Foot infections in diabetic patients can rapidly create a septic state or spread widely with the deeper planes of the foot, and therefore demand immediate intervention. Not all foot infections, however, require hospitalization. Superficial infections might be given a first-generation cephalosporin, nonweight-bearing status on the involved extremity, and close follow-up. More commonly, patients present with ulceration or gangrene involving the deeper planes of the foot, including tendon and bone.
These patients require immediate hospitalization, foot elevation, debridement and initial broad-spectrum antibiotics, which may be narrowed when wound culture results are complete. The duration of antibiotic therapy depends upon clinical resolution of the infection. In the face of osteomyelitis, prolonged intravenous antibiotic therapy is required, usually for 4 to 6 weeks. The course might be curtailed when the infected bone is thoroughly debrided.
Abscesses and deep-space infections are promptly incised and drained. All necrotic tissue must be surgically debrided. In advanced infections, amputation might be essential to allow for complete drainage and excision of devitalized tissue. Although all necrotic tissue should be removed, care is come to conserve as much viable tissue as possible. An overly aggressive method of debridement can result in higher amputations and problems during closure.
After debridement and drainage, the wound is followed closely to make sure appropriate healing and eradication of the infection. Wounds are kept moist and weight-bearing on the affected limb should be kept low. During convalescence, nutrition should be optimized and serum blood sugar levels strictly controlled. Progressive foot necrosis, in the face of optimal medical management and wound care, may signify underlying ischemia or might be indicative of an undrained abscess.
There are many adjuncts to wound care that can maximize healing in these difficult wounds. Vacuum assisted closure (VAC) has revolutionized the management of the number of wounds. Animal and human research has shown an accelerated rate of granulation tissue formation and increased nutrient blood flow towards the wound compared to saline moistened gauze. Early data on diabetic wounds benefit by an accelerated rate of healing and decreased wound area, compared with saline-gauze dressing.
The best strength from the VAC device is being able to contract the wound, thereby decreasing its depth. The patient may then be spared a major reconstruction, with all of its associated risks and morbidities. Disadvantages from the device include added cost and patient discomfort. We stress that VAC therapy doesn't replace debridement.
This therapy should commence after adequate debridement has occurred. Wet-to-dry gauze dressing, in conjunction with surgical debridement has been the standard wound treatment through which others happen to be measured. There's some evidence in the literature that debriding agents such as hydrogels and collagen-alginate preparations might be more efficacious in the treatment of diabetic foot ulcers. Further research is necessary to define the perfect applying these this emerging modalities.
Of many studies that have tested the efficacy of numerous growth factors for that treatment of chronic foot ulceration, only topical platelet-derived growth factor (PDGF) indicates significant improvement in healing the diabetic foot. Becaplermin gel, also known as Regranex, may be the recombinant human PDGF isoform BB and the only growth factor licensed for that treatment of chronic, full-thickness diabetic foot ulcers. Due to its significant cost, ($300-$400 for any 30-gram tube), becaplermin is recommended only for well-perfused, chronic diabetic foot ulcers that have failed standard wound therapy.
Following the infection is controlled and signs and symptoms of systemic toxicity have resolved, attention should be centered on maximizing pedal perfusion. Macrocirculatory dysfunction, as well as well as an impaired inflammatory response, predisposes the diabetic foot to ulceration in the face of even moderate ischemia. Restoration of impaired inflow is essential for healing and limb salvage. Options include endovascular techniques (i.e., angioplasty and stenting), bypass grafting or perhaps a mixture of both.
The process of preference should be tailored to each individual patient in relation to anatomy, comorbidities and operative risk. The vascular surgery team will lead in this endeavor. Communication between your vascular and plastic surgeons is crucial at this time if a reconstructive procedure is planned. For instance, the vascular surgeon might not consider the fact that his target vessels in a bypass procedure may also serve as the site of anastomosis for a future free flap.
Changes in the bony architecture of the foot create abnormal pressure points resulting in characteristic patterns of ulceration. By relieving the local stress created at these points, recurrence of the ulcer can be prevented and the reconstruction from the affected area may be protected. Redistribution of pressure is possible surgically (e.g., metatarsal head resection, arthrodesis, partial calcanectomy, or Posterior muscle group lengthening) or by custom orthotic footwear, tailored to evenly distribute pressure towards the dorsum of the foot.
These custom-made orthotic devices made of plaster or fiberglass allow for distribution of pressure off the wound so that the patient can remain partially active while the wound heals. The unit may be worn in your own home. Some patients complain of discomfort in the device, but it is a highly effective means of protecting the foot from further damage while it heals.
Reconstructive issues particular to the diabetic foot are discussed here. Prior to surgery, systemic and local infection, including osteomyelitis, should be eradicated. All necrotic tissue is debrided and local perfusion is optimized by peripheral bypass surgery and/or local wound care. The individual should be nutritionally optimized, and blood sugar tightly controlled.
Lastly, the individual must understand the type of reconstruction planned and the measures necessary for complete wound healing. Patient compliance with postoperative care (e.g., leg elevation, no weight bearing, glucose control etc.) can't be overstated. The convalescence phase may take several weeks and also the patient should be aware of their role in protecting the wound.
Most foot ulcers, due to the inelasticity of the surrounding skin, aren't amenable to primary closure. Skin grafts aren't recommended to cover wounds over primary weight-bearing areas. Small, well-perfused, noninfected neuropathic ulcers could be repaired in a single-stage procedure that includes debridement, bony reconstruction (for offloading of the affected area) and primary closure using a random flap. Scarring around the wound secondary to chronic inflammation limits the reach, and therefore the use, of random flaps.
Wounds less than 3x6 cm with exposed tendons, joints or bone might be repaired with a local muscle flap. These flaps possess the advantage of straightforward dissection, with minimal donor defects and primarily closure. The process can be performed with regional anesthesia, minimizing anesthetic risk. Again, it should be noted that such a task need a commitment from both patient and surgeon. Although a long-term salvage rate of 89% has been reported, an average a hospital stay is 27 days, and the average time for you to wound healing is 125 days.
Larger defects not within reach of local muscle flaps might be repaired with free flaps in selected patients. Free flap success are equivalent in diabetic and nondiabetic patients. However, the diabetic patient is generally more debilitated and it has significant comorbidities, which might preclude free flap reconstruction.
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