative
literature and references cited in relevant articles [29]. of substantial statistical heterogeneity [34]. In such cases,
a qualitative analysis and narrative synthesis were pro-
Data collection, extraction and management duced. Risk ratios (RR) were chosen for reporting the
Two review authors (VB and MBF) independently pooled effect of dichotomous data with a confidence
assessed the titles and abstracts of all studies obtained interval (CI) of 95%. Generic effect of inverse variance
from the databases, and full copies of the articles that model was used when studies reported association mea-
met the inclusion criteria were consulted for the next sures. Statistical significance was set at p < 0.05. To as-
step. In case of disagreement or doubt between the two sess publication bias, a funnel plot of the overall
authors, a decision was obtained by consensus following estimate of a primary outcome and its standard error
a discussion between reviewers (VB and MBF). If a (SE) was performed.
Blanchette et al. Journal of Foot and Ankle Research (2020) 13:15 Page 4 of 12

Subgroup analysis reviewed for titles and abstract after removing duplicates.
We decided to analyse whether the role of podiatrists in Following this selection, the Cohen’s kappa was calculated
the MDT with regard to their implication in the team between the two independent authors (VB and MBF) and
was primary (leading role or core of the team), second- was of 0.96, indicating excellent agreement between both
ary (support to the MDT but not the leading role), or reviewers. We then identified 26 articles that met the eligi-
tertiary (external consultation when needed). We also bility criteria (10 cohorts, 16 comparative pre and post co-
conducted different subgroup analyses based on our pre- horts, and 0 RCTs). None of studies from the grey
determined outcomes such as risk stratification of the literature or reference lists were included.. A PRISMA
population, healthcare setting, quality of studies, comor- flow diagram with motives for exclusion of 178 studies is
bidities and risk factors, types of wound (neuropathic, is- represented in Fig. 1, and details of excluded studies are in
chemic), etc. Additional file 4. Twenty-six studies that reported out-
comes for podiatric interventions in an MDT context
Results were included in this systematic review. Of these, 3 sets of
Literature search articles were from the same group of authors, [35–38] and
From 4987 titles retrieved from the databases, 2 from grey [39, 40]. The decision was made to exclude the oldest
literature, and another 10 from reference lists of potential ones, based on the fact that the same data set was used.
included studies (see Additional file 3), 476 articles were Therefore, 23 studies were included in this systematic

Fig. 1 PRIMA flow diagram

Blanchette et al. Journal of Foot and Ankle Research (2020) 13:15 Page 5 of 12

review and only 12 for the meta-analysis, considering that categories (high and low risk) [38, 42, 49, 54] and 4 arti-
11 studies did not meet the eligibility criteria after full-text cles had a system of classification of their population or
reading and analysis. One included cohort study had 4 DFUs: surgery classification [47], LEAs risk with King’s
substudies [41] and another, 2 substudies [38]. Reasons classification [60], Wagner’s classification for ulcers [59],
for exclusion (consensus between authors) were: mixed and Texas University classification for DFUs [54].
data when reporting primary outcome [42], eminent dif- The specific podiatric interventions were all poorly de-
ference of basic population [43–45], podiatric interven- scribed (without information concerning nature, inten-
tions pre and post cohort [46] and incomplete data for sity, duration, frequency) and very heterogeneous. In the
pooling the outcomes [40, 47–51]. 12 included studies, podiatric interventions are stated as
contact with podiatry [36, 40–42, 45, 49, 51, 55, 58, 59,
Description of included articles 61, 63]. Thus, we classified the podiatric interventions as
Characteristics of the studies included for meta-analysis educational strategies [38, 43, 50, 54, 57, 60], foot care
(n = 12), such as study design and information concern- strategies [38, 43, 46, 50, 54, 56, 57, 60], offloading strat-
ing length of follow-up, setting, source of data, partici- egies [43, 46, 48, 55–57], wound care and infection con-
pants, interventions and description of the MDT, trol strategies [44, 48, 54], surgical strategies [44, 47, 54],
comparison, outcomes, and risk stratification are pre- and stratification [38, 42, 49]. Only a few studies had de-
sented in Additional file 5. All 23 studies included in the fined exposure to the interventions as a weekly exposure
systematic review were in English. We identified 6 stud- to podiatry [56, 60], a regular follow-up in podiatry or
ies from the United States [40, 45, 47, 48, 54, 55], 2 from monthly appointments [38, 43, 50] or at least every 3
Canada [44, 55] and 10 from Europe, of which 5 were months [57]. Concerning the role of the podiatrist, we
from the United Kingdom [41, 43, 50, 56, 57], 2 from decided a posteriori to distinguish their role according
Spain [36, 38], 1 from Sweden [51], 1 from the to their implication in the MDT. With this in mind, the
Netherlands [58] and 1 from Italy [49]. There were also podiatrist intervenes in a primary role in 8 articles (lead-
3 articles from Asia, of which 2 were from China [42, ing role or core of the team) [36, 43, 44, 47, 48, 54, 55,
59] and 1 from Singapore [60]. One publication was re- 59]. Specifically, in these articles, the podiatrist formed
spectively from Australia [61] and another from New the core of the team with endocrinologists [36, 59],
Zealand [46]. Publication years were from 1990 to 2019. nurses [43, 55], and vascular surgeons [44, 47, 54]. Podi-
Four articles were published before 2000 [50–52, 57], atrists are sole leaders in one article [48]. In 8 articles,
and 3 articles were from 2000 to 2009 [38, 43, 49], while they had a secondary role (support to the MDT but
the majority (16 articles) was published between 2010 without a leading role) [45, 46, 49, 51, 56, 58, 60, 61]
and 2019 [36, 40–42, 45–47, 54–56, 58, 60–63]. Lengths and in 2 articles, they had a tertiary role (external con-
of follow-ups were between 1 and 14 years, with a me- sultation when needed) [38, 42]. Podiatrists’ role was
dian of 3.8 years and a mean of 3.6 years. Study settings similar to other team members in two articles [50, 57] .
were mostly in tertiary care [36, 38, 40, 43–47, 50, 54, Finally, in 3 articles, it was impossible to determine the
55, 57–59, 61]. There were 4 studies based in primary level of the podiatrist’s implication in the MDT because
care [42, 48, 49, 63], 3 in secondary care settings [51, 56, no description of the team was provided. In one article
60] and 1 unknown [41]. Three articles collected pro- [52], it was a podiatry-established critical pathway and in
spective data [38, 50, 57]; all other analyses were carried the two others, it was with other lower-extremity spe-
out using retrospective data (electronic medical records, cialists [40, 41]. The MDTs composition was also vari-
medical charts, databases with coding). The 12 articles able; some MDTs showed care management in 2 levels
which were combined for meta-analysis accounted for of team members’ implication [36, 42, 47, 49]. Finally,
545,829 patients. The participants’ characteristics at funding and conflict of interest in the included articles
baseline were heterogeneous. According to our stratifica- were clearly mentioned in the full text of 14 out of 23
tion system of choice for the population (SIGN) [30], 21 articles [36, 41–44, 47, 48, 51, 54, 55, 57, 60–62].
studies had a population stratification categorised as
high risk. This is explained by the fact that the popula- Primary outcomes
tion included in the studies could either have a DFU or All the studies included in the meta-analysis (n = 12) re-
a history of DFU [45, 47, 50, 55, 57, 58, 60, 61], an am- ported favourable data for people with diabetes in an
putation or a history of amputation [36, 40, 43–45, 48, MDT management that included podiatry. Therefore,
51, 61], peripheral vascular disease (PVD) [45, 56], or we retrieved data related to our pre-defined outcomes
diabetic foot infection [52, 61, 62]. Stratification of the about DFUs and LEAs as stated in Table 1. All included
population with PVD, neuropathy, cellulitis, osteomye- articles had data concerning primary outcomes: LEAs
litis or Charcot foot is also categorized as a moderate to [36, 38, 41, 54–58, 60, 62, 65] and DFUs [38, 54, 55, 57,
high-risk population [41]. Four articles included both 58]. With regard to the 11 studies excluded for the
Blanchette et al. Journal of Foot and Ankle Research (2020) 13:15 Page 6 of 12

meta-analysis, but included in the systematic review I2 = 64%, P = 0.002). For major LEAs (level defined as
(n = 23), 10 out of 11 studies reported data in favour of above knee amputation and/or below knee amputa-
MDTs including podiatry [40, 42, 44–47, 49–51, 53] and tion), results were also in favour of MDTs with
one article reported no effect of the interventions [43]. podiatry and still significant (RR: 0.45, 95% CI 0.23–
That led us to conduct two separate meta-analyses based 0.90, I2 = 67%, P < 0.02). The result was not significant
on study design (see Fig. 1). Main results are shown in for minor LEAs (level defined as amputations at any
Fig. 2 from available data pooled together, which level of the foot) (RR: 0.93, 95% CI 0.59–1.40, I2 =
respects criteria of heterogeneity. For total LEAs as 55%, P = 0.76). We succeeded in pooling results from
the primary outcome, the random effect model was 2 pre and post cohorts’ with cohort study analysis,
applied and a significant result was found in favour of which increased the number of studies included to 8
MDTs with podiatry (RR: 0.69, 95% CI 0.54–0.89, for meta-analysis. Raw data from these 2 studies

Fig. 2 Forest plot for cohort studies a) Total LEAs b) Major LEAs c) Minor LEAs
Blanchette et al. Journal of Foot and Ankle Research (2020) 13:15 Page 7 of 12

allowed us to calculate the prevalence of LEAs per for low risk of bias, but the majority of the studies in-
year per period pre-and post-intervention from a cluded (4/6) had a low risk of bias for the following pa-
sample size based on government census data in the rameters: population, confounders identified, outcomes
area. Therefore, events of LEAs from exposed group measured, follow-up time, and appropriate statistical
to MDTs and non-exposed group to MDTs were cal- analysis. High risk of bias was present concerning the
culated [36, 56]. For the remaining pre and post co- baseline population (those who were not free of LEAs or
hort (n = 4) [55, 58–60], because of the significant DFUs at the beginning of the study) and the exposure
heterogeneity between studies, we decided not to pool (valid and reliable method to measure MDTs contact
the data with association measure. Pre and post co- and intervention) (see Fig. 4a). Bias analysis for pre and
hort MDTs have reported significant results in favour post cohorts have also shown the same trend of high risk
of MDTs to improve DFU healing rate [55, 58] and of bias in included studies. None of the included studies
reduce total LEA [58, 59] and major LEA [58–60]. fulfilled all parameters for low risk of bias, but the ma-
Visual inspection of the funnel plot for the included jority of the studies included (4/6) had a low risk of bias
cohort studies for total LEAs has demonstrated no for 2 parameters: outcome measurements and appropri-
strong evidence of publication bias of the studies in ate statistical analysis. In almost all studies, there is con-
favour of the interventions (Fig. 3). The heterogeneity fusion about the cause and effect variables (5/6) and
in DFU data has not allowed meta-analysis for cohort difference about follow-up time between pre and post
studies. cohorts (4/6). Exposition to intervention was a low risk
of bias for only 2 study out of 6. Few studies had a con-
Secondary outcomes trol group (2/6) (see Fig. 4b).
According to our predefined secondary outcomes (Table 1),
data was available for mortality/survival [36, 41, 43, 54, 58], Discussion
recurrence [43, 54, 57], other complications [54, 61, 64], and A rigorous systematic search of the literature led to the
healthcare data [49, 54, 56, 57, 59, 61, 63, 64]. Meta-analyses inclusion of 8 studies in a meta-analysis performed to
were performed for some studies, but heterogeneity was over answer our research question. This was allowed because
75%. No articles reported data concerning patients’ satisfac- the heterogeneity of included studies, depending on the
tion with care provided by MDTs. outcomes, was lower than 75% and the Chi-square test
result was less than 30% with significant p-value (IC
Risk of bias assessment of included studies 90%) [33]. The ultimate aim in diabetic foot care is to
In relation to the critical appraisal of quality and experi- avoid DFUs and resulting LEAs for individuals with
mental designs, bias analyses for cohorts have shown diabetes. The goals and benefits from an MDT that in-
that none of the included studies fulfilled all parameters cludes a podiatrist reside in complementary work and

Fig. 3 Funnel plot of cohort included studies for total LEAs

Blanchette et al. Journal of Foot and Ankle Research (2020) 13:15 Page 8 of 12

Fig. 4 Potential risk of bias with JBI tools a) Cohort studies b) Pre and post cohort studies

synergy of skills and knowledge to achieve best out- guidelines for DFU management and very specific to the
comes for the patients [65]. This was addressed in all in- podiatry competency framework [28]. Only one study in-
cluded studies on MDTs that included podiatry. tegrated specific competencies in their MDT manage-
However, even though our study has looked closely at ment [47]. For these reasons, we have analysed the
different podiatric interventions in an MDT, there is not relative effect of contact with MDTs that include podiat-
enough reported information and descriptions of inter- ric interventions as a relative reduction of risk.
ventions to examine specific podiatric interventions’ effi-
ciency. Despite this, from the information available, Clinical significance
interventions were mainly educational strategies and foot The results of this systematic review support the concept
care strategies. It becomes problematic to distinguish that MDTs with podiatrists lead to a statistically signifi-
precisely whether it is the intervention as performed cant reduction of LEAs (total and major LEAs) com-
specifically by a podiatrist that is effective or if it is the pared to interventions without MDTs. After qualitative
intervention itself. According to the interventions de- analysis, authors of the included studies examining
scribed in the included studies, podiatric interventions minor LEAs as outcomes (all except [38, 61]) have
could have been done by other team members (for ex- shown that there are more minor LEAs with MDT inter-
ample, by a nurse). The evidence of value added by podi- ventions. However, upon analysis of results in relation
atrists in an MDT remained weak in that context. It with other severities of LEAs (major versus minor) and
would have been relevant to have a description of inter- with total LEAs, level of LEAs may decrease with an
ventions requiring specific podiatrist skills and know- MDT with podiatry management. There is a 31% relative
ledge in the MDT such as foot surgeries and offloading, risk reduction in undergoing a LEA, either major or
which are interventions highly recommended in minor, with MDT management with podiatry for people
Blanchette et al. Journal of Foot and Ankle Research (2020) 13:15 Page 9 of 12

at risk for diabetic foot. Considering only major LEAs, PVD, and Charcot neuroarthropathy at baseline [52, 56,
the relative risk reduction was of 55%. These results are 59, 61, 63, 64, 72]. These intrinsic variations of the
clinically meaningful in favour of the intervention, con- population within a study are a factor that explains het-
sidering the high 5-year mortality rate and the low qual- erogeneity of the results and the gap with the true effect
ity of life of patients with diabetes who undergo LEAs size.
[4, 5]. Even if these results are consistent with the
current literature, this should be interpreted with cau- Limitations and strengths
tion. Hence, this review cannot make any new recom- To the best of our knowledge, this is the first systematic
mendations about practice due to several review that investigates contact with podiatry in an
methodological flaws discovered during quality appraisal MDT context on the occurrence of LEAs in individuals
of the included studies. with diabetes. It was also a first attempt to describe po-
diatric interventions specifically in MDTs. This had been
Literature comparison and findings suggested for further work from a previous meta-
Three Cochrane reviews of interventions that evaluated analysis [24]. The strengths of this systematic review are
the outcomes of LEAs or DFUs in patients with diabetes the rigorous search strategies, including an attempt to
concluded that there is insufficient evidence that com- address the risk of bias. The relevance of the findings to
plex interventions and educational interventions can re- clinical practice is coherent with the recommendations
duce the risk of LEA or DFUs [66–68]. A fourth review, of different diabetes associations and organisations
from the International Working Group on the Diabetic which support MDT management of DFUs, such as the
Foot, concluded that integrated foot care in MDTs can American Diabetes Association, the Canadian Diabetes
prevent DFUs in at-risk patients [69]. These authors also Association, and the International Working Group on
mentioned substantial heterogeneity between articles the Diabetic Foot, to name only a few examples. Al-
concerning the description of team members, interven- though these recommendations are mainly based on
tions, and design. Previous reviews did not attempt to retrospective cohort studies, it highlights the need for re-
single out one member in particular, contrary to this search with stronger designs like RCTs to avoid con-
systematic review which focuses on podiatry, but have founding factors and confusion with cause and effect
suggested focusing on similarities of team makeups to variables. Moreover, the majority of studies have been
help determine the real impact [12, 13]. In general, these published in the last decade, which reflects the growing
studies highlighted the complexity of comparing the re- interest for MDTs and interdisciplinary management of
sults of team work from one study to another to draw DFUs.
conclusions, particularly with teams which did not have This review has limitations that need to be considered
the exact same set of skills and organization. Research of when interpreting the results. The available data is
true effect size with the specific criterion of contact with largely derived from retrospective cohorts and pre and
podiatry, could have helped to assess the collective effort post cohorts. Therefore, there is a limited ability to de-
in MDTs. A common conclusion from all of these previ- termine true association between interventions and out-
ous publications was that high-quality evidence from in- comes. Observational studies are also not the preferred
cluded studies is lacking. Our findings are also coherent design for meta-analysis. The review was also limited by
with other reviews about the effectiveness of MDTs in unavailable data or data that precluded us from pooling
reducing major LEA [14, 15]. the effect size even after multiple outreaches to authors.
Studies included in this systematic review were very One important concern regarding the high risk of bias
heterogeneous, as it was concluded in previous system- of the included studies arose mainly due to insufficiency
atic reviews. Confounders and risk factors for LEAs and of reporting within the studies, making many criteria un-
DFUs are well known in people with diabetes [70, 71]. clear. None of the included studies declared whether the
Few studies presented a strategy of risk classification in researchers had played a role in the delivery of care in
management (5/12) that allowed us to split the cohort the MDT. Because we looked at the specific role of the
according to the risk [38, 41], but it was not possible for podiatrist, podiatrist researchers could introduce a bias
the other articles [54, 59, 60]. Even with the efforts of in favour of the intervention. Another concern is the
stratification of the risk for the population at baseline heterogeneity of populations and confounding factors.
(low risk to active DFUs) across the studies to pool the Authors also agree that studies included in the meta-
results, the characteristics of the included populations analysis are heterogeneous in terms of methodology.
were sometimes not specified [36, 41, 42, 48]. The base- This is explained by nonblinded studies with no control
line population can also lead to poor prognoses, inde- groups and the difficulties in addressing biases and con-
pendently of the interventions. Such was the case for founders in retrospective studies. In addition, we pooled
patients presenting with infections, gangrene, necrosis, unadjusted association measure data from observational
Blanchette et al. Journal of Foot and Ankle Research (2020) 13:15 Page 10 of 12

studies. Although we made every attempt to address het- Available of data and materials
erogeneity by conducting subgroup analyses, it made no The datasets used and/or analysed during the current study are available
from the corresponding author on reasonable request.
difference because of the small number of studies
included. Author contributions
There is a need to seek further evidence concerning VB was the first literature reviewer for research and data collection. She
the effect of interventions for patients with diabetes and contributed to the methodological framework and study coordination. She
analysed and interpreted the results. She was the major contributor in
to determine the role of podiatrists in MDTs related to writing the manuscript. MBF was the second literature reviewer and she
guideline recommendations [16, 19, 24, 73]. Moreover, contributed to the data analysis and discussion. LC was the third reviewer
more studies with stronger designs and methods are and supervised the study. She intervened at every step of the research
realisation. All the authors read and approved the final manuscript.
needed to determine the effects of interventions on
DFUs and LEAs, with a special concern about risk strati-
Ethics approval and consent to participate
fication in their population to avoid confounding fac- Not applicable.
tors.. The research process should begin with better
published studies. Future MDTs could also benefit from Consent for publication
addressing timing and care trajectories with stronger de- Not applicable.
scriptions of their specific interventions. It would also be
interesting to look at the impact between different popu- Competing interests
The authors declare that they have no competing interests. There is no
lations (low risk versus high risk) and of other team source of funding to declare.
members’ interventions.
Author details
1
Department of Human Kinetic and Podiatric Medicine, Université du
Québec à Trois-Rivières, 3351, boul. des Forges, C.P. 500, Trois-Rivières,
Conclusion Québec G9A 5H7, Canada. 2Centre intégré universitaire de santé et de
This systematic review of interventions concerning out- services sociaux de la Mauricie-et-du-Centre-du-Québec (CIUSSS-MCQ)
comes of LEAs in individuals with diabetes concludes affiliated to Université de Montréal, Faculty of Medicine, Family Medicine
Unit, Trois-Rivières, Québec G9A 1X9, Canada. 3Department of Nursing,
that there is insufficient evidence that MDTs with podia- Université du Québec à Trois-Rivières, 3351, boul. des Forges, C.P. 500,
try management can reduce the risk of LEAs. Even with Trois-Rivières, Québec G9A 5H7, Canada.
a favourable outcome of the intervention, the lack of
Received: 27 November 2019 Accepted: 27 February 2020
high-quality studies included and considerable hetero-
geneity nuanced the results concerning relative risk re-
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