Living with diabetes means being cautious about even the smallest wounds, especially on the feet. Due to nerve damage (neuropathy) and poor circulation, diabetic patients are more prone to developing foot ulcers, which, if left untreated, can lead to serious infections and even limb loss.

While many diabetic foot ulcers heal with conservative measures like dressings, antibiotics, and offloading, some wounds become chronic, infected, or resistant to treatment. In these cases, surgery becomes essential. Surgical treatment can remove infection, promote healing, restore foot structure, and ultimately prevent amputations.

Procedure for Diabetic Foot Ulcer Surgery

Preoperative Evaluation and Diagnosis
Before surgery is considered, a thorough clinical and diagnostic evaluation is conducted to understand the extent and cause of the ulcer.

Key steps in this phase include:
- Wound examination :- Doctors assess the size, depth, drainage, and presence of necrotic tissue or exposed bone.
- Imaging studies :- X-rays, MRI, or CT scans are used to check if the ulcer has penetrated into the bones or joints (osteomyelitis).
- Blood tests :- Tests such as CBC, CRP, ESR, and HbA1c help detect systemic infection and assess sugar control.
- Doppler or angiography :- These tests evaluate blood circulation in the legs and feet, which is crucial for healing.
- Bacterial culture :- A wound swab or tissue biopsy is sent to identify infection and guide antibiotic treatment.
This stage ensures the patient is fit for surgery and helps plan the best surgical approach based on the condition’s complexity.
Stabilizing the Patient Before Surgery
In diabetic patients, controlling blood sugar levels before any surgery is vital to prevent complications and support post-operative healing. If infection or sepsis is present, intravenous antibiotics, insulin therapy, or even fluids may be started to stabilize the patient before surgery. In cases with poor circulation, vascular procedures may be done before ulcer surgery to restore blood flow.

Doctors also stop any medications that may interfere with healing, and ensure the patient has adequate nutritional support, as wound healing is slower in malnourished individuals.
Anesthesia and Surgical Preparation
The type of anesthesia depends on the severity of the ulcer and overall surgical plan:
- Local anesthesia is used for minor procedures like superficial debridement.
- Regional anesthesia (spinal or nerve block) may be used for moderate surgeries.
- General anesthesia is required for extensive procedures like amputation, bone resection, or reconstruction.
The foot is thoroughly cleaned and sterilized before surgery to minimize the risk of surgical site infection.
Surgical Debridement : The Core of Ulcer Treatment
Surgical debridement is the most common and essential procedure in diabetic foot ulcer care. It involves the removal of all infected, necrotic (dead), or unhealthy tissue from the wound.

Objectives of debridement
- Reduce bacterial load
- Remove barriers to healing
- Prevent infection from spreading
- Stimulate the body’s natural healing response
In many cases, repeated debridement may be required over days or weeks until healthy tissue appears. This also helps in assessing the viability of surrounding tissues and bone.
Drainage of Abscesses (If Present)
If the ulcer has led to an abscess a collection of pus under the skin or in deeper tissues the surgeon performs incision and drainage (I&D). This involves making a small cut in the infected area to allow pus to escape, relieving pressure, and decreasing the risk of systemic infection (sepsis).

Abscess drainage is often followed by a course of targeted antibiotics, based on the results of pus culture.
Bone Resection or Partial Amputation (If Bone Is Infected)
If the ulcer has progressed to the bone (osteomyelitis), the surgeon may need to remove the infected bone through bone resection. This may involve:
- Partial removal of a toe bone
- Removal of part of the metatarsal or tarsal bone
- Joint removal if the infection is near a joint
In more severe cases, a partial amputation (such as a toe or part of the foot) may be performed to stop the spread of infection and save the remaining limb.

This step is crucial to preserve as much function as possible while eliminating the infection source.
Structural Correction of the Foot (If Deformity Exists)
In many patients, ulcers form due to abnormal pressure points caused by foot deformities like:
- Claw toes or hammertoes
- Charcot foot
- Bony prominences
The surgeon may perform tendon lengthening, joint release, or bone shaving to correct these deformities and redistribute pressure. This improves the chances of long-term healing and helps prevent future ulcers.

These procedures are often done during the same operation or in a staged approach after initial wound healing.
Skin Grafting or Flap Coverage (For Large Wounds)
When a large ulcer or surgical wound is left behind after debridement, skin closure is needed. Surgeons may use:
- Split-thickness skin grafts :- Skin taken from the patient’s thigh or another body part is transplanted onto the ulcer site.
- Flap surgery :- Nearby skin and soft tissue are rotated or moved to cover the wound (pedicle flap or free flap).
These techniques help close the wound, reduce healing time, and protect underlying tissues from exposure and infection.
Wound Closure and Dressing
After completing the surgical procedure:
- The wound may be closed with stitches, partially closed, or left open for drainage (especially if infection was severe).
- A sterile dressing is applied.
In complex cases, negative pressure wound therapy (NPWT) or vacuum dressings may be used to help reduce swelling, increase blood flow, and promote granulation tissue formation.
Post-Surgery Recovery and Rehabilitation
Postoperative care is as important as the surgery itself. A well-managed recovery plan includes:

Medical Care:
- Regular dressing changes and wound monitoring
- Continuation of IV or oral antibiotics if infection was present
- Blood sugar control with insulin or medication adjustments
- Pain management and anti-inflammatory medication
Physical Care:
- Use of offloading devices like a cast, walker, or diabetic shoes
- Bed rest or limited movement until healing begins
- Physiotherapy for mobility and strength once safe
Long-Term Care:
- Regular follow-ups with the podiatrist and surgeon
- Lifestyle changes like quitting smoking and dietary improvements
- Monitoring for early signs of recurrence
Healing time varies; minor surgeries may heal in 2 – 4 weeks, while complex reconstructions or amputations can take months.

Conclusion

The diabetic foot ulcer surgery procedure involves a series of carefully planned steps from initial evaluation and infection control to wound cleaning, tissue reconstruction, and rehabilitation. The goal is always to save the limb, reduce infection risk, restore mobility, and most importantly prevent the ulcer from coming back.

While surgery may sound serious, it can be life-changing. When performed on time and followed by proper care, it gives diabetic patients the best chance at recovery and a return to daily life without fear of worsening ulcers or amputation.