To the Editor:

In their review [1], Jeffcoate and van Houtum quote two community-based studies from Germany [2, 3] that failed to demonstrate any decrease in amputation rates between 1990 and 1998. It should be mentioned, however, that no attempt was made to decrease the amputation rates in these communities during this period. In 2001, amputation rates estimated from hospital discharge data from all over Germany [4] remained unchanged as compared with those reported by earlier surveys [2, 3]. The German health authorities subsequently implemented diabetes disease management programmes for general practitioners, with emphasis on foot screening, and podiatry was made available on medical prescription for high-risk diabetic patients. However, it remains to be seen whether these interventions will decrease the incidence of amputation in the near future in the same way they did in The Netherlands [5].