Surgical interventions are being used more frequently for the management and treatment of diabetic foot ulcerations.
Need to be stabilized from a metabolic, renal and cardiovascular perspective prior to surgery.
Removal of necrotic or nonviable skin – remove down to viable skin.
Incision and drainage:
Indicated for acute foot infection.
Stabilise acute infection
For deep infection or fascial plane abscess
Removal of all nonviable tissue.
After feasibility for vascular reconstruction established
Digital or partial foot amputations
Indications for amputation:
as part of debridement to control acute infection
chronic neuropathic ulcer when there is significant tissue loss
extensive tissue loss
ischaemia that can not be revascularised, or failed revascularisation
Charcot’s neuroarthropathy (if severe, causing an unstable foot or ankle)
See Surgical Interventions chapter
Achilles tendon lengthening:
Being used more to reduce forefoot pressures.
Cavanaugh’s chapter in Kominsky
Aim is to reduce risk of complications developing by surgically correcting structural and functional problems that may be leading to areas of increased pressure. Becoming more common.
Specific goals of corrective surgery :
to provide a foot of good configuration that is plantigrade and that can be fitted with shoes making ambulation possible
to improve quality of life and to avoid amputation with better, more normal gait
to eliminate the infectious focus
to hasten the healing of ulcers by eliminating bone prominences
Metatarsal head resection is commonly used for higher pressure relief – no studies compared efficacy compared to footwear or orthoses
For management of soft tissue defects; being more widely used due to improvements in distal revascularisation procedures
Grafts – piece of tissue that has been detached from its native vascular supply
Flaps – piece of issue transferred with its vascular supply
Vascular surgery (revascularizations):
Vascular reconstruction has been shown to give good short and long term benefits in those with diabetes. The aim is to help the disabling ischaemic symptoms, preserve or restore tissue integrity and to preserve or restore function of the limb.
Pre-requisites for suitable candidate:
• reasonable life expectancy
• reasonable potential for rehabilitation
• associated cardiac disease is stable
• renal function is stable
• active infection is adequately controlled
The cutaneous microcirculation dysfunction in those who also have neuropathy has been shown to improve considerably, but not completely following successful bypass grafting surgery (Arora et al, 2002).