This document discusses diabetic foot reconstruction. It begins by defining diabetic foot as a complex of diseases involving the skin, muscles or bones of the foot resulting from nerve damage, poor circulation or infection related to diabetes. Classification systems are discussed to facilitate treatment and monitoring of foot ulcers. Epidemiology data on diabetes and foot complications in Egypt is provided. Various surgical reconstruction techniques are described including revascularization procedures, wound debridement, negative pressure therapy, flap reconstruction using local, regional and free flaps, and microvascular surgery. Postoperative care and prevention strategies to reduce amputations through early detection and education are also summarized.

1. Diabetic Foot Reconstruction
BY
Ahmed Fawzy Mashaly MSc.

2.  Diabetic foot is a disease complex that
can develop in the skin, muscles, or
bones of the foot as a result of the
nerve damage, poor circulation and/or
infection that is associated with
diabetes.
 The Diabetic Foot may be defined as a
syndrome in which neuropathy,
angiopathy, and infection will lead to
tissue breakdown resulting in
morbidity and possible amputation (
WHO 1995 )
 Any foot pathology that result from
diabetes or it’s long – term results
Definition

3. Epidemiology and facts
The prevalence of type 2 DM In Egypt is increasing
rapidly , it is around 15.6%.
The yearly incidence rate of diabetic foot diseases has
been estimated to be up to 25% in some studies.
The prevalence of diabetic foot ulcers has been
estimated to be 19%.
More than 10 % of DM patients at the time of
diagnosis had one or two risk factors for foot disease,
often peripheral vascular disease , peripheral
neuropathy.
The rates of re-ulcerations are very high being greater
than 60 % after 3 years.

4.  Cellulitis occurs 10 times more in
diabetics
 Osteomyelitis of the foot 15 times more
in diabetics .
 Diabetic patients are 15x at risk of BKA
 Nearly half of non-traumatic LLA caused
by diabetes.
 70% of lower limb amputations begin
with a foot ulcer
 ~50% of diabetics with LLA require 2nd
LLA within 5 years
 The annual direct and indirect costs is
high
 the death rate after 5 years for a major
amputation can be as high as 78 percent.
 Diabetic patients fear major lower limb
amputatiom more than death.
Up to 85% of amputations can be avoided.

35. Valid classification system of foot ulcers
facilitate appropriate treatment.
help in monitoring the progress of healing.
serve as a communication code across specialties in
standardized terms.
Despite its disadvantages, the University of Texas
classification system offers many advantages over the
Meggitt‐Wagner system
for clinical use, while the PEDIS system may offer advantages
for research purposes.

44. Increased plantar pressure secondary to a hammertoe
deformity causing an ulceration at the distal tip of the
second digit.

56. Ulceration
directly
plantar to
the first
metatarsal
head.

62. Internal amputation of a marginal plantar metatarsal head wound.
Initially an infected fifth submetatarsal head wound with clear radiographic
evidence of cortical destruction.
Instead of performing a partial fifth ray resection, an internal amputation
of the affected bone was performed with preservation of the digit distally.
The wound healed by secondary intention in a matter of weeks, maintaining the
length and width of the foot.

65. Metatarsal head resection (MHR). (A) Incision. (B) Bone resection. (C) Operative
offloading. (D) After operation.

66. MHR will have a high rate of success for neuropathic wound
healing in this specific subset of patients regardless of
demographic features, as long as there is no ischemia to
impair healing by secondary intention.

73. Improved compliance with offloading, speedy ulcer
healing, and the patient can maintain a degree of
mobility and continue to be productive in the
family/community.

79. A clinical appearance of the edematous
and deformed acute CNA foot.
Originally described by William
Musgrave in 1703 and further
elaborated on by Jean- Martin
Charcot in 1868
a neuropathically mediated
destruction of the bones and
joints of the foot that can lead
to a rockerbottom collapsed
deformity primarily clustered
about the tarsometatarsal and
naviculocuneiform joints
Charcot neuropathic
arthropathy (CAN)

87. Postop. lateral radiograph of the realigned and reconstructed malalignment
with intramedullary fixation in the first and second metatarsals , calcaneocuboid
arthrodesis s, and a cannulated partially threaded screw across the subtalar
arthrodesis site.

90.  improve the vascularity to the critically ischemic limb in non-
healing diabetic ulcer.
 In failing conservative therapy revascularization aids in limb salvage.
 angioplasty and bypass procedures.
 Revascularization improves the limb salvage rate by more than 50%,
Illig et al.
Revascularization procedures

91. two or more debridement to achieve a good wound bed and
to reduce infection preceding the reconstructive procedure .
The latency period is the time period between the
revascularization and reconstruction.
This is the period in which wound healing is established due
to the improvement in vascularity of the foot. In our study,
the average latency period is 35.36 days ranging between 20
and 60 days.
Negative pressure wound therapy was used .
Negative pressure wound therapy was found to
reduce the time taken for wound closure and
increase healing

92. Reconstruction of the foot after the revascularization
is necessary as revascularization alone is not sufficient
for the healing and to prevent limb loss.
The reconstruction was carried out by locoregional
flaps and free flaps.
Microvascular free flap surgery is proven to be safe
procedure for providing stable cover to the wounds
after revascularization.

97. a. Defect of the plantar foot. b. Planned propeller flap.
Dot marks perforator found on handheld Doppler exam.
c. Flap elevated with intact perforator.

102. Dorsoplantar arterial links

103. Seven and
a half month
follow up.

107. Loss of cutaneous
substance exposing
the calcaneus and
the damaged medial
plantar pedicle
covered by a distally
hinged adipose
pedicled flap
(minimizing esthetic
sequelae at the
donor site)
vascularized by the
branches of the
posterior tibial
artery and
associated with a
secondary skin graft

109. 69-year-old diabetic patient presenting an extensive chronic ulcer
over the posterior heel (a); After wound debridement and reverse
sural flap harvesting, the final result 15 months after
reconstruction was satisfactory (b)

110. Design of the peroneal artery perforator propeller flap in
a 77-year-old man with a chronic ulcer over the lateral
malleolus (a); 6-month-postoperative result with the
donor site covered with a skin graft (b)

111. defect over
the medial
malleolus -
a posterior
tibial artery
perforator
propeller
flap (a);
immediate
distal flap
necrosis (c);
final result
after skin
grafting

112. the raising and final appearance of the DMtAP flap. (a) Photograph of the flap raised
and the distal defect with exposure of tendons and webspace (blue dye for sentinel
lymph node biopsy). (b) Inset of the DMtAP flap into the defect. (c) Final closure and
insertion of drains. (d) 3-month lateral view of the flap and donor site (e) End on
view of the DMtAP flap.

113. Modified reversed superficial peroneal artery flap was applied in the ankle
defect . the tendon was exposed - flap was harvested and the superficial
peroneal nerve spared intact. (d) flap was transferred to cover the defect.

114. (e) The flap survived completely and the patient was discharged on the 14th day post-
operation. (f) Appearance at three-month follow-up.

115. • free-flap application on
diabetic foot showed 91.7%
success rate eventually leading
to 84.9% limb salvage rate.
• Meta-analysis of a systematic
review of free-tissue transfer in
528 diabetic patients in 18
studies showed that flap
survival was 92% and limb
salvage rate of 83.4% over a 28-
month average follow-up
period.

116.  Debridement, infection control and
vascular intervention are key steps to
prepare for a successful microsurgical
reconstruction.
 The core of reconstruction is to provide a
well-vascularized tissue to cover on the
defect leading to infection control,
adequate contour for footwear, durability
and solid anchorage to resist shearing
forces during gait.
 Rehabilitation after reconstruction should
address the issue of adequate footwear
and gait.
 Education must be provided to teach how
to manage and care one’s feet through
regular follow-ups.

117. Microsurgery by using a spared segment of a
major vessel as an end-to-side anastomosis
or by using branches originating from these
major vessels.

118. Free flaps used for reconstruction
are
• free latissimus dorsi muscle flap
(preferred in large defects).
• free gracilis muscle flap (regional
anesthesia and minimal donor site
morbidity
• radial free forearm flap
• para scapular free flap (the weight
bearing area)
• free anterolateral thigh flap
• Free medial plantar artery flap
from the opposite foot to give a like
tissue reconstruction.

119. 38-year-old patient, 11.5 years after latissimus dorsi flap and split-thickness skin
graft for plantar reconstruction after open crural fracture and heel separation.

121. an avulsion injury to the dorsum of foot.
numerous debridements, loss
dorsiflexors and toe extensors, exposing
underlying bone (a). The tibialis anterior
tendon was reinserted and a NVAF flap
measuring 7.5 5.5 cm was used to cover
the defect. The flap suffered minor distal
necrosis (b). The wound went on to heal
completely without grafting (c). The
patient was ambulating at 2 months
without assistance

122. reconstruction in the diabetic foot by Dr
Skanda Shyamsundar

129. The traditional idea of microsurgery being difficult for diabetic
foot reconstruction
the lack of proper vessels for use as recipient vessels because
of calcification, which is considered a contraindication.
This may be true for ischemic limbs where no evident major
vessel can be seen.
However, even in limbs with insufficient major vessels, most of
the skin of the ischemic limb is intact, with good bleeding. This
is most likely because of the slow but persistent formation of
collateral vessels supplying the distal limb and subdermal
plexus of the skin.
the territory of ischemia and necrosis coincides with the
angiosome territory, and the surrounding angiosome is spared
from necrotic change.
We hypothesized that distal small arteries within this
surrounding healthy angiosome can be used as recipient
vessels, as they are derived from multiple collateral vessels

130.  Postoperative care with splinting, maintenance of
adequate hydration, patient in sitting position, and
use of vasodilators (prostaglandin E1) were routine.
 Along with subjective findings of the flap, duplex
scanning was used to evaluate the actual velocity of
the blood flow into the flap.
 The patient started wheelchair ambulation on day 4
or 5 and a compression garment was applied on
day 7.
 The patient was discharged or transferred within 10
days.

131. ACASE
The dorsalis pedis is not shown in the
angiogram, the wound with the correlating
angiosome.
After angioplasty, better flow was noted, with
an increased velocity of the perforator from 13
cm/second to 21 cm/second.

132. The perforator of the first metatarsal artery was used along with the accompanying
vein to connect the superficial circumflex iliac artery perforator flap.
The follow-up at 2 years 6 months showed good contour, with a well-preserved,
functioning foot.

134. Prevention
 Early detection of neuropathy
 Educate patient about:
 Optimizing glycemic control
 Using appropriate footwear
 Avoid foot trauma
 Perform daily self examination
 Smoking cessation
 Refer patient with critical ischemia

135. Key Message
 Of all late complications of diabetes,
foot problems are the most easily
detectable and easily preventable.
 Relatively simple interventions can
reduce amputations by 50 - 80%.
(Bakker et al 1994).
 Strategies aimed at preventing foot
ulcers are cost effective and cost
saving.
 “The pathway to amputation Is
littered with bandages and dressings
which have deceived both the doctor
and patient into thinking that by
dressing an ulcer they were curing it”
 Diabetics should treat their Feet like
their Face