Why This Matters

1.    Multidisciplinary collaboration significantly reduces major amputation rates in patients with complex wounds and CLTI, with team-based care associated with up to 40% fewer above-ankle amputations compared with traditional care models. 
2.    Coordinated care improves patient outcomes across the continuum. From early wound assessment and revascularization to post-healing rehabilitation, this model unites podiatry, vascular surgery, wound care, endocrinology, and other specialties. 
3.    The “Toe and Flow” approach enhances healthcare efficiency and strength of systems by reducing hospital stays, optimizing resource utilization, and empowering providers with shared decision-making frameworks proven to improve long-term limb salvage.

“Toe and Flow”: A New Paradigm for Limb Preservation

Diabetes and peripheral artery disease (PAD) contribute to a growing global epidemic of chronic wounds and limb loss. In the United States alone, non-traumatic lower extremity amputations exceed approximately 150,000 annually, with a disproportionate share linked to diabetes and CLTI.¹ These events not only devastate patients’ lives but also impose staggering economic costs (estimated at over $55,000 per patient per year) and contribute to high morbidity and mortality.¹

Traditionally, care for these complex patients has been fragmented across specialties, with inadequate communication between providers focusing on vascular status, wound care, metabolic control, and functional rehabilitation. Toe and Flow — a term that encapsulates the essential collaboration between podiatric (“toe”) and vascular (“flow”) specialists — integrates these critical domains into a unified model aimed at preserving limbs, reducing amputation risk, and driving wound healing success.²
 

The Burden of Chronic Limb-Threatening Ischemia and Diabetic Foot Complications

Chronic limb-threatening ischemia represents the most advanced spectrum of peripheral arterial disease (PAD) and serves as a key driver of lower extremity amputations, especially among patients with diabetes and neuropathy. Studies report that foot ulcers affect up to 25% of individuals with diabetes during their lifetime, and 85% of these ulcers precede lower limb amputations.^3,4 Patients who undergo major amputation face a 3-year mortality rate as high as 71%, underscoring the gravity of this clinical landscape.¹ 

Because CLTI intersects vascular insufficiency, infection, neuropathy, and systemic comorbidities, no single discipline can adequately manage the full complexity. Optimal care requires integrated wound care, timely revascularization, glycemic control, infection management, and ongoing patient education — all under a coordinated team framework.⁵ 
 

What Is the “Toe and Flow” Care Model?

At its core, the Toe and Flow model emphasizes the symbiotic relationship between experts in foot and wound care (podiatrists) and specialists in vascular diagnostics and revascularization (vascular surgeons/interventionalists). Early proponents of this model, including Joseph Mills, MD and David Armstrong, DPM, MD, PhD, recognized that combining expertise on wound pathophysiology with vascular restoration yields a comprehensive strategy that both prevents and treats limb loss.⁶ The model stresses collaborative diagnosis, co-managed treatment plans, and shared decision-making.^1,5,7

Evidence Supporting Multidisciplinary Limb Preservation

The most compelling data supporting Toe and Flow and team-based limb preservation stem from recent evaluations of multidisciplinary teams in chronic wound and chronic limb-threatening ischemia (CLTI) care. In the BEST-CLI (Best Endovascular versus Best Surgical Therapy in Patients With Chronic Limb Threatening Ischemia) trial, patients treated at centers with formal limb preservation teams experienced a 40% reduction in major amputations compared with those at sites without such teams.⁷

Other outcomes associated with multidisciplinary care include⁷: 
•    Lower high-to-low amputation ratios indicating more minor, limb-preserving procedures. 
•    Greater involvement of podiatry and wound care specialists in patient management. 
•    Improved interdisciplinary communication, with 71% of team-based centers reporting high effectiveness versus 29% without teams.

External evaluations also show that access to specialized limb preservation programs results in reduced hospitalization rates and shorter length of stay for patients with diabetic foot complications when compared with standard of care.⁸ 
 

System-Level Benefits: Efficiency, Cost-Reduction, and Healthcare Performance 

Beyond patient outcomes, the Toe and Flow model strengthens healthcare systems by reducing unnecessary hospital admissions, decreasing length of stay, and lowering the overall financial burden on payers and providers. Lower amputation and readmission rates translate into better resource allocation and cost savings. For example, coordinated care programs have shown up to 21% shorter hospital stays and significant reductions in hospitalization risk.⁷

This efficiency also enhances clinician satisfaction by creating shared care pathways, reducing redundancy, and improving patient follow-up and continuity. Teams built around coordinated care frameworks mirror high-quality models in oncology and cardiology, positioning limb preservation for similar systemic integration and guideline adoption.¹
 

The Take-Home for Wound Professionals 

The Toe and Flow model exemplifies how collaboration between podiatric and vascular specialists — augmented by wound care, endocrinology, infectious disease, rehabilitation, and nursing — drives superior outcomes for patients at risk of limb loss. The future of wound healing and limb preservation lies in collaboration — where Toe and Flow isn’t just a concept, but a clinical standard that transforms patient care. 

References
1.    Norris J, Gopaul D, Grant B, et al. Multidisciplinary team approach to limb salvage. Curr Surg Rep. 2025;13:41. doi:10.1007/s40137-025-00472-w
2.    Naiem AA, Callahan RT, Reyzelman AM, Conte MS. Institutional toe & flow programs: how and why the teams work. Semin Vasc Surg. 2025;38(1):3-10. doi:10.1053/j.semvascsurg.2025.01.008
3.    Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376(24):2367-2375. doi:10.1056/NEJMra1615439
4.    Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990;13(5):513-521. doi:10.2337/diacare.13.5.513
5.    Wolf H, Singh N. Using multidisciplinary teams to improve outcomes for treating chronic limb-threatening ischemia. Ann Vasc Surg. 2024;107:37-42. doi:10.1016/j.avsg.2023.11.055
6.    Vascular Cures. Vascular innovation spotlight: limb-saving toe and flow model with Dr David Armstrong, part I. Accessed March 3, 2026. https://www.vascularcures.org/post/vascular-innovation-spotlight-limb-s…
7.    Jones DW, Farber A, Armstrong DG, Azene E, Duncan A, Todoran TM, Doros G, Strong MB, Rosenfield K, Conte MS, Menard MT. Characteristics of multidisciplinary limb preservation teams and their impact on outcomes in the BEST-CLI trial. J Vasc Surg. Published online 2025. doi:10.1016/j.jvs.2025.08.028
8.    Manji A, Basiri R, Harton F, Rommens K, Manji K. Effectiveness of a multidisciplinary limb preservation program in reducing regional hospitalization rates for patients with diabetes-related foot complications. Int J Low Extrem Wounds. 2025;24(1):117-123. doi:10.1177/15347346241238458