The appropriate management algorithm for diabetic foot: A review of 274 cases over 12 years

Abstract

Diabetic foot management is a challenge for reconstructive surgeons, because it combines dramatically decreased circulation and chronic infection. The goal of managing this condition is to maximize viable tissue, however, unsatisfactory results, such as extremity amputation, are unavoidable in some cases. For appropriate management, thorough understanding of diabetic foot and the phased approach to its management is needed. The purpose of this study is to introduce an optimal algorithm for diabetic foot management by analyzing cases over 12 years. A total of 274 patients with diabetic foot at Hanyang University Guri Hospital from 2005 to 2017 were reviewed. The management process was divided into 5 steps: patient evaluation, wound preparation, improving vascularity, surgery and dressing, and rehabilitation. Patient evaluation included a microbial culture, evaluation of vascularity, and an osteomyelitis assessment. During wound preparation, debridement and negative-pressure wound therapy were performed. Vascularity was improved by radiological intervention or surgical method. Surgery and dressing were performed depending on the indications. Rehabilitation was started after complete wound healing. An infection was confirmed in 81.0% of the cases. Of the cases which a vascular study was performed, 83.8% showed arterial occlusion. When surgery was performed with complete eradication of the infection, the rate of revision surgery, such as re-amputation or flap revision, was 20.6%. The revision rate after surgery with a remnant infection was 40.9%. When surgery was performed after revascularization for improving blood flow, the rate of revision surgery was 21.3%. In contrast, the revision rate after surgery without revascularization was 28.2%. The ambulation rate after complete healing was 72.3%. Diabetic foot is a debilitating disease arising from multifactorial process. As its management is complex, a comprehensive but accessible treatment algorithm is needed for successful results. For this reason, the appropriate algorithm for diabetic foot management introduced in this study is significant.