The Diabetic Foot: Medical and Surgical Management (Contemporary Diabetes)

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Surgeons can manipulate antibiotic-impregnated cement to form beads or blocks that they can place into wound defects and provide local antibiotic delivery without increasing systemic toxicity. Skin ulcerations provide a direct pathway for infections and are often present in the diabetic Charcot foot and ankle as consequences of neuropathy and deformity. These patients often do not notice a deformity until an ulcer occurs or deformity impedes their ability to ambulate or wear regular shoe gear.

The midfoot, particularly the tarsometatarsal joint complex or Lisfranc joint, is one of the most frequent locations for joint collapse and disorganization. However, the hindfoot and ankle are becoming increasingly prevalent locations for Charcot. Excessive pressure at these areas in the diabetic insensate foot and in the absence of proper offloading can lead to extensive neuropathic ulcerations. Charcot neuroarthropathy with ulceration can drastically increase amputation risk.

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This may include corrective procedures including but not limited to ostectomy, osteotomy and arthrodesis. Circular external fixation may be an option for complicated cases requiring extensive osseous and soft tissue reconstruction as these devices can provide overall stability, access to wounds for frequent care and effective offloading. It is important for surgeons to be aware that osteomyelitis can precede the development of Charcot with operative treatment for osteomyelitis itself being known as a trigger for the onset of neuropathic osteoarthropathy.

A high index of suspicion is necessary to diagnose this stage of Charcot accurately and provide adequate immobilization. Staging of procedures is a useful approach with Charcot foot and ankle osteomyelitis to eradicate infection, leaving healthy, viable soft tissue and bone that can maintain definitive long-term correction. A well-balanced foot amputation can remove the infected portion of the foot and produce a functional and plantigrade foot that is less prone to future skin breakdown. As techniques for revascularization constantly improve, surgeons are now able to preserve limb function with amputations at the foot level.

Diabetic foot amputations require adequate arterial sufficiency to ensure healing. For this reason, it is paramount to evaluate the vascularity of the limb and coordinate treatment with the vascular team to determine the best level of amputation if peripheral arterial disease is present. As DFUs affect a large proportion of the diabetic population, several potential complications place these patients at high risk for major limb loss. Fortunately with ongoing research, treatment protocols and strategies continue to evolve and lead to additional surgical approaches in addressing isolated DFU and those with soft tissue infections, osteomyelitis and Charcot neuroarthropathy.

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The Diabetic Foot Medical and Surgical Management

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