C Biehl1, M Eckhard2, G Szalay3, C Heiss3. 1. Klinik und Poliklinik für Unfall-, Hand-, und Wiederherstellungschirurgie - Operative Notaufnahme, Universitätsklinikum Gießen und Marburg GmbH, Rudolf-Buchheim-Str. 7, 35392, Gießen, Deutschland. christoph.biehl@chiru.med.uni-giessen.de. 2. Medizinische Klinik und Poliklinik III, Universitäres Diabeteszentrum Mittelhessen, Universitätsklinikum Gießen und Marburg GmbH, Gießen, Deutschland. 3. Klinik und Poliklinik für Unfall-, Hand-, und Wiederherstellungschirurgie - Operative Notaufnahme, Universitätsklinikum Gießen und Marburg GmbH, Rudolf-Buchheim-Str. 7, 35392, Gießen, Deutschland.
Abstract
OBJECTIVE: The treatment strategy for diabetic foot syndrome must take into account protective sensibility of the foot, open wounds, infection status, and the rules of septic bone surgery. Interventions are classified as elective, prophylactic, curative, or emergency. Amputations in the forefoot and midfoot region are performed as ray amputations (including metatarsal), which can often be carried out as "inner" amputations. Gentle tissue treatment mandatory because of greater risk of revision with re-amputation compared to classical amputation. INDICATIONS: Good demarcation of infection, acute osteomyelitis, osteolytic lesions, neurotropic ulcer, arterial and venous blood flow to the other toes, gangrene of other toes with metatarsal affection. CONTRAINDICATIONS: Arterial occlusive disease, infection of neighboring areas, avoidable amputations, poorly healing ulcers on the lower leg. SURGICAL TECHNIQUE: Primary dorsal approach; minimal incisional distance (5 cm) to minimize skin necrosis risk. Atraumatic preparation, minimize hemostasis to not compromise the borderline perfusion situation. In amputations, plantar skin preparation and longer seams placed as dorsal as possible, either disarticulated and maintain cartilage, or round the cortical metatarsal bone after resection. POSTOPERATIVE TREATMENT: Diabetes control. Braun splint, mobilization in a shoe with forefoot decompression and hindfoot support, physiotherapy. Antibiotics based on resistance testing. If no complications, dressing change on postoperative day 1. Optimal wound drainage by lowering foot several times a day; drainage removal after 12-24 h. Insoles and footwear optimization. RESULTS: Amputations require continued attention and if necessary treatment to avoid sequelae. Insufficient treatment associated with recurrent ulceration and altered anatomy.
OBJECTIVE: The treatment strategy for diabetic foot syndrome must take into account protective sensibility of the foot, open wounds, infection status, and the rules of septic bone surgery. Interventions are classified as elective, prophylactic, curative, or emergency. Amputations in the forefoot and midfoot region are performed as ray amputations (including metatarsal), which can often be carried out as "inner" amputations. Gentle tissue treatment mandatory because of greater risk of revision with re-amputation compared to classical amputation. INDICATIONS: Good demarcation of infection, acute osteomyelitis, osteolytic lesions, neurotropic ulcer, arterial and venous blood flow to the other toes, gangrene of other toes with metatarsal affection. CONTRAINDICATIONS: Arterial occlusive disease, infection of neighboring areas, avoidable amputations, poorly healing ulcers on the lower leg. SURGICAL TECHNIQUE: Primary dorsal approach; minimal incisional distance (5 cm) to minimize skin necrosis risk. Atraumatic preparation, minimize hemostasis to not compromise the borderline perfusion situation. In amputations, plantar skin preparation and longer seams placed as dorsal as possible, either disarticulated and maintain cartilage, or round the cortical metatarsal bone after resection. POSTOPERATIVE TREATMENT: Diabetes control. Braun splint, mobilization in a shoe with forefoot decompression and hindfoot support, physiotherapy. Antibiotics based on resistance testing. If no complications, dressing change on postoperative day 1. Optimal wound drainage by lowering foot several times a day; drainage removal after 12-24 h. Insoles and footwear optimization. RESULTS: Amputations require continued attention and if necessary treatment to avoid sequelae. Insufficient treatment associated with recurrent ulceration and altered anatomy.
Entities:
Keywords:
Amputation; Diabetes; Foot ulcer; Human forefoot; Infection
Authors: F J Aragón-Sánchez; J J Cabrera-Galván; Y Quintana-Marrero; M J Hernández-Herrero; J L Lázaro-Martínez; E García-Morales; J V Beneit-Montesinos; D G Armstrong Journal: Diabetologia Date: 2008-08-22 Impact factor: 10.122