Limb Salvage for the Diabetic Foot

Limb salvage and soft tissue coverage of the diabetic patient is a challenging problem. It can be complicated by both the medical comorbidities and the deformity in bony architecture. It needs careful preoperative planning and patient optimisation. Initial assessment is made by a multidisciplinary team, allowing medical issues to be resolved, orthotics to be planned and any vascular insufficiency investigated and optimised. Active infection must be eradicated. Appreciation of the size and location of a tissue defect combined with a knowledge of the relevant anatomy provide a logical approach to limb salvage in the diabetic foot. Using the classic reconstructive ladder of increasingly complex tissue replacement, one can work primarily from healing by secondary intention, through application of a split skin graft, soft tissue advancement, local rotational flaps and to free tissue transfer. Less invasive alternatives to split skin grafting, with lower donor-site morbidity have recently become more viable thanks to commercially available kits, albeit with equivocal evidence of efficacy at present. Epidermal grafts can be harvested by suction blisters and autologous, heterogeneous skin cell suspensions that include keratinocytes, and fibroblasts can be derived from very small split skin donor sites.