Meet the surgeons transforming diabetic foot care
Arvind Mohan and Kshem Yapa are consultant plastic & reconstructive surgeons at Imperial College Healthcare, working across NHS and private care services. They specialise in complex soft tissue reconstruction and limb salvage following major trauma. They are also pioneering the use of plastic surgery techniques in complex diabetic foot ulceration. This World Diabetes Day, they discuss the service and what got them involved in the field.
What is involved in having reconstructive surgery?
Having diabetes makes you more at risk of developing diabetic foot disease, which can lead to serious complications such as a diabetic foot ulcer – an open wound or sore on the skin that's slow to heal. High blood sugar, a symptom of diabetes, can damage your blood vessels, causing the blood supply to your feet to become restricted. This can lead to infection of the skin and underlying bones which can compromise a patient’s ability to use their feet normally, and ultimately result in the need for an amputation. Reconstructive surgery is all about repairing damaged tissue and restoring function. As plastic surgeons, we utilise a wide range of reconstructive techniques to achieve this. The main aim is to restore the body, or the function of a specific part of the body, to normal.
Even if other factors causing ulceration, such as blood supply, glucose control and infection are treated effectively, ulcers will not heal unless the skin is adequately repaired. At Imperial College Healthcare, we are pioneering the use of plastic surgery techniques to heal complex foot and ankle ulceration that would otherwise result in amputation.
By creating bespoke treatment plans and utilising techniques such as skin grafts, dermal matrices, negative pressure therapy and microsurgical reconstruction we can offer patients the chance of complete healing and limb salvage.
How do different teams work together to make this happen?
We have a multidisciplinary team of specialists who work together to ensure that all aspects of a patient’s care are optimised.
The foundation of successful treatment is adequate control of blood sugar levels. In the first instance, our endocrinologists are able to optimise patients’ diabetic control and our podiatrists optimise wound care and footwear. Vascular surgeons and interventional radiologists then work to optimise blood flow to the foot which is crucial to enable ulcer healing. And our microbiologists are able to analyse tissue samples and identify which antibiotics are most suitable to treat infection. Following this, orthopaedic surgeons are able to remove any infected bone and plastic surgeons can replace diseased tissue with healthy skin using a variety of techniques to achieve complete healing.
Arvind and Kshem
"As reconstructive surgeons there is no greater satisfaction than seeing patients return to work and hobbies that they thought were no longer possible."
How have patients’ quality of life been improved by these new techniques?
Diabetic foot ulceration has a huge impact on patients’ lives. There have been a number of studies which have demonstrated a significant reduction in quality of life in patients who develop foot ulceration.
Patients are often unable to work or need to modify their employment, lose their ability to perform hobbies and socialise, and are committed to regular visits to hospital.
In many cases, prior to referral to Imperial College Healthcare, patients were told that amputation was the only option available to them. We provide the option of limb salvage which allows patients to live much more fulfilling lives in the future.
What impact has the service had to date?
We have performed plastic reconstructive procedures on over 80 patients now who would otherwise have required an amputation. Our limb salvage rate is over 90%. However, this does not tell the whole story.
By getting these patients healed, we are able to avoid the need for them to attend hospital. Previously, many patients were returning for regular dressing changes for months and sometimes years for their ulcers before being referred to our care. Our service therefore has a positive impact on both the patient and the hospitals that provide their care.
Our case study series has demonstrated that the majority of patients have returned to a pre-ulceration level of function. This is crucial so that patients can return to work, social life and hobbies.
Arvind and Kshem
"We are incredibly proud to offer a service that very few units around the world are able to offer."
How did you become interested in this area?
When we were training, plastic surgical reconstruction of diabetic foot ulcers was generally considered impossible. This was due to the complexity of the wounds, the co-morbidities of the patients and the poor quality and often absence of blood vessels required to make microsurgical soft tissue reconstruction possible.
We have always believed that there is another way and that limb salvage is possible even in the most complex foot ulceration. By joining the internationally recognised diabetic foot team at Imperial College Healthcare, we as plastic surgeons are able to provide reconstructive options to patients who would otherwise have to have an amputation. As reconstructive surgeons there is no greater satisfaction than seeing patients return to work and hobbies that they thought were no longer possible.
As microsurgeons, complex diabetic foot ulceration provides us with the greatest reconstructive challenge. We need to push the limits of what is possible, employing techniques that are world leading and shaping the future of diabetic foot treatment. We have been able to transfer these same skills to our cohort of trauma patients and directly improve their functional and aesthetic outcomes.
What are your proudest moments in this area?
It is honestly impossible to choose just one moment. What we can say is that we are incredibly proud to offer a service that very few units around the world are able to offer. Both our NHS and private patients from the UK and abroad are benefitting from the treatments that we provide.
We recently treated a gentleman with a foot ulceration who got in touch wanting to ensure he’d explored all possibilities after previously being told amputation was the only option for him. We were able to provide him with a reconstructive option that cleared his deep bone infection and resurfaced his ulcer with healthy tissue.
He went on to complete healing and is now living a full life and active life. Seeing photos of him on holiday walking normally, swimming and playing sport is hugely gratifying and he is just one example.
We are excited to develop the service further. Our aim is to demonstrate to patients and healthcare providers alike that there are options for reconstruction and limb salvage in even the most complex wounds. We want as many of our patients to be able to return to as normal a life as possible.
