A Keck Medicine of USC podiatric surgeon outlines actionable steps for optimizing diabetic foot ulcer care.
Each year, diabetic foot ulcers affect nearly 18.6 million people globally, contributing to more than 1.6 million amputations annually. These devastating outcomes are not only preventable but reversible when interdisciplinary care and a systematic approach to diabetic limb preservation are employed. This approach, which has been pioneered and scaled at institutions like ours at Keck Medicine of USC, is centered around four actionable steps. These steps — creating a “hot foot line,” developing wound-healing clinics, establishing remission clinics and implementing screening programs — form the backbone of a scalable model that could significantly reduce preventable amputations worldwide.
This was the central theme of a lecture I delivered at a recent symposium in Malta, addressing an audience of global leaders in limb preservation. The conversation was not just about treating disease but about how care-delivery systems can proactively manage chronic conditions to save both limbs and lives. Let us explore these four steps and their potential for global impact.
Step 1: Establishing a “hot foot line”
The first line of defense against limb-threatening complications is an effective, rapid response system. The “hot foot line,” a dedicated hotline for emergency department referrals, ensures that patients presenting with diabetic foot infections or ischemia are immediately triaged to a specialized limb-salvage team. This interdisciplinary team, often led by podiatric and vascular surgeons, assesses whether the primary issue involves infection, ischemia or both.
For instance, patients with tissue loss, infection and palpable pulses may be managed primarily by podiatric surgeons for debridement, while vascular surgeons are consulted for ischemia-related complications. This integrated triage system allows for prompt and tailored care, reducing delays that can lead to major amputations. Studies show that streamlined care pathways like the “hot foot line” can lower major amputation rates by as much as 50% when compared to traditional models.
Step 2: Developing wound-healing clinics
Once the acute phase is managed, the focus shifts to outpatient wound care. Wound-healing clinics are designed to address active tissue loss and move patients toward remission. These clinics employ an interdisciplinary approach to optimize healing through advanced modalities like total contact casting, vascular diagnostics and surgical debridement.
Equally critical is the availability of comprehensive resources, such as offloading devices, advanced wound dressings and physical therapy services. In one study, the implementation of wound-healing clinics reduced time-to-healing by nearly 30%, while also decreasing hospitalization rates. These clinics embody the ethos of proactive, rather than reactive, care by addressing the root biomechanical, neurological and vascular factors contributing to chronic wounds.
Step 3: Establishing remission clinics
Healing a wound is only half the battle. Up to 65% of diabetic foot ulcers recur within five years of healing. Remission clinics aim to extend ulcer-free, hospital-free and activity-rich days for patients. These clinics combine patient education, biomechanical evaluations and preventive interventions to reduce the risk of recurrence.
For example, patients may be equipped with pressure-relieving footwear, thermal monitoring devices to detect pre-ulcerative hotspots, and personalized exercise regimens. A meta-analysis highlighted that patients using home-based dermal thermometry experienced a 49% reduction in diabetic foot ulcer recurrence rates compared to standard care. By leveraging technology and education, remission clinics empower patients to take an active role in their own care, thereby reducing reliance on acute interventions.
Step 4: Implementing screening clinics
Prevention is the ultimate goal, and annual foot screenings are the cornerstone of early detection. Screening clinics assess patients for risk factors like neuropathy, peripheral artery disease and foot deformities, using tools such as the American Diabetes Association’s Comprehensive Diabetic Foot Examination and Risk Assessment.
These clinics also employ a tiered care model, where patients identified as high risk are referred to remission or wound-healing clinics, while those with limb-threatening pathology are escalated to the “hot foot line.” This proactive approach has been shown to reduce major amputation rates by targeting early intervention. In underserved areas, mobile screening programs and community-based education initiatives have proven especially effective in bridging health care disparities.
The global opportunity
The implementation of these four steps has already yielded significant results at Keck Medicine of USC and beyond. For example, the multidisciplinary team at the Southwestern Academic Limb Salvage Alliance (SALSA) has demonstrated measurable reductions in amputation rates by adopting this model. A similar approach has been implemented in regions of sub-Saharan Africa, Latin America and Southeast Asia, where health systems face unique challenges in managing diabetes-related complications.
Moreover, these steps are scalable and adaptable to different health care environments. Whether in a tertiary care center in Los Angeles or a rural clinic in India, the principles of early detection, interdisciplinary care and patient empowerment remain the same. Programs that incorporate data collection and outcome monitoring further ensure quality improvement and sustainability.
Pathway to optimizing care
Preventable amputations are a global challenge that demands global solutions. The four-step model of diabetic limb preservation is not just a medical innovation but a framework for systemic change. By integrating “hot foot lines,” wound-healing clinics, remission clinics and screening programs, health care systems can dramatically improve patient outcomes and quality of life.
At its core, this approach is about giving patients the chance to lead ulcer-free, active lives. As I shared in Malta, saving limbs is about much more than avoiding amputation; it’s about restoring mobility, dignity and hope. Together, through interdisciplinary care and global collaboration, we can take the steps needed to save two limbs at a time, worldwide.
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