SLR - October 2019 - Alyson H. Slater

Limb Salvage in Diabetic Foot Disease: A Classification to Aid Successful Reconstruction

Reference: Wheble GAC, Emam AT, Khan UM. Limb Salvage in Diabetic Foot Disease: A Classification to Aid Successful Reconstruction. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2019 July; 72 (7): 1110-1120

Scientific Literature Review

Reviewed By: Alyson H. Slater, DPM
Residency Program: Palmetto General Hospital – Hialeah, FL

Podiatric Relevance: Management of diabetic foot and ankle pathology is one of the most indispensable skills of the podiatric surgeon. Due to the globally increasing rate of type 1 and type 2 diabetes, ulcerative lesions pose a continued threat to the vitality of afflicted patients. While many grading systems are available to guide the treatment of diabetic wounds, this article sites a new, simple classification method which distinguishes whether reconstructive surgery or major amputation should be attempted. The authors discuss their experience with 24 diabetic foot reconstructions over a seven year period, providing insight into limb salvage efforts to limit morbidity in this at-risk patient population.

Methods: A level IV retrospective cohort study was performed by the authors according to the STROBE guidelines. The patients who met inclusion criteria underwent reconstructive repair of foot or ankle defects caused by diabetic foot disease. The research was stratified over a seven year period, from 2011-2018 and 24 procedures were identified in 22 patients. Each lesion was classified according to the proposed system as simple, complex, complicated or unreconstructable.

Results: This study aims to provide physicians with a simple measure to determine whether or not diabetic wounds are reconstructible. The effectiveness of the method  is supported by the study cited in the paper. The classification system denotes simple wounds as those with ulceration and no underlying exposed structures while complex wounds have exposed but preserved structures. Complicated wounds may be infected and have exposed and damaged structures. These wounds would permit a retained functional foot with excisional reconstruction. An unreconstructable wound denotes destruction of structures that would not leave a functional foot following surgical intervention. All wounds in the study fell under the categories of complex or complicated. According to the proposed classification system, simple wounds do not require surgical intervention and unreconstructable wounds do not warrant salvage attempts. Following optimization by techniques such as revascularization, each wound was aggressively excised beyond the margins of the lesion in the fashion of tumor resection. Eighty-three percent of the wounds were repaired with free flaps while the remaining 17 percent were treated with pedicled flaps to cover the heel. Six patients (27 percent) suffered from incomplete healing of the graft while one suffered from failure of the medial pedicled flap in the immediate post-op period. Patients were followed for an average of 23 months. Three patients sustained further ulcerations while one patient sustained a below knee amputation after two years. The remaining patients had successful long term resolution of the condition.

Conclusions: With an increasing prevalence of limb threatening lesions, it is helpful for surgeons to have a mechanism for determining whether or not a reconstructive procedure should be considered to improve the overall health of the diabetic patient. 

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