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Diabetic foot ulcer is a common complication of the disease and are a frequent cause for hospital admission and surgery. These ulcers are often chronic and heal slowly. They tend to have persistent infection that may extend to the underlying bone, tendons or other critical structures. It is a common wish for individuals and their healthcare providers to avoid unnecessary amputations and their associated morbidity and functional loss. Successful reconstruction permits limb salvage and brings about improved quality of life and tremendous satisfaction to individuals.
Diabetic feet often present as ulcers, gangrene or infected surgical wounds. Diabetic ulcers often occur at pressure points arising from inappropriate footwear or due to accidental trauma. Common sites include the base of the big toe, the side of the little toe and the heel. Diabetic gangrene often arises in the toes first and may spread proximally (in the direction of the ankle). Gangrene may be divided into dry (uninfected) or wet (infected) gangrene. In some cases, individuals may already have had a minor amputation which is slow-healing which may have persistent infection. Reconstruction is required in such cases to provide blood supply and stable soft tissue coverage to the minor amputation stump to avoid further amputation.
Diabetes mellitus affects many organ systems. The blood vessels may be narrowed and this causes reduction in blood supply to the tissues, especially at the tips of the extremities (i.e. toes). Nerve function is affected and results in reduction of sensation hence vulnerability to poor-fitting footwear. There is also impaired immunity and delayed wound healing. These factors result in the formation of chronic wounds and persistence of infection. In cases where the infection has extended to involve the underlying critical structures such as bone, cartilage, tendon and/or blood vessels, surgical management is necessary to prevent its progression. Infection of the critical structures may result in bacterial invasion of the bloodstream (sepsis).
Successful management of diabetic ulcers requires a multidisciplinary management. Vascular surgeons are integral in the assessment of the blood supply of the affected extremity and a variety of measures may be used to increase the blood flow. Podiatrists are often required to assess and manage the footwear to prevent future ulcerations. Wound management by specialist nurses is important in early stages of infection to optimize wound healing, which may be achieved with a combination of wound care, specialized wound dressings and/or hyperbaric oxygen therapy. Reconstructive surgeons assist with providing stable tissue coverage in these non healing wounds and coverage of vulnerable critical structures.
It is a common wish for individuals and their healthcare providers to avoid unnecessary amputations and their associated morbidity and functional loss. Management of the diabetic foot requires the coordinated care of a team of healthcare specialists, including vascular surgeons, reconstructive plastic surgeons, wound nurses, radiologists, podiatrists and physical therapists. Successful outcomes are possible in the majority of cases once infection is cleared, and extremity preservation often leads to tremendous relief and satisfaction to the individual.
Reconstructive surgery for the diabetic foot provides well-vascularized soft tissue and promotes expedient wound healing. Depending on the anatomical location of the defect, size and depth, a variety of skin grafts, regional or distant flaps may be performed for its coverage. The latter requires the application of microsurgical techniques that involve connecting the blood vessels of the flap to vessels in the vicinity of the defect using ultra-fine sutures that are thinner than a strand of hair. Successful outcomes are possible in the vast majority of cases and require careful preoperative planning, precise technical execution and an experienced practitioner.
Most individuals will require a short hospital stay following the surgery. Weightbearing is often possible once the wounds are healed and dependent on postoperative physical therapy and rehabilitation.
Smokers are advised to for cessation of smoking for at least 3 weeks postoperatively to minimize the possibility of complications relating to delayed wound healing. Skin grafts and flaps placed over mobile areas such as joints will require a short period of immobilization until the graft is fully healed.
The lower extremity has locomotive, psychological and aesthetic functions. Extremity preservation is of significant importance to many individuals and successful reconstruction prevents many amputations. Dr Yeo is experienced in the field extremity preservation. He completed a fellowship in Advanced Microsurgical Reconstruction under Professor Hung-Chi Chen, one of the international pioneers and leaders in this field. He has since performed many successful cases of extremity salvage in Singapore since completion of his fellowship.