Modalities of Soft-Tissue Coverage in Diabetic Foot Ulcers Sohaib Akhtar, MD, MBBS, MS, MCh; Imran Ahmad, MBBS, MS, MCh; A.H. Khan, MBBS, MS, MCh; and M. Fahud Khurram, MBBS, MS, MCh, DNB ABSTRACT OBJECTIVE: The objective of this study was to establish an algorithm for surgical reconstruction of diabetic foot ulcers (DFUs). STUDY DESIGN: Retrospective study MATERIALS AND METHODS: In this series, 75 patients with diabetic foot ulceration were treated at the Jawaharlal Nehru Medical College from October 2008 to August 2013, and were retrospectively reviewed. All patients in the study underwent surgical reconstruction of the foot in the form of a skin graft, local flaps, or free flaps, depending upon the characteristic of the defect, general condition of the patient, and vascular status of the limb. The medical notes of the patients were retrospectively analyzed according to age, gender, ankle-brachial pressure index, and comorbidities. RESULTS: Twenty-eight patients (37%) underwent skin grafting, 39 (52%) underwent local pedicled flaps, and 8 (11%) underwent free flap transfers. Sixty-eight patients (91%) achieved complete healing, and amputation of the lower extremity could be avoided. With the exception of 1 patient who experienced ulcer recurrence within the following year and 6 patients in whom amputation of the lower extremity was performed, all patients healed completely. The mean hospital stay was 4.0 T 1 week. CONCLUSIONS: From the results of this study, the authors conclude that radical debridement and soft-tissue cover in the form of a skin graft/flap is an effective method of managing DFUs. KEYWORDS: diabetic foot ulcer, soft-tissue coverage, surgical reconstruction of the foot ADV SKIN WOUND CARE 2015;28:157Y62 INTRODUCTION Diabetic foot ulceration is the most common complication seen in the patient with diabetes. 1 The lifetime risk of a foot ulcer for patients with diabetes may be as high as 25%, 2 and it is the most critical risk factor for lower-extremity amputation. 3 Treatment of diabetic foot ulcers (DFUs) requires management of a number of systemic and local factors. 4Y7 The most common cause of hospitalization of patients with dia- betes is soft-tissue and bone infections involving the foot. 8,9 The main predisposing factors for the development of diabetic foot infections are macroangiopathy, microangiopathy, peripheral neurop- athy, and the altered immunologic response of patients with diabetes. 8,10 Presence of infection in the DFU is associated with substantial morbidity and mortality. 11 Diabetic foot ulcers with infections need to be detected at an early stage to avoid major limb ampu- tations and prevent further complications. Wounds with infection alter the normal healing process by disrupting the healing and prolonging the inflammatory phase. 12 Many clinicians tend to treat the DFUs by conservative means because of a lack of experience with care for patients with DFUs. Although many patients with DFUs are hospitalized and treated with conservative means, the role of surgical management in the form of skin graft and flap is often underestimated, and DFUs can lead to sepsis. Sepsis of the limb can become a life-threatening event that may result in amputation of the lower extremity. It has been in- vestigated by various researchers 13Y15 that sepsis increases the patients’ risk for above-ankle amputation, as well as increases the burden of cost, as these patients are subjected to prolonged conservative ther- apy. Early aggressive surgical intervention may prevent eventual limb loss and the need for above-ankle amputation, decrease the total cost to treat the patient, and may restore full ambulation earlier. 15 In other studies, 16 any amputation, regardless of the level, was considered a treatment failure. Because limited amputation may restore the ability to function, the authors consider debridement and limited amputation to be part of the therapy. The authors use the end point of above-ankle amputation to describe treatment failure, as past studies have also done. 15 In this study, the authors reviewed their experiences with DFUs and established an algorithm for surgical reconstruction of DFUs. MATERIALS AND METHODS In this study, a total of 75 patients with DFUs undergoing surgical management from October 2008 to August 2013 were included and retrospectively analyzed. The potential risk factors for healing were documented from each patient’s medical record, including ADVANCES IN SKIN & WOUND CARE & APRIL 2015 157 WWW.WOUNDCAREJOURNAL.COM ORIGINAL INVESTIGATION Sohaib Akhtar, MD, MBBS, MS, MCh, is the Senior Resident; Imran Ahmad, MBBS, MS, MCh, is an Associate Professor; A.H. Khan, MBBS, MS, MCh, is a Professor; and M. Fahud Khurram, MBBS, MS, MCh, DNB, is an Assistant Professor, all at the Jawaharlal Nehru Medical College in Uttar Pradesh, India. The authors have disclosed that they have no financial relationships related to this article. Submitted December 6, 2013; accepted March 7, 2014. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.