Surgical Treatment of the Ulcerated Foot
John M. Giurini, DPM
Foot ulceration with infection is one of the leading causes of hospitalization for patients with diabetes mellitus. Although solid data on the true incidence and prevalence of diabetic foot ulcerations do not exist, it is believed that approx 15% of patients with diabetes will develop a foot or leg ulceration in their lifetime (1). The rate of recidivism is also staggering in this population with 50% of ulcerations recurring within 18 months.
The number of lower extremity amputations among patients with diabetes has been well documented for years. Patients with diabetes are 15 times more likely to undergo a major lower extremity amputation than patients without diabetes, with the total number of major limb amputations being more than 50,000 (2).
When one considers there are 16 million people in the United States with diagnosed or undiagnosed diabetes mellitus, this not only places a significant sociological impact on the health care system but an enormous economic impact as well (3). It is estimated that in 1992 in the United States, the direct and indirect cost for care of the patient with diabetes was $91.8 billion. In comparison, $20.4 billion was spent in 1987. Treatment of diabetic foot infections cost $300 million per year and lower extremity amputa- tions $600 million per year (1,3). These numbers are so staggering that the Department of Health and Human Services set as a goal of Healthy People 2000 a 40% reduction in diabetic amputations by the year 2000 (4).
The ability to achieve this goal requires a thorough understanding of the risk factors for ulcerations and amputations. Current algorithms take advantage of recent advances in antimicrobial therapy, wound healing strategies including topical growth factors and surgical intervention. One of the key components in establishing successful outcomes is identifying a dedicated team of healthcare professionals to manage these complex problems (5–8).
GOALS OF SURGERY
There was a time not too long ago when surgery on the patient with diabetes was to be avoided at any cost. In the past 5 years, however, surgical intervention is more read- ily accepted as a form of treatment and prevention of chronic ulcerations.
As with any surgery, the goals of the procedure must be clearly delineated. This is no different in patients with diabetes. What is different is the goals of surgery in patients with neuropathy as opposed to patients with normal sensation.
From: The Diabetic Foot, Second Edition
Edited by: A. Veves, J. M. Giurini, and F. W. LoGerfo © Humana Press Inc., Totowa, NJ