A team approach to the medical care of patients with diabetes is necessary for successful surgical management. Prior to surgical intervention, patients require thorough preoperative medical assessment and aggressive management of their diabetes and comorbid conditions. Prompt attention must be directed to cardiovascular, renal, peripheral vascular and infectious disease issues. There is also a need to assess the patient's nutritional status and requirements for help from the dietitian. Wounds will not heal without adequate nutrition, nor will they heal with insufficient distal perfusion. Clinicians should be well trained to recognize emergency diabetic foot problems, and to distinguish immediately between limb-threatening and non-limb-threatening presentations. Successful surgical intervention demands timely drainage of infection and debridement of necrotic, bacteria-laden tissues. The risk of tissue loss and amputation is increased with inadequate antibiotic coverage and long delays in providing surgical care. It is important to emphasize that antibiotics alone are not sufficient for the management of most diabetic foot infections. Infected wounds must be incised and dependent drainage established. Postoperatively patients must be followed closely, with lifetime surveillance in the diabetic foot clinic. Appropriate footwear and preventive services are required.
Principles of surgical management include:
• Prompt detection and intervention
• Preoperative medical work-up and clearance for surgery
• Medical management of diabetes and comorbid conditions
• Targeted antibiotic coverage of infection
• Vascular work-up
Foot and ankle surgeon Infectious disease specialist Vascular surgeon Diabetologist Prosthetist/orthotist Physiotherapist
• Wound care and dressings
• Postsurgical surveillance
• Podiatric care, footwear and orthoses.
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