Newer concepts in the surgical management of lesions of the foot in the patient with diabetes.

Ulcerative lesions of the foot are commonly due to ischemia, neuropathy or a combination of these factors. When these lesions fail to respond to conservative measures, they are usually treated by ablative or destructive procedures which often result in the loss of a portion of the foot or deformities, or both. These procedures or deformities may, themselves, lead to further problems as the weight is transferred to other areas not designed for this purpose. Reconstructive procedures may prevent these problems, as well as conserve the foot. Lesions of the heel, middle of the foot and forefoot were managed by excision and closure of the defects by the transposition of muscle or muscles into the area with or without subsequent skin grafts. A total of 31 patients were treated; in 22, muscles were transposed with primary healing of the lesion in 15, delayed healing in three, necrosis of the muscle in two and delayed healing of the incision in two. Ablative operations were required in nine patients, when 15 procedures were carried out, including below-knee amputations in two. In five patients, the peroneal tendons were explored behind the fibular malleoulus, and in two, unsuspected necrosis of a tendon was found. It is concluded that reconstructive rather than destructive surgical treatment be considered in ulcerative lesions of the foot. Spread of infection from foot to leg along the tendon sheaths should be suspected when supperative foot lesions persist despite apparently adequate treatment; small incisions over the suspected tendons may confirm this suspicion and allow timely surgical treatment which will prevent extensive surgical treatment on the leg, including amputation.