Singh, N, DG Armstrong, and BA Lipsky. :Preventing foot ulcers in patients with diabetes. .JAMA 293::217. ,2005. .
Clayton Jr, W and TA Elasy. :A review of the pathophysiology, classification, and treatment of foot ulcers in diabetic patients. .Clin Diabetes 27::52. ,2009. .
Roukis, TS . : “Skin Grafting Techniques for Open Diabetic Foot Wounds. ,” inSurgical Reconstruction of the Diabetic Foot and Ankle. , edited byZgonis, T. , p129. ,Lippincott Williams & Wilkins. ,Philadelphia. ,2009. .
Jewell, L, R Guerrero, AR Quesada, et al. :Rate of healing in skin-grafted burn wounds. .Plast Reconstr Surg 120::451. ,2007. .
Thourani, VH, WL Ingram, and DV Feliciano. :Factors affecting success of split thickness skin grafts in the modern burn unit. .J Trauma 54::562. ,2003. .
Mowlavi, A, K Andrews, S Milner, et al. :The effects of hyperglycemia on skin graft survival in the burn patient. .Ann Plast Surg 45::629. ,2000. .
Mahmoud, SM, AA Mohamed, SE Mahdi, et al. :Split-skin graft management of diabetic foot ulcers. .J Wound Care 17::303. ,2008. .
Younes, N, A Albsoul, D Badran, et al. :Wound bed preparation with 10-percent phenytoin ointment increases the take of split-thickness skin graft in large diabetic ulcers. .Dermatol Online J 12::5. ,2006. .
Johnson, TM, D Ratner, and BR Nelson. :Soft tissue reconstruction with skin grafting. .J Am Acad Dermatol 27::151. ,1992. .
Browne, EZ . :Complications of skin grafts and pedicle flaps. .Hand Clin 2::353. ,1986. .
McCampbell, B, N Wasif, A Rabbitts, et al. :Diabetes and burns: retrospective cohort study. .J Burn Care Rehabil 23::157. ,2002. .
Manchio, JV, CR Litchfield, S Sati, et al. :Duration of smoking cessation and its impact on skin flap survival. .Plast Reconstr Surg 124::1105. ,2009. .
Reiber, GE . :The epidemiology of diabetic foot problems. .Diabet Med 13 ( suppl 1:):S6. ,1996. .
Fagot-Campagna, A, I Bourdel-Marchasson, and D Simon. :Burden of diabetes in an aging population: prevalence, incidence, mortality, characteristics and quality of care. .Diabetes Metab 31( Spec No. 2:):5S35. ,2005. .
Jones, KB, KA Maiers-Yelden, JL Marsh, et al. :Ankle fractures in patients with diabetes mellitus. .J Bone Joint Surg Br 87::489. ,2005. .
Peppa, M, P Stavroulakis, and SA Raptis. :Advanced glycoxidation products and impaired diabetic wound healing. .Wound Repair Regen 17::461. ,2009. .
Blakytny, R and EB Jude. :Altered molecular mechanisms of diabetic foot ulcers. .Int J Low Extrem Wounds 8::95. ,2009. .
Krishnan, ST, C Quattrini, M Jeziorska, et al. :Neurovascular factors in wound healing in the foot skin of type 2 diabetic subjects. .Diabetes Care 30::3058. ,2007. .
Liu, ZJ and OC Velazquez. :Hyperoxia, endothelial progenitor cell mobilization, and diabetic wound healing. .Antioxid Redox Signal 10.:1869. ,2008. .
Trengove, NJ, MC Stacey, S MacAuley, et al. :Analysis of the acute and chronic wound environments: the role of proteases and their inhibitors. .Wound Repair Regen 7::442. ,1999. .
Williams, AS . :Recommendations for desirable features of adaptive diabetes self-care equipment for visually impaired persons: Task Force on Adaptive Diabetes for Visually Impaired Persons. .Diabetes Care 17::451. ,1994. .
Kohner, EM, SJ Aldington, IM Stratton, et al. :United Kingdom Prospective Diabetes Study, 30: diabetic retinopathy at diagnosis of non-insulin-dependent diabetes mellitus and associated risk factors. .Arch Opthalmol 116::297. ,1998. .
Wattanakit, K, AR Folsom, E Selvin, et al. :Kidney function and risk of peripheral arterial disease: results from the Atherosclerosis Risk in Communities (ARIC) Study. .J Am Soc Nephrol 18::629. ,2007. .
Ndip, A, LA Lavery, and AJ Boulton. :Diabetic foot disease in people with advanced nephropathy and those on renal dialysis. .Curr Diab Rep 10::283. ,2010. .
Guerrero-Romeo, F and M Rodriguez-Moran. :Relationship of microalbuminuria with the diabetic foot ulcers in type II diabetes. .J Diabetes Complications 12::193. ,1998. .
Löndahl, M, P Katzman, O Fredholm, et al. :Is chronic diabetic foot ulcer an indicator of cardiac disease? J Wound Care 17::12. ,2008. .
Marston, WA . :Risk factors associated with healing chronic diabetic foot ulcers: the importance of hyperglycemia. .Ostomy Wound Manage 52::26. ,2006. .
Driver, VR, RA Goodman, M Fabbi, et al. :The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity: a retrospective cohort study. .JAPMA 100::235. ,2010. .
Ramanujam, CL, JJ Stapleton, KL Kilpadi, et al. :Split-thickness skin grafts for closure of diabetic foot and ankle wounds: a retrospective review of 83 patients. .Foot Ankle Spec 3::231. ,2010. .
Armstrong, DG and BA Lipsky. :Diabetic foot infections: stepwise medical and surgical management. .Int Wound J 1::123. ,2004. .
Massin, P, K Angioi-Duprez, F Bacin, et al. :Detection, monitoring and treatment of diabetic retinopathy: recommendations of ALFEDIAM. .Diabetes Metab 22::203. ,1996. .
American Diabetes Association :Nephropathy in diabetes. .Diabetes Care 27::579. ,2004. .
American Diabetes Association :Peripheral arterial disease in people with diabetes. .Diabetes Care 26::3333. ,2003. .
Split-thickness skin grafts can be used for foot wound closure in diabetic and nondiabetic patients. It is unknown whether this procedure is reliable for all diabetic patients, with or without comorbidities of diabetes, including cardiovascular disease, neuropathy, retinopathy, and nephropathy.
We retrospectively reviewed 203 patients who underwent this procedure to determine significant differences in healing time, postoperative infection, and need for revisional surgery and to create a predictive model to identify diabetic patients who are likely to have a successful outcome.
Overall, compared with nondiabetic patients, diabetic patients experienced a significantly higher risk of delayed healing time and postoperative complication/infection and, hence, are more likely to require revisional surgery after undergoing the initial split-thickness skin graft procedure. These differences seemed to be related more to the presence of comorbidities than to diabetic status itself. Diabetic patients with preexisting comorbidities experienced a significantly increased risk of delayed healing time and postoperative infection and a higher need for revisional surgery compared with nondiabetic patients or diabetic patients without comorbidities. However, there were no significant differences in outcome between diabetic patients without comorbidities and nondiabetic patients.
For individuals with diabetes but without exclusionary comorbidities, split-thickness skin grafting may be considered an effective surgical alternative to other prolonged treatment options currently used in this patient population. (J Am Podiatr Med Assoc 103(3): 223–232, 2013)