in 2000 , a multidisciplinary healthcare team with emphasis on diabetic limb salvage was established in our institution and , currently , more than 1,000 patients per year with a diabetic foot problem visit our clinical setting .
the team consists of orthopedic surgeons specializing in diabetic foot and ankle surgery , nurses , orthotists and/or prosthetists , physiotherapists , cardiologists , nephrologists , infectious disease specialists , and internists .
this team works closely with the diabetic foot protocols and guidelines and collaborates in the management of the diabetic foot .
the patient is initially evaluated and examined by the orthopedic team , which establishes the clinical pathway and eventual treatment of the diabetic patient .
pertinent history and physical examination , including the patient 's musculoskeletal , neurological , vascular , and dermatological status , are obtained during the patient 's first visit with a diabetic foot problem .
in addition , a biomechanical examination and/or pertinent laboratory and medical imaging tests are also obtained . at that point ,
the necessary referrals are established for the overall medical management of diabetes in this patient population .
patient education on proper foot care through an intensive nursing program is also established early in the patient 's visit .
in addition , the patient has the opportunity to be assessed by an orthotist and/or prosthetist , who defines with the orthopedic team the conservative functional or post - reconstructive treatment plan for the diabetic patient .
the final treatment is decided upon our plan that is being facilitated by multiple healthcare members , clinical settings , teaching and patient education .
several classification systems have been used for the treatment of the diabetic foot and table 1 represents our generic classification that guides the patient 's treatment and clinical investigation protocols ( 11 ) . 
 
our main strategies include appropriate patient education and prevention , advanced wound care modalities and treatment , appropriate offloading with a total contact cast and/or custom - made orthopedic shoes , curative and reconstructive surgery , post - operative management , and amputee rehabilitation program when needed ( 10 , 1215 ) . all diabetic patients in our clinical setting present from the public healthcare system , and almost all have attended this system on other occasions .
we have to highlight that most of these patients come to our clinic without minimum parameters of glycemic control , such as glycosylated hemoglobin a1c or self - monitoring blood glucose levels .
the majority of these patients have minimal knowledge about the care of their diabetic feet and are not aware of the complications of diabetic neuropathy .
in addition , many patients also present with other inabilities that complicate the care of their feet , for example , a decrease of visual acuity ( 16 ) .
education is a strong tool in the patient 's overall treatment of diabetic foot pathology ( 17 ) .
it has been documented that objective education actually decreases the incidence of ulcers and amputations ( 8 , 17 , 18 ) .
the first step is to warn the patient and the patient 's family of the potential limb and/or life - threatening case scenarios that can arise from a diabetic foot ulceration .
the second step is to educate the patient about proper foot self - inspection and seek medical care when necessary .
the final step is the consideration of prophylactic and elective diabetic foot surgery in the presence of pedal deformities that can not be accommodated in custom - made diabetic shoes ( 8) .
urgent and emergent diabetic foot cases are performed immediately by surgeons who specialize in diabetic foot and ankle surgery .
post - operatively , the reconstructed or amputee patients are referred to an orthotist and/or prosthetist for the prescription of custom foot orthosis and/or shoes ( 16 , 19 ) .
this type of multidisciplinary team approach has been very beneficial to our institution and the overall public healthcare system in sao paulo , brazil .
it has decreased the number of amputations , ulcerations , and prolonged hospitalizations similar to other diabetic foot units around the world ( 9 , 2022 , 23 ) .
in this paper , we report our success in the management of the diabetic foot in a university hospital with a public healthcare system in sao paulo , brazil . through extensive patient education , prevention , reconstructive surgery , and rehabilitation , we are able to provide excellent patient care and decrease the amount of yearly amputations and re - ulcerations due to dm .
our diabetic foot treatment program has been effective in providing a dialogue with public healthcare personnel and solving major problems within our system .
we hope to continue this multidisciplinary program and provide an excellent model to many other diabetic clinical settings around the world .
the authors have not received any funding or benefits from industry to conduct this study .
 diabetes mellitus can cause devastating foot problems including loss of protective sensation with subsequent ulcerations and amputations . 
 the natural history and pathophysiology of diabetic foot ulcers is best understood and managed by a multiprofessional team approach . 
 the main factors for prevention and treatment of these devastating diabetic foot conditions are shown , with special attention to education of the patient . 
 this approach decreases the morbidity of the disease , besides its economical and social feasibility . 
Team approach to diabetic limb salvage
Clinical strategies
Conclusion
Conflict of interest and funding