Pertinent Insights On Plastic Surgery And The Diabetic Foot

Volume 24 - Issue 3 - March 2011
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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.

Author(s):

Zacharia Facaros, DPM, Crystal L. Ramanujam, DPM, John J. Stapleton, DPM, FACFAS, and Thomas Zgonis, DPM, FACFAS

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16. Capobianco CM, Zgonis T. Abductor hallucis muscle flap and staged medial column arthrodesis for the chronic ulcerated charcot foot with concomitant osteomyelitis. Foot Ankle Spec 2010;3(5):269-73.
17. Attinger CE, Ducic I, Cooper P, et al. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg 2002;110(4):1047-57.
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Editor’s note: For related articles, see “Emerging Concepts In Fixation For Charcot Midfoot Reconstruction” in the February 2011 issue of Podiatry Today, “Conquering Plastic Surgery Complications In Wound Care” in the July 2005 issue, “A Closer Look At Plastic Surgery Techniques” in the March 2003 issue, “Is Rocker Bottom Reconstruction A Viable Option For Limb Preservation?” in the December 2004 issue or “Managing Ulcers On The Charcot Foot” in the July 2003 issue.