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Wounds
The International Journal of Lower Extremity
 http://ijl.sagepub.com/content/12/1/71
The online version of this article can be found at:
 
DOI: 10.1177/1534734613476519
 2013 12: 71 originally published online 26 February 2013International Journal of Lower Extremity Wounds
Peter Lamont, Kerryn Franklyn, Gerry Rayman and Andrew J. M. Boulton
Update on the Diabetic Foot 2012: The 14th Biennial Malvern Diabetic Foot Conference, May 9-11, 2012
 
 
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The International Journal of Lower 
Extremity Wounds
12(1) 71 –75
© The Author(s) 2013
Reprints and permission: 
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534734613476519
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The 14th biennial Malvern Diabetic Foot Conference was 
held in May 2012. Since the first meeting in 1986, chaired 
by Dr Henry Connor and Professor A. J. M. Boulton, the 
conference has attracted increasing numbers of attendees 
and this year saw a record number of abstracts submitted 
albeit only one third could be accepted. Physicians, podia-
trists, nurses, orthotists, surgeons, radiologists, and other 
professionals attended to reflect on the diabetic foot. There 
were delegates present from every continent except Antarc-
tica, representing 25 different countries. The conference 
comprised interactive workshops, oral presentations of new 
research findings, and lectures from leading figures in the 
world of the diabetic foot.
The conference was opened by Sir Michael Hirst, who is 
the incoming President of the International Diabetes 
Federation and the first nonmedical chairman of Diabetes 
UK. His interest in diabetes was sparked when his daughter 
was diagnosed with diabetes when she was 5 years old. He 
has been able to use his political career to influence policy 
changes, specifically ensuring that the UK drug tariff now 
includes disposable syringes. Sir Michael acknowledged that 
there is an inequality of care provided to diabetes patients 
across the world and wishes to raise awareness through edu-
cation for patients and care professionals alike. He identified 
the importance of the influence that policy makers have when 
initiating change and highlighted the massive challenges that 
exist when dealing with chronic disease.
Epidemiology/Health Economics
Gerry Rayman (UK) introduced session 1, which was on 
Epidemiology and Health Economics. He discussed the 
uneven rates of amputation throughout England and noted 
that major amputation rates varied 10-fold across primary 
care trusts (PCTs) in the United Kingdom. This fact was 
highlighted in a discussion by Marion Kerr, Health 
Economist, who discussed the human and financial cost of 
amputation. A total of 61 000 people with diabetes in 
England will have a foot ulcer at any one time. The risk of 
lower extremity amputation is 23 times that of a nondia-
betic individual. She noted that mortality rates are now at a 
similar level to some of the major cancers such as breast, 
prostate, colon, and lung. In 2010, 38 000 people had a first 
incidence of diabetic foot ulceration; only breast cancer has 
a higher incidence. The 5-year survival rate after a diabetic 
foot ulcer is 57%; however, after amputation the 2-year 
survival rate may be as low as 50%, although this rate is an 
association rather than an attribution. The discussion went 
476519 IJL12110.1177/1534734613476519The 
International Journal of Lower Extremity WoundsLamont et al
© The Author(s) 2011
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
1Manchester Foot Hospital, Manchester, UK
2Ipswich Hospital, Ipswich, UK
3Manchester Royal Infirmary, Manchester, UK
Corresponding Author:
Peter Lamont, The Foot Hospital, Rusholme, Manchester M14 5NP, UK. 
Email: peter.lamont@cmft.nhs.uk
Update on the Diabetic Foot 
2012: The 14th Biennial Malvern 
Diabetic Foot Conference, 
May 9-11, 2012
Peter Lamont, MSc, Hons, Podiatry1,Kerryn Franklyn, MSc, Hons, Podiatry1, 
Gerry Rayman, MD1, Andrew J. M. Boulton, MD2,3
Abstract
The 14th biennial Malvern Diabetic Foot Conference was held in May 2012. Physicians, podiatrists, nurses, orthotists, 
surgeons, radiologists, and other professionals attended to reflect on the diabetic foot. The conference comprised interactive 
workshops, oral presentations of new research findings, and lectures from leading figures in the world of the diabetic foot. 
Over the 3 days, topics such as epidemiology, neuropathy, screening, vascular disease, prevention, and management among 
others were discussed. The conference has been an excellent platform from which to share new and ongoing research and 
it will without a doubt improve the treatment of the diabetic foot across the world.
Keywords
diabetic foot, Malvern, amputation
Regular Features
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72 The International Journal of Lower Extremity Wounds 12(1)
on to describe the financial cost of diabetic foot care in the 
United Kingdom alone. In 2010/2011, the National Health 
Service (NHS) spent between £639 and £662 million, the 
majority of this in community, outpatient, and accident and 
emergency settings. In addition, £1 in every £150 of total 
NHS spending is required to treat the diabetic foot.
Marion Kerr (UK) presented some key issues that were 
echoed during the rest of the conference. In the community 
setting, there appears to be discrepancies in collating infor-
mation and foot screening. The point being made was 
whether patients who receive a foot screen and risk stratifi-
cation really understand the meaning of the latter. In addi-
tion, the question arose as to whether patients were receiving 
the correct care pathway following their risk categoriza-
tion? There were also issues with inpatient care with three 
quarters of inpatients having no foot examination during 
their stay. This is despite the fact, based on the available 
data, that 2.2% of diabetes inpatient beds are occupied by 
someone who has developed a foot ulcer during their stay in 
hospital. It was alarming to note that over 18 sites, there was 
a variation of 0% to 27% for hospital admissions due to a 
diabetic foot ulcer. This emphasizes the many variations in 
data recording across the country. Multidisciplinary team 
care with community links has been shown to result in 
improved patient outcomes and savings. Two case studies, 
from Southampton and Middlesbrough, showed a reduction 
in annual amputations and an annual saving of 4 and 7 times 
the cost of the service, respectively. This highlights the need 
for quality and efficiency within services as the cost of dia-
betic foot care is certain to rise substantially.
William Jeffcoate (UK) supported much of the previous 
discussion in his talk on whether the diabetic foot is the 
cancer of diabetes. Data from Nottingham in 2003 found 
that diabetic patients with foot ulceration had a mortality 
rate of 16.7% at 12 months and 50% at 5 years. This is com-
parable with colon cancer. It is surprising then that amputa-
tion was perceived as a personal threat more than a mortality 
risk. He reiterated Rayman’s introduction by noting a 
10-fold variation between PCTs inthe United Kingdom and 
questioned whether such a variation would be acceptable in 
cancer or heart disease? Is the diabetic foot the cancer of 
diabetes? Jeffcoate argued that it is now more important 
than cancer.
Neuropathy: From Painless to 
Painful
Professor Boulton (UK) provided an introduction to the dia-
betic somatic sensory neuropathies by stating that they can 
present as pain, insensitivity, or a combination of the two. He 
pointed out that it is a length-dependent neuropathy, affecting 
the longest nerves, and that importantly height is a risk fac-
tor. Neuropathy is twice as common in type 2 compared to 
type 1 diabetic patients, and the diagnosis depends on the 
exclusion of other causes. Electrophysiology will not inform 
the cause of the neuropathy, and the diagnosis cannot be 
made without a clinical examination. Clinical tests comprise 
monofilament, vibration, and pin-prick sensations together 
with reflexes, Neuropathy Disability Score, and Quantitative 
Sensory Testing such as Vibration Perception Threshold. 
There are also new quick chair-side tests available, such as 
the Vibratip and the Ipswich Touch Test. The latter is a quick, 
inexpensive, and reliable clinical test that will prove useful 
for situations where equipment is not readily available, such 
as on the ward or in developing countries.
B. Nijafi (USA) presented the findings of an interesting 
gait variability (GV) study and discussed how this can be 
altered by neurodegenerative diseases. Aside from being a 
strong predictor of falls, GV may increase energy cost and 
shear force. Investigating methods to modify GV may have 
a practical application for foot care.
To close the session, D. Ziegler (Germany) provided a 
comprehensive overview on the diagnosis and treatment of 
painful diabetic neuropathy. He reiterated the importance of 
bedside tests for large and small fiber function. The gold 
standard test is skin biopsy to detect any decrease in nerve 
fiber density; however, corneal confocal microscopy is also 
a newly developed technique. He provided a thorough over-
view of treatment options, but in summary his recommen-
dations for successful results consisted of initial treatment 
as soon as possible, taking into account pain relief and qual-
ity of life, physical and emotional functioning, and sleep 
quality. Choice and dose of treatment should be made with 
consideration to other comorbidities such as renal and car-
diovascular disease and therefore needs careful titrating. 
Most guidelines list Duloxetine or Pregabalin as first-line 
therapies for painful diabetic neuropathy. A drug should not 
be judged as ineffective until it has been administered for at 
least 2 to 4 weeks at an effective dose. Finally, analgesic 
combinations should be tried and interactions should be 
considered.
Symposium on Screening
The screening of patients and allocation of risk stratifica-
tion in Scotland has improved the treatment of the diabetic 
foot by focusing resources on the necessary areas, accord-
ing to Graeme Leese (Scotland), who discussed the find-
ings of a new traffic light system that is similar to that 
suggested by the International Working Group on the 
Diabetic Foot (IWGDF). They found that between 2007 
and 2012, the number of diabetic patients who have been 
screened has risen from 25% to 86%. The development of 
some excellent leaflets and a new online training service 
has helped educate both patients and clinicians and infor-
mation is available to all at www.diabetesframe.org. They 
have also focused on creating stronger links between com-
munity services and specialist teams at the hospitals.
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Lamont et al 73
Rodger Gadsby (UK) discussed the new Quality and 
Outcomes Framework (QoF) guidelines. QoF have increased 
foot care points from 6 to 7 with the emphasis on screening, 
which is an improvement; however, it is not at the level 
achieved in Scotland. The key drawback with this system is 
the referral pathway after screening. It has been noted that 
20% of trusts do not have access to a multidisciplinary team 
and therefore there is no obvious pathway for these high-risk 
patients to be followed-up. Dr Gadsby concluded that, with 
the implementation of the commissioning act, these issues 
will be addressed because all trusts will have to have a mul-
tidisciplinary team. This reiterated Sir Michael Hirst’s final 
point in his address that the policy makers are the key to 
initiating change to improve the service.
G. Rayman (UK) summarized the recent diabetes inpa-
tient audit. This was performed over 230 hospitals, repre-
senting 96% of all acute hospitals in England. More than 12 
000 patient’s care was audited and 56% of patients returned 
a patient experience questionnaire. The audit found that 
15% of all inpatients had diabetes. Only 9% were admitted 
for a diabetes complication, the majority being admitted for 
another medical or surgical condition although diabetes 
invariably complicated their stay. Twelve percent of all dia-
betes admissions had foot problems and half of these 
patients were admitted specifically for diabetic foot disease. 
As previously mentioned, only about a quarter of diabetes 
admissions had a foot inspection of any sort. A key problem 
when performing a foot screen is time and access to equip-
ment. This led to the development of the Ipswich Touch 
Test, which was discussed in Prof Boulton’s talk. Dr 
Rayman found that use of the Touch Test and a heel check 
every day lead to a 63% reduction in foot lesions after 
admission over a 3-year period. The audit highlighted varia-
tions in service availability across trusts, with 40% not hav-
ing access to a multidisciplinary team, 7% not having access 
to a podiatrist or orthotist, and 12% without access to an 
interventional radiologist. Dr Rayman’s team has devel-
oped an informative DVD to educate clinicians in primary 
care setting as to how diabetic patients can be screened for 
foot problems and risk stratification.
Biomechanics and Vascular Disease
N. Reeves (UK) presented on the biomechanics of the dia-
betic foot and spoke in general about the mechanics of the 
whole lower limb during gait. He provided some back-
ground into what is known about gait in people with diabe-
tes. It has been demonstrated that a diabetic patient with 
peripheral neuropathy will perform a variable gait pattern 
with slower speed and a more cautious strategy, which 
leads to a higher number of falls compared to matched 
controls. Reeves presented some of his recent findings, 
which showed that diabetic patients with peripheral neu-
ropathy appear to use a different muscle activation pattern 
compared to age-matched controls and diabetics without 
peripheral neuropathy. They appear to be slower to develop 
the required forces, which may indicate more difficulty in 
responding to unexpected events, which may suggest a 
higher likelihood to falls in this cohort.
T. Richards (UK) discussed peripheral vascular disease 
diagnosis and management. He talked about advances in 
diagnostics and his use of the magnetic resonance scan, 
which produces similar results to the angiogram. Color 
duplex scanning is commonly used, but can be fraught with 
problems, particularly in the presence of calcified arteries. 
He recommended further investigations if pulses cannot be 
palpated, and not to rely solely on the hand-held Doppler. 
Identification of anastomoses and the formation of collater-
als is necessary to find areas of impaired blood supply as 
this will indicate a limb has lost direct blood flow to the 
foot. A speedy referral of complex patients suffering from 
spreading cellulitis, deep tissue infection, abscess, whole 
toe gangrene, and sepsis is imperative. Richards expressed 
concern regarding variations across hospitalsand empha-
sized the importance of data linkage and teamwork in this 
complex group of patients. Amputation is not a failure if 
there is a chance of rehabilitation and the patient’s quality 
of life will improve. He summarized his talk by highlight-
ing 2 key treatment principles of sepsis drainage and 
improvement of blood flow.
This talk was followed by J. Reekers (Netherlands), who 
spoke about both the diagnostic capabilities and the endo-
vascular procedures that are performed by the interven-
tional radiologist. The advantages of the small vessel 
percutaneous procedures are that they are minimally inva-
sive requiring no general anesthetic and can be done in the 
outpatient setting, with results comparable to surgery. 
Moreover, they can be repeated if needed. Disadvantages 
are that they require a high level of skill, training, and expe-
rience. The option to do either open or endo surgery is very 
much patient and wound specific; however, he feels that an 
interventional radiologist is a vital member of the multidis-
ciplinary team.
G. Andros (USA) followed with a talk on the manage-
ment of the highest risk patient: who is the diabetic patient 
on dialysis with foot problems. He described 2 different 
types of vascular angiopathy, one being diabetes and the 
other caused by hypertension/tobacco. End-stage renal dis-
ease (ESRD) is not widely recognized as an independent 
risk factor for diabetic foot ulceration. ESRD is 2.5 times 
greater than 10 years ago, with those with diabetes account-
ing for 50% on hemodialysis. There is a relationship 
between the severity of renal disease and the risk of foot 
complications. It was noted that 1 in 5 diabetic patients with 
ESRD have a foot ulcer, and an amputation is usually 
required in those with ESRD suffering from a heel ulcer 
with exposed bone. In addition, mortality rates are poor in 
this cohort, with the cumulative survival postamputation 
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74 The International Journal of Lower Extremity Wounds 12(1)
being 50% at 2 years. As healing rates can be impaired in 
those patients with edema, he discussed the possible bene-
fits of transferring a patient with an ulcer from peritoneal 
dialysis to hemodialysis. He noted that a primary below 
knee amputation is probably preferable to multiple open 
endovascular procedures, especially in the young, echoing 
the previous discussion by Mr Richards on rehabilitation 
and quality of life.
Prevention and Management
S. Morbach (Germany) discussed the “Step by Step” team 
exchange program introduced to developing countries to 
increase awareness, reduce amputations, and develop basic 
diabetes services. The program consists of a basic course 
covering screening and management of foot lesions. This is 
followed a year later by the advanced course, which 
involved case discussions and training in offloading. Pilot 
projects were undertaken in India and Tanzania. The pro-
gram has now moved to Pakistan, Egypt, Congo, and the 
Caribbean, with future plans for the rest of the Caribbean 
Islands, Central America, and French-speaking Africa.
This was followed by a discussion by Z. Abbas (Tanzania), 
who talked about the application of the “Step by Step” pro-
gram to pan-African foot care. He mentioned that the true 
prevalence of amputations in Africa is unclear. Dr Abbas 
predicted that there will be a 93% increase in the next 15 
years. Most of these will be identified through improve-
ments in screening. He highlighted the problems associated 
with managing at-risk patients due to the use of herbal rem-
edies and traditional medicines and the delay in presentation 
of acute problems. The aims of the project were to increase 
awareness and training and the education of staff and 
patients, with the overall target to reduce amputations. He 
also presented their education video. Small improvements 
are beginning to show, with the number of treatment centers 
increasing as well as the awareness of foot problems.
R. Lobmann (Germany) then presented on the dysfunc-
tion of wound healing in diabetic patients, in particular the 
disorganized processes of construction and destruction in 
the chronic wound. He gave a thorough overview of the role 
of matrix metalloproteinases (MMPs) in wound healing and 
noted that one of the characteristics of these patients is the 
high level of MMPs in normal skin. Wound healing begins 
at a cellular level, and in chronic diabetic wounds they tend 
to be stuck in the inflammatory stage, and this is where the 
use of cytokines and growth factors may play a role in treat-
ment. The goal of wound treatment in these patients is to 
bring the wound back into balance by good wound bed 
preparation. Eighty percent of diabetic foot wounds will 
respond to offloading and debridement, with the remaining 
requiring the use of additional treatments, for example, 
growth factors and protease inhibitors. There are also high 
levels of infection in diabetic wounds. This infection is 
linked to inflammation with pro-inflammatory mediators 
upregulated by bacteria. Staphylococcus aureus releases 
MMPs and increases levels of interleukin-6 and tumor 
necrosis factor-α.
B. Lipsky (USA) presented a concise update of the new 
guidelines for managing infection in the diabetic foot. These 
guidelines were the combinations of the IWGDF, the 
Infectious Disease Society USA, and NICE guidelines 
(UK). He advised anyone involved in the management of 
the diabetic foot to be aware of these guidelines and to 
remember that “guidelines are like a map—implementation 
is the journey.”
D. Armstrong (USA) closed the morning session with an 
overview on negative pressure therapy. This device is evolving, 
becoming smaller and more easily portable, but still highly 
effective on large wounds. A new development is the intro-
duction of therapies to the wound through the device such as 
MMP modulators, antibiotics, antibiofilms, and antiseptics. 
Another development is the transition from battery power to 
a smaller “spring” powered vacuum-assisted treatment 
device, with research indicating no significant difference 
between the traditional and newer devices.
Management Challenges and the 
Future
E. Jude (UK) began the final session of the conference on 
Osteomyelitis and Charcot. He presented the findings of a 
joint task force on Charcot neuroarthopathy available (Rogers 
L et al, The Charcot foot in diabetes. Diabetes Care. 
2011;34(9):2123-2129). If presenting with a red, hot, swol-
len foot, initial investigations in such a patient should include 
radiographs and bone scans; however, there is a time issue 
with both of these. A magnetic resonance imaging scan is 
helpful but a computed tomography scan is not recom-
mended. Inflammatory markers and leukocyte scans are also 
used. First-line treatment is with offloading, ideally in an 
irremovable total contact cast or alternatively with a prefab-
ricated removable walking cast. However, there is no ran-
domized control trial of the air cast to recommend its use in 
Charcot. The mean casting time is 5 to 6 months. Once 
swelling has resolved and the temperature is within 2 degrees 
of the contra lateral foot, the patient may be transferred to a 
bespoke shoe. In summary, the diagnosis can be missed; 
hence, a high level of suspicion is required in the red, hot, 
swollen, neuropathic foot. Offloading is the initial treatment; 
however, surgical management is an option. Continuous 
follow-up in clinic is recommended to monitor for signs of 
recurrence or other diabetic foot complications.
This was followed by F. Game (UK), discussing the med-
ical versus surgical management of osteomyelitis. It would 
appear that both a medical and surgical approach is required. 
The IDSI guidelines are particularly helpful, and as in any 
management,patient preference should be considered.
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Lamont et al 75
D. Wukich (USA) followed with a pragmatic overview 
of the surgical management of the diabetic Charcot foot 
although Charcot reconstruction is technically difficult. 
About 25% to 50% of patients will require some type of 
surgery, and 90% limb salvage is possible with good patient 
selection and good technique. The aim of surgery is to cre-
ate a stable plantar grade foot that can fit in a shoe and avoid 
amputation. He presented the findings of a review of his 
ankle and hind foot surgeries in diabetes versus nondiabetic 
controls. In the diabetic group, there was a 3-fold increase 
in complications. For elective procedures, he suggests that 
the HBA1c is below 8%. He also found a high level of com-
plications in tobacco users and therefore will not operate 
unless the patient has stopped smoking. There is no high-
level evidence for surgical management and outcomes are 
based on expert anecdotal experience; however, he did note 
that a poor result from surgery is worse than a poor result 
from nonsurgery and that the best surgery is the one he 
never has to perform.
The final talk at the conference was from C. Attinger 
(USA), who spoke on the Georgetown experience of major 
amputation in diabetes. Prevention is naturally better than 
cure; prophylactic care being the best and most cost-effec-
tive treatment. He noted that, even when all of the treatment 
tools are available, only 79% of patients will achieve com-
plete healing. In these cases, a frank and early discussion is 
required regarding the realistic expectations of limb salvage 
versus amputation. Their criteria for amputation are a leg 
not salvageable due to infection, pain due to peripheral arte-
rial disease, and young patients whose quality of life is 
reduced due to a diseased leg. They also use the Ertl ampu-
tation, which is a more distal amputation but found to be 
particularly good on young patients.
Conclusions
The key points resulting from the conference were that 
amputation is not always a failure if it is likely to improve 
the patient’s quality of life, reducing the inequalities in the 
treatment of the diabetic foot and continued improvement 
the foot screening and risk stratification of all our diabetic 
patients. The biennial Malvern Diabetic Foot Conference 
has been an excellent platform from which to share new 
and ongoing research. It will without a doubt improve the 
treatment of the diabetic foot across the world.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with 
respect to the research, authorship, and/or publication of this 
article.
Funding
The author(s) received no financial support for the research, 
authorship, and/or publication of this article.
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