Foot Care and Prevention of Lower Extremity Amputation

Co-Leads: Mohammad Al-Omran, Thomas Forbes

Project Coordinator: Abdelrahman Zamzam



The diagnosis of diabetic foot ulcers identifies patients with the highest risk for underlying multiple complications related to diabetes including peripheral vascular disease, neuropathy, poor glucose control and associated determinants of health that require multi-disciplinary intervention. Currently, there is no standardized care path in Ontario for an individual with diabetes and complex chronic complications unless they develop renal failure requiring dialysis or advanced cardiac or vascular disease resulting in stroke.

While rates of myocardial infarctions and strokes in persons with diabetes has decreased in Ontario over the past decade, the prevalence of diabetic foot ulcers leading to lower limb amputations has increased in Ontario over the same time period.  The human and financial toll of this condition is exceptional. According to the International Diabetes Federation, persons with diabetes are 15 to 40 times more likely to require lower limb amputation compared to the general population. Approximately 85% of amputations are preceded by the development of a neuropathic foot ulcer with a life time risk for foot ulceration in people with diabetes being 15-25%. Following amputation, the 5 year mortality rate is 50%.[1]

The health economic analysis indicates that diabetic foot ulcers leading sato prolonged hospitalization and/or amputation are among the highest costs in our health care system. Of the $1.6 billion in direct health care costs in Ontario for diabetes and its complications, $400million are related to diabetic foot ulcer disease alone. Recent analytics from the GEMINI group at St. Michael’s has revealed that, among 7 Toronto hospitals, the mean in-patient cost for treatment of a diabetic foot ulcer is $22,754 per hospital stay and $48,808 if a major amputation is required.

This team  has recently developed a pilot end-to-end health care delivery path at St. Michael’s Hospital in Toronto that tracks patients with diabetic foot ulcers that require intensive treatment from admission to hospital, to rehabilitation – a previously fragmented process.  This process is a chiropody led approach that includes assessments from entry into emergency room to rehabilitation with appropriate triage from internal medicine and vascular surgery.  Recently, this team was successful in securing funding for their chiropody-led program to reduce amputations in patients with diabetes and chronic renal failure from the CHIR Operating Grant competition for SPOR Innovative Clinical Trials with Diabetes Action Canada as a funding partner.

Furthermore, we are exploring collaboration with the Indigenous Diabetes Health Circle (IDHC), a healthcare team that has established a community-based foot care program to prevent amputations in Indigenous and underserved areas in Ontario, to assist in evaluating its effectiveness.