The diabetic foot is one of the most common complications of the diabetes mellitus and is the most common cause of the amputation in the world. If the appropriate treatment is not applied, it can also result in death due to an infective event. The vascular damage and neuropathy, the two main complications of diabetes mellitus, are the main causes of diabetic foot.
Who is a candidate for this surgery?
The diabetes mellitus is a very important health problem due to its incidence and the morbidities caused by its complications. The foot ulcers are one of the most important reasons for the hospitalization of the diabetic patients and cause serious problems for the patient and his/her family, as well as a high rate of the morbidity and mortality. The diabetic foot wounds are among the issues that should be emphasized in terms of causing serious problems ranging from the high level to the leg amputation. The studies conducted have shown that approximately 15% of the diabetic patients develop scars on their feet at some point in their lives. The diabetes is the most common cause of the foot amputation worldwide. The diabetes-related amputations account for 51% of the patients who underwent lower extremity amputation.
The diabetic foot ulcers are caused by the isolated or combined effects of the peripheral neuropathy, vascular insufficiency, infection, and immune system disorders. The most important and most common complication is the peripheral neuropathy accompanied by the peripheral sensory loss.
The main responsible factor for the formation of the diabetic foot ulcers is the deterioration in sensory, motor and autonomic nerve functions. The sensory neuropathy is in the style of the glove-sock distribution. In other words, the patients lose their foot touch sensation, hot cold sensation and pain sensation. When their feet get cold, they do not feel the burning of the heat sources such as the stove they approach to warm up as a result of the excessive heat. They do not feel the pain caused by the foreign objects such as nails or small stones in their shoes. In the advanced patients, the similar losses occur in the hands.
Since the foot, which has completely lost its sense, becomes insensitive to repetitive the traumas, there is a tendency to develop the ulcers.
             In addition, the feet of the diabetic patients suffer from the sweating along with this loss of the sensation. As a result of the lack of sweating, the skin of the feet dries up, cracks and most importantly, it becomes easier to open the wound by rubbing during walking.
As a result of the development of the autonomic neuropathy, there is a loss of the function in the sebaceous and sweat glands. The normal sweating and heat regulation mechanisms are disrupted in the foot. As a result, the soles of the feet become dry, peeling and dead skin thickening by resulting in the tiny cracks in the skin, and infection and subsequent complications develop as a result of the entry of the bacteria from here. Since the detection of these damages is delayed due to the sensory loss, early preventive and therapeutic interventions cannot be performed and the scar formation accelerates. The dead skin thickenings, i.e. the hyperkeratotic lesions (callus) on the skin, act like a foreign body and create additional pressure.
The deformities that develop due to the motor neuropathy in the foot form the beginning of a series of the events that lead to Charcot deformity, also called diabetic neuroarthropathy, as a result of which changes occur on the surfaces of the foot that are exposed to the pressure.
The preoperative preparations and evaluation for the wound treatment
In addition to the treatment of the hyperglycemia, the appropriate antibiotic therapy and, in necessary cases, the hyperbaric oxygen therapies are beneficial. When treating the diabetic foot ulcers, the basic wound care principles are required to be applied completely. Since the cellulite and edema can be present on the dorsum of the foot, the elevation should be applied to reduce the foot edema. The cultures should be taken before starting the antibiotic therapy.
The surgical interventions:
In the diabetic foot ulcers, some of the ulcers can heal spontaneously with the wet dressings made with the saline without the need for the surgical intervention, while a significant part of them requires the surgical intervention. There are many different reconstruction alternatives available for the closure of emerging soft tissue defects. The foot reconstructions in the diabetic patients are more difficult than in the traumatic tissue defects because the diabetic complications reduce the success rate of the surgical interventions to be performed here.
The diabetic wound repairs with the debridement and appropriate tissue transfers can also provide the significant reductions in the rate of leg and life-threatening infections, which are the main causes of the major extremity amputations.
Of course, this surgery has risks and side effects. However, if these attempts are not made, the loss of foot can be an inevitable result. The post-operative care and return to the normal life stages are as important as surgeries. For the continuity of the result achieved, a gradual return to the normal life should be followed patiently. After these attempts, the foot can never return to its previous solid state.