Diabetic Foot Syndrome (DFS)
The presence of diabetes over many years often leads to the appearance of diabetic foot syndrome (diabetic foot) even if blood sugar levels are well-regulated. A blood circulation disorder appears (diabetic polyneuropathy). The sensation on the feet is usually affected in what is described as a glove-stocking distribution, in which balance and the patient’s ability to walk with ease are also impaired, increasing the risk of a fall. Wound healing is also impaired so that in advanced stages even trivial injuries can lead to extensive and poorly healing wounds.
Causes of diabetic foot syndrome are often from internal pressure, such as from incorrect posture, bony prominence (where the bone is close to the skin) or bone disintegration. Pressure can also come from external sources such as incorrect footwear. The risk of injury through such pressure points is significantly increased because pains from wounds are absent due to the nerve disorder. An ulcer can also appear as the direct consequence of nerve damage, for example, through the paralysis of the small foot muscles.
Neuropathic Decompression Surgery
Diabetics should have their feet checked at least once year in order to test the nerves and, above all, the skin sensation on the feet. This gives information about the development of a neuropathy. If an operative intervention is performed early enough, a significant improvement of abnormal sensation and reduction in pain can be achieved. If open wounds (ulceration) already exist or even if amputation is necessary, it frequently makes sense to decompress nerves. The surgical nerve release not only often leads to an improvement in sensation on the soles of the feet, but also to better blood circulation. Operative decompression of several nerves can often assist in stopping the damage of nerve fibres and can actually even encourage them to regenerate. We can determine during an examination if such an operation would be of benefit to you.
The current German Medical Association guidelines concerning diabetic foot syndrome are as follows:
"Measures using plastic surgery should be considered in order to maintain the affected extremities before amputation becomes an option. Amputations are not to be considered as primary treatment methods in cases of poorly healing ulcers."
In fact, amputation should rather be the final measure in a course of extensive therapy to treat chronic wounds. This involves the patient receiving specialist wound care as an out-patient, which in turn forms the basis for interdisciplinary vascular, orthopaedic and plastic reconstructive surgery methods, should they be necessary.
If there are diabetic ulcers, then wound debridement should always be carried out before introducing adequate local therapy. In doing so, the wound can be prepared in various ways for the following local wound treatment thus accelerating healing. Debridement can be surgical, enzymatic or biological. Surgical debridement, or in other words mechanical cleaning using a scalpel, depends on diagnosis and can extend to bone resection. This method is distinctly different to other debridement methods in that the others are limited to the removal of surface tissue layers only.
A further measure taken in the avoidance of amputation is to reduce pressure on the foot with the help of orthopaedic shoes and, if necessary, the resection of any bony prominences. In acute stages, the patient will be confined to bed with the legs held elevated and an accompanying antibiotic therapy will often be necessary.
All these measures become of increasing importance when one considers that 70% of amputations in Germany are performed on diabetics. A time-guideline of 6 weeks can be estimated before introducing surgical measures. Should the wounds fail to heal after this length of consequent, conservative treatment (without an operation), then plastic surgery methods should be applied to cover the defect. In addition, external bone stabilisation may be necessary using a so-called “external-fixator” or using screws and/or plates internally.
Plastic surgery methods for defect coverage are as follows:
- Split thickness skin graft for good wound beds without exposed bones, joints or tendons
- Local flap surgery. This can be considered for defect coverage if the larger blood vessels are not completely blocked yet.
- If local or regional flap procedures are no longer possible, then microsurgical techniques can be conducted in order to avoid amputation.
- Free flap tissue transfer, where appropriate after surgical intervention to blood vessels in order to improve blood circulation.
- During soft-tissue surgery to the wound closure we also carry out nerve release to improve circulation and care of the tissues. A prophylactic release of the nerve can also be sensible.
In every case, the diabetic should regularly use a mirror to check the soles of the feet for pressure points and any small injuries. A regular check-up to test nerve functions is also necessary.
If an amputation is no longer avoidable, in order to ensure the patient’s mobility, high-regard should be paid to retaining as much of the sole and foot as possible. In this way, the patient’s agility is maintained at the best possible level after surgery is complete.