Soft tissue reconstructive options for the ulcerated or gangrenous diabetic foot

Abstract

The complex biomechanics of the foot and ankle allow for a highly efficient and coordinated functional unit capable of nearly 10,000 steps a day. However, changes in sensation, motor function, skeletal stability, blood supply, and immune status render the foot and ankle susceptible to breakdown. Inability to salvage the injured foot traditionally has led to major amputation, carrying with it dramatic morbid sequelae and a lifetime dependence on prosthetic devices. Worldwide, a limb is lost to diabetes nearly every 30 s. Consequently, the relative 5-year mortality rate after limb amputation is greater than 50%, a startling figure when compared to mortality rates of lung cancer (86%), colon cancer (39%), and breast cancer (23%). Because the foot and ankle is such a complex body part, salvage often demands a multidisciplinary team approach. This team ideally should consist of a vascular surgeon skilled in endovascular and distal bypass techniques, a foot and ankle surgeon skilled in internal and external (Ilizarov) bone stabilization techniques, a soft tissue surgeon familiar with modern wound healing as well as soft tissue reconstructive techniques, an infectious disease specialist to manage antibiotic therapy, and an endocrinologist to help manage the glucose levels. Surgical goals include transforming the chronic wound into an acute healing wound with healthy granulation tissue, neo-epithelialization, and wrinkled skin edges. This may include ensuring a good local blood supply, debriding the wound to a clean base, correcting any biomechanical abnormality, and nurturing the wound until it shows signs of healing. The subsequent reconstruction can then usually be accomplished by simple techniques, 90% of the time and complex flap reconstruction in 10% of cases. This chapter focuses on the critical aspects of limb salvage including evaluation, diagnosis, and treatment with a focus on flap-based reconstructions.