Diabetic Foot Surgery

Introduction

Diabetic foot encompasses any foot pathology resulting from chronic complications of diabetes. The treatment of diabetic foot varies depending on its severity, a determination made during consultation with Dr. Amit Agarwal . Treatment options include both non-surgical and surgical approaches, with a success rate of approximately 80%-90%, meaning that 80-90 out of 100 feet can be saved from amputation.

Non-Surgical Treatment for Diabetic Foot

Non-surgical treatment is suitable for early cases of diabetic foot and includes the following:

Wound Care : Keeping wounds clean and properly dressed.

Antibiotics : Administering antibiotics, minimal painkillers, and, if necessary, injectable medications.

Immobilization Devices : Using devices like cast boots.

Observation : Regularly monitoring the toe and foot for any signs of infection or gangrene.

Corn and Callosity Treatment : Timely management of corns or callosities on the foot.

Blood Sugar Control : Maintaining proper control of blood sugar levels.

Surgical Treatment for Diabetic Foot

When non-surgical treatments prove insufficient, surgery becomes a viable option, with the choice of surgical procedures dependent on the severity of the condition.

Staged Surgical Procedures

Surgical procedures for diabetic foot can be divided into four stages:

Stage 1 – Debridement/Fasciotomy :

What is Debridement surgery?

Debridement is the thorough cleaning of the wound and removing unhealthy infected and dead tissues from the wound.

What is Fasciotomy surgery?

If the patient presents with rapidly increasing swelling, redness, or pain in the leg and foot, and even after antibiotic treatment it does not subside, it can lead to compartment syndrome (increased pressure in the muscle compartment). This is an emergency condition and urgent Fasciotomy is required to relieve the pressure otherwise it can lead to gangrene of the limb and severe sepsis in the whole body.

How is fasciotomy done in diabetic foot?

In this, we give long incisions over the leg and foot such that pus, excess fluids, and toxins are drained without disturbing the blood supply of the limb.

In cases of large and dirty wounds, debridement is done along with fasciotomy.

Is one debridement surgery enough for diabetic foot?

The patient may require more than one debridement surgery to remove the unhealthy portion of the wound if the wound is very large and dirty. After this, regular dressings are done daily.

What is the next step after debridement/fasciotomy?

After initial fasciotomy and debridement, Negative Pressure Wound Therapy (VAC) before the definite procedure is done to reduce the toxins and infection in the body.

Stage 2 – Skin Grafting :

What is the next stage after debridement surgery in the diabetic foot?

After the wound area has settled, a definite Procedure to close the wound is done last which may be skin grafting, local or free flaps as per the requirement of the wound.

What is skin grafting? When is it done for diabetic foot?

Skin grafting is the transfer of a thin sheet of skin, usually taken from the thigh, to cover the raw areas of the leg and foot region. Once the wound is healthy, skin grafting may be done if the defect is not much deep and vital structures are embedded in granulation tissue.

Post-operative recovery in skin grafting-

• Dressing is done every alternate day after surgery.
• Patients may be discharged from the hospital after 2-3 days, and
• Regular follow-up is required.
• The area gradually heals and needs a compression garment later to avoid hypertrophy of scars and to reduce swelling.

Stage 3 – Flap Surgery :

When is FLAP surgery done on Diabetic foot?

If the wound is deep and any vital structure is visible & exposed, like a blood vessel, nerve, bone, or tendons, then flap surgery is advised in the diabetic foot, and skin grafting is not done.

What is a local flap?

The local flap is the transfer of the flap of skin from the surrounding areas to the defect site. It is done when the defect is deep, and the surrounding area is normal and sufficient enough to cover the defect.

What is a free flap? ( Microvascular reconstruction )-

If not, or the local flap fails, then a flap taken from other parts of the body is used to cover the wound through microvascular reconstruction .

It needs surgical expertise and a good working team. Dr Amit Agarwal specializes in diabetic foot microsurgical reconstruction and has saved innumerable feet and legs from amputation.

Post-operative recovery in Free Flap-

• The flap should be monitored frequently post-surgery.
• Hospital stay is increased, with respect to skin grafting or local flap procedures, but it is the best modality to cover the defects in diabetic foot patients.
• The dressing is done every alternate day and the patient is admitted for at least 7-8 days and discharged once the flap is settled.

What are the results of microvascular surgery in Diabetic foot?

The results of microsurgical reconstruction in the diabetic foot can be quite unpredictable as it is dependent on multiple factors like the status of blood vessels, the level of immunity of the patient, and his/ her health status and protein level to withstand the procedure.

What is the routine care required after surgery for diabetic foot?

• After the surgery, the patient is bedridden for 2-3 weeks.
• No ambulation is advised, and the limb has to be elevated by using pillows underneath.
• After several dressings, when the operated site is completely stable, the patient is given a pressure garment and ambulation is started.
• Shoe modification is required to prevent future injury and offloading from the pressure points.

Stage 4 – Amputation of the Limb :

What is an Amputation?

Removal of the limb or toe is responsible for spreading the infection from the body.

When is amputation required in the diabetic foot?

If a patient fails to reach the appropriate hospital or doctor for management of such cases on time, or due to other comorbidities, which decrease the immunity of the body, delay in healing occurs and infection spreads much more quickly. In this scenario, the patient might require amputation, which means it becomes imperative to remove the affected portion of the foot or leg from the body.

What are the levels of amputation required in neglected diabetic feet?

Amputation is done when the severity is to the fullest and the main motive is to save the life of the patient. Amputation can be of a toe, forefoot, midfoot, or below-knee amputation depending on the part of the limb that needs to be removed.

The level of amputation depends not only upon the extent of the disease but also on the function desired in the remaining stump.

What is the incidence of amputation in Diabetics?

In peripheral artery disease, the probability of amputation within one year after the first ulcer or gangrene is 34.1% and the death rate has been reported to be 5.5%.

What are the various indications for amputation in diabetics?

• The viability of a part is destroyed by injury or disease – a dead limb.
• The life of a patient is at risk because of the spread of a local infection – a deadly limb.
• Patients may be better served by an artificial limb because of deformity or paralysis -a deformed limb.
• Dying limb – acutely ischemic limb (sudden onset of black discoloration of limb), late presentation.

When is prosthesis advised after amputation of the limb in diabetes?

Post amputation when the stump completely settles, after about 2-3 months period, a prosthetic limb is advised.

Post-Surgery Care and Rehabilitation

• After surgery, patients are typically bedridden for 2-3 weeks.
• No ambulation is advised initially, and the limb should be elevated using pillows.
• Once the operated site stabilizes, patients are given compression garments, and rehabilitation is initiated.
• Shoe modifications may be necessary to prevent future injuries and alleviate pressure points.

Conclusion

Diabetic foot surgery aims to preserve limbs and lives. Recognizing the severity of the condition and consulting with a specialist like Dr. Amit Agarwal is crucial in achieving successful outcomes. Whether through non-surgical or staged surgical approaches, timely intervention is essential in the treatment of diabetic foot to prevent complications and improve the patient’s quality of life.