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Case Study 8: A Podiatric Limb Preservation Team in Action

Vickie R. Driver, D.P.M.


The Limb Preservation Service at Madigan Army Medical Center in Tacoma, Washington, began as a “foot-at-risk” clinic in the Department of Podiatry. Over time, the foot-at-risk clinic specialized in the management of diabetes-related foot disease and became the Limb Preservation Service that provides both inpatient and outpatient services. The medical center is a 172-bed military regional tertiary care hospital with a beneficiary population of about 350,000. Madigan is one of three designated Level 2 trauma centers in the U.S. Medical Command.

Team members

The Limb Preservation Service is headed by the podiatry department. Clinic podiatrists conduct the first evaluation of patients with diabetes, assess risk factors, and manage foot ulcers and emergency treatment of foot infections. Vascular surgeons participate in the management of critical limb ischemia and peripheral arterial disease. A specialized wound care nurse assists the physician in carrying out wound care treatment plans. She or he also works independently as a wound care provider. A pedorthist provides customized shoe and orthotic devices.


Regular care of the foot in patients with diabetes depends on the severity of their condition and the presence of risk factors. Patients followed by the limb preservation team receive comprehensive inpatient and outpatient care that includes

  • state-of-the-art advanced wound care management
  • medical and surgical management of infection
  • at least a quarterly clinic visit (the frequency of the visits depends on the severity of the problem)
  • ongoing education that includes families
  • orthotic devices, extra-depth shoes, and custom made shoes as needed

Patient education is a high priority and is usually provided by a podiatrist or wound care nurse during both inpatient and outpatient visits. An individualized education plan is part of the electronic medical record. The higher the risk for limb loss, the more intensive the educational program.


Electronic medical records are used. Team members consult in person to discuss the most complex cases. Since it is an army medical center, specialist referrals are easily made and recommendations incorporated into the medical record. Two important factors contribute to the success of the limb preservation service: close collaboration among team members, and the fact that the patients remain within the military hospital system for a long period of time.

Insurance coverage

Patients pay for their care through TRICARE, the single-payer health care program of the United States Department of Defense Military Health System.


From the beginning of the Limb Preservation Service in 1999 to 2003, the rate of non-traumatic lower extremity amputations decreased significantly despite the increase in the overall population of patients with diabetes who were referred to the service.

Data were then collected on a random sample of 485 patients among the 8,422 patients with diabetes followed at the medical center between June 1999 and June 2004. Patients were stratified according to the University of Texas classification system that classifies diabetic wounds based on risk and severity and divided in two groups: those followed by the Limb Preservation Service and those followed by a non-specialized service. Over the five-year period, patients referred to the Limb Preservation Service had more severe disease than patients who were receiving non-specialized services. This resulted in a higher proportion of minor amputations in the Limb Preservation Service group but no significant increase in major amputations.

Related references

Driver VR, Goodman RA, Fabbi M, et al. The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity: a retrospective cohort study. J Am Podiatr Med Assoc. 2010; 100(4):235-41.

Driver VR. Reducing amputation rates in patients with diabetes at a military medical center. Diabetes Care. 2005; 28(2):248-53.

February 2013​​​​