Pertinent Insights On Plastic Surgery And The Diabetic Foot

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Essential Insights To Ensuring Proper Patient And Procedure Selection

A multidisciplinary team approach is necessary for comprehensive management of patients with DFUs who often present with several comorbidities that can potentially impair wound healing.3

The reconstructive surgeon should be the “superintendent” when considering the type, extent and timing of the surgical closure. Important contributing factors include but are not limited to: the patient’s age, presence of comorbidities, level of adherence, presence of infection, vascular status, associated foot or ankle deformities, and the level of medical stabilization. One needs to heavily weigh all of these factors prior to selecting wound closure procedure(s).4

Physicians should not underestimate the assessment of the patient’s psychosocial status and home support system as these can dramatically influence surgical expectations and the postoperative course.

Treating physicians should pursue appropriate diagnostic testing in order to ensure appropriate medical optimization prior to surgery. Hemodynamic instability may require further cardiology and nephrology consultation for medical clearance and anesthesia considerations. One should address any infectious process through extensive surgical debridement and tailored antibiotic therapy before contemplating soft tissue reconstruction. The presence of greater than 105 organisms per gram of tissue cannot sustain a skin graft or flap, and will require further debridement before definitive coverage.5

The patient must also undergo a full evaluation for peripheral vascular disease in order to ensure viable perfusion, which can support the vascular demand required for healing.6 Staging of surgical procedures is often warranted to provide the clinical setting most suitable for plastic surgery techniques.

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67
Author(s): 
Zacharia Facaros, DPM, Crystal L. Ramanujam, DPM, John J. Stapleton, DPM, FACFAS, and Thomas Zgonis, DPM, FACFAS

Given the challenges of healing complicated wounds in patients with diabetes, these authors discuss the use of plastic surgery techniques ranging from split-thickness skin grafts and local random flaps to muscle flaps and pedicle flaps.

The prevalence of diabetes mellitus has been increasing exponentially with more than 220 million people affected. The World Health Organization projects that this number will double between 2005 and 2030. Up to 6 percent of patients with diabetes may develop a diabetic foot ulcer (DFU) with over 15 percent requiring an amputation.1 For those wounds that become non-salvageable and require major lower limb amputation, the long-term prognosis is dire with 50 percent of these patients deceased at five years.2

   The global impact of the diabetic foot has made abundantly clear the need for durable, sound surgical options to facilitate the expedited closure of wounds.

   The treatment of the diabetic foot wound challenges the surgeon with multiple obstacles on the road to eventual wound closure. Numerous options are available and one must be familiar with each modality in order to select the best treatment for the patient. Surgeons must also ensure a thorough diagnostic workup and carefully consider a host of factors (patient age, vascular status, comorbidities, adherence, etc.) in determining the best course of treatment. (See “Essential Insights To Ensuring Proper Patient And Procedure Selection” at right.)

   Plastic surgery techniques for soft tissue reconstruction have demonstrated success for long-term healing and stabilization. Expedited healing of these complicated wounds not only improves the patient’s quality of life but can also significantly decrease health care costs associated with extended wound care. These techniques require meticulous perioperative planning (see “Keys To Perioperative Care” at right) and carry with them potential complications that the surgeon must be equipped to handle.

   The fundamental goals of plastic surgery techniques in wound closure have not changed since ancient times: preservation of form and function. A thorough understanding of the stepwise approach to the use of such procedures is imperative for successful outcomes.

   Regardless of the approach you use, the main objective is achieving a healthy, non-infected wound with adequate perfusion and biomechanical stability. Ultimately, you are striving for a plantigrade, functional foot without residual and recurrent ulcerative lesions.

   Surgeons may perform concomitant osseous reconstructive procedures to correct underlying deformity and further promote stabilization of the foot for soft tissue reconstruction.8 Furthermore, adequate offloading techniques, such as thorough casting, splinting or external fixation with assistive devices, are vital to the durability of the soft tissue reconstruction of the soft tissue reconstruction. However, the detailed discussion of these offloading techniques is beyond the scope of this article.

   Let us now take a closer look at soft tissue coverage through a logical progression along the well established plastic surgery reconstructive approach.9

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