Diabetic Foot Surgery

Surgery for acute and chronic diabetic foot problems has long been an integral component of care.

Surgical management of diabetic foot attack

Most infected DFUs respond well to local debridement, administration of culture specific antibiotics and offloading of the foot in a brace or cast. Some develop rapid spread of infection along the tissue planes and tendon sheaths and present with local tissue necrosis, spreading cellulitis and systemic inflammatory response. These can potentially be limb threatening without timely intervention as delay will lead to further tissue loss. The concept of ‘time is tissue’ is applicable to such infection, which is labelled as a ‘Diabetic Foot Attack’.23

The management of diabetic foot attack is best delivered in a multidisciplinary setting using a structured approach. The management principles are as follows:

1.1.1 Diagnose infection rapidly

A thorough clinical assessment, including the vascular examination and routine investigations often help achieve the diagnosis. The serum C-reactive protein level is frequently elevated to greater than 100 mg/L. Ultrasound examination can immediately assess the presence of deep soft tissue fluid collections and osteomyelitis. Plain radiographs, magnetic resonance imaging (MRI), computed tomography or bone scintigraphy can also determine presence of osteomyelitis and/or soft tissue infection spread along the tissue planes.

1.1.2 Identify bacteria responsible

Obtain deep tissue specimens for aerobic and anaerobic microbiological cultures prior to starting intravenous antibiotics.24 Ultrasound guided aspiration can be considered for microbiological cultures if there is any clinical or MRI evidence of deep collection and if this does not lead to any further delay in surgical debridement.

1.1.3 Aggressive antibiotic therapy

Initiate appropriate empirical intravenous antibiotic therapy soon after obtaining tissue samples, based on the previous microbiological cultures on the same patient if available or as per the local hospital protocols. The antibiotics are then changed further, if required, based on the microbiological sensitivities of deep tissue cultures.

1.1.4 Emergent surgical debridement

Surgery for diabetic foot attack is a Class IV procedure. Aggressive and radical surgical debridement consisting of exposing all infected tissue planes and removal of infected and necrotic bone and soft tissues should be performed soon after the diagnosis. Any associated instability due to bone resections can be managed with a temporary stabilization using threaded wires passed across the bones, external fixator, or a windowed cast. Deep soft tissue and bone specimens are obtained for microbiology cultures. Repeat surgical debridement is performed if there is progressive tissue necrosis or further deep infection.

Targeted intravenous antibiotics are continued until complete infection clearance is achieved. The multidisciplinary team (MDT) should aim to achieve complete healing of the wound in a timely manner and various methods can be used to achieve this; including negative pressure wound therapy (NPWT), followed by skin grafting or a similar form of plastic surgical procedure, depending on the extent of the wound and its location. Any subsequent instability or deformity in the foot and ankle can be managed with a brace, cast or surgical stabilization procedure.