Diabetic Foot Wound & Solutions

This is a case that I hold very fondly in my memories from residency. It is the reason I went into fellowship so that I can learn more about diabetic limb salvage and advanced wound care in depth from both podiatrists and plastic surgeons. 

This is a 50 year old male with poorly controlled diabetes who initially presented with a foot infection. In the picture, you can see the progression of a neglected infection. 

 What started as a callus became gas gangrene that had to be urgently taken to the operating room to limit the spread of the infection. Once it was controlled, the wound remained open due to tissue loss. After several attempts of conservative measures with local wound care, another infection occurred resulting in the loss of his entire forefoot (transmetatarsal amputation, TMA). The open wound continues to be in a chronic state with little evidence of healing. 

What started as a callus became gas gangrene that had to be urgently taken to the operating room to limit the spread of the infection. Once it was controlled, the wound remained open due to tissue loss. After several attempts of conservative measures with local wound care, another infection occurred resulting in the loss of his entire forefoot (transmetatarsal amputation, TMA). The open wound continues to be in a chronic state with little evidence of healing. 

What started out as a callus from improper shoes later developed into an ulcer (pressure of the callus breaks down the skin underneath) that became infected. It was so severe that it converted to gas gangrene quickly spreading deep in the foot. Unfortunately, Mr. S also had severe peripheral neuropathy, a common complication from uncontrolled diabetes, that he could not feel the destruction happening in his foot. It wasn't until a family member forced him to see a podiatrist that he then realize how severe the problem was. Along with peripheral neuropathy, other microvascular structures like your eyes can be affected from diabetes, so his vision was also affected and that was why he couldn't see his feet well. So a double whammy in delayed care, can't see, can't feel. 

Luckily for us, we had just learned of a microsurgeon who was able to help our patient. We desperately needed someone to help us close a large wound to prevent further infection and prevent a higher level amputation, like a below the knee amputation (BKA). 

 Pre-operative planning, all chronic non-viable tissues were cut out (outlined by the blue markings), often making the wound bigger than before. It is necessary to remove anything that may impede healing. A free flap, taken from the thigh, was then performed to close the wound. The donor site was able to be closed primarily even in a flap this size. 

Pre-operative planning, all chronic non-viable tissues were cut out (outlined by the blue markings), often making the wound bigger than before. It is necessary to remove anything that may impede healing. A free flap, taken from the thigh, was then performed to close the wound. The donor site was able to be closed primarily even in a flap this size. 

I had the privilege to participate in this case from start to finish and it had really opened my eyes to all of the potential ways we can heal a patient. From utilizing standard wound care dressing protocols to more advanced approaches like local rotational flaps or free flaps like in this case. 

Most important for this patient and any patient with diabetes was having a multi-disciplinary approach which included those who specialize in the medical management of diabetes (endocrinologist), infectious disease doctors, vascular surgeons, microsurgeons/plastic surgeons & podiatrists, to name a few. Performing surgery in people with poorly controlled diabetes is incredibly challenging so when they fail it is heartbreaking. However, when they succeed it is the most rewarding. 

A friendly reminder to have established podiatry care early on if you or a loved one has diabetes.