Surgical approaches to diabetic foot ulcers: an algorithm for applying the reconstructive ladder

Abstract

Diabetic foot ulcers (DFUs) affect over 18 million people worldwide and account for more than 70% of lower-limb amputations in the United States, emphasizing the need for effective limb-preservation strategies. This narrative review synthesizes current evidence on the algorithmic surgical management of DFUs using the reconstructive ladder to provide a practical decision guide for multidisciplinary teams. Scientific papers, society guidelines, and orthoplastic experience are integrated to outline surgical treatment recommendations, including preoperative optimization, serial debridement, wound conditioning with reconstructive adjuncts, and definitive closure techniques aligned with the reconstructive ladder. Early radical debridement combined with vascular optimization, tight glycemic control, and infection eradication forms the foundation for surgical success, while the reconstructive ladder provides the algorithm for closure, from secondary intention or tension-free primary closure for small superficial wounds, to split-thickness skin grafts for larger well-granulating defects, and to local or regional pedicled flaps for larger defects. Knowledge and application of this algorithm have the potential to reduce major amputation rates while restoring durable ambulation in complex DFU cases.

Keywords

Diabetic foot ulcer / reconstructive ladder / surgical debridement / skin graft / pedicled flap / limb salvage / multidisciplinary care

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