Limb salvage in diabetic foot disease: A classification to aid successful reconstruction

Abstract

Diabetes is a global epidemic. If poorly managed, innocuous injury in a diabetic foot leads to intractable ulceration, bone and joint destruction and subsequent major amputation. It is estimated that every week in the UK there are 100 lower limb amputations of which 80 could have been prevented had diabetes been better managed. It is widely recognised that prevention is critical; nonetheless diabetic foot lesions continue to increase in prevalence. Reconstruction of diabetic foot lesions has a dismal reputation despite promising published work. Reconstruction in the correctly chosen patient can be successful. Multiple classification systems and scores have been published, but these do not guide the clinician as to which lesions are reconstructible, and those in which attempts to salvage are futile. These patients would be better served with primary amputation. A tertiary referral centre's experience of diabetic foot reconstruction over 7 years is presented in a series of 22 consecutive patients who were assessed using a new classification system. Twenty-four flaps were performed all of which were either complex (n = 7) or complicated (n = 17) wounds as per our classification. Five patients (22%) had donor site healing problems, but only one flap (5%) in the series failed. Average follow-up was 23 months (range 4-75 months) and all patients were ambulant at discharge. Our simple classification system and aggressive approach to excision and reconstruction of diabetic foot lesions is a useful adjunct to existing systems, and helps promote the cause that limb salvage is warranted in these challenging cases when appropriately managed.

Keywords: Diabetes; Foot; Free flap; Pedicled flap; Reconstruction.