Level one evidence exists for debridement of diabetic foot ulcers. Herein we describe details of the surgical technique to correct the underlying cellular impairments present in diabetic foot ulcers.

Operative notes of 280 consecutive surgical debridements of persons with diabetic foot ulcers were reviewed. The technique is illustrated in a patient with a metatarsal wound and bilateral plantar foot ulcers. Pathology using hematoxylin and eosin was analyzed. The skin edge was stained for phosphorylated beta-catenin, a known marker of abnormal wound keratinocytes. dUTP-biotin nick end labeling (TUNEL), a marker of apoptosis, was performed in 8 of these patients, including the one highlighted.

Surgical techniques and relevant cellular and molecular basis shown in the video:

• Wide excision past the margin of callus into adjacent soft skin is emphasized. Techniques of hemostasis are detailed. H&E stained sections of epidermis were hyper-proliferative and showed an abnormally thick cornified layer (hyperkeratosis), as compared to sections of normal foot skin. The stain for beta-catenin as a molecular marker of inhibition is illustrated.
• Sharp excision of the ulcer down to the level without scar and infection, including bone is demonstrated. Routine histology is described of fibrosis, osteomyelitis and granulation tissue.

Surgical techniques are detailed, to where wide and deep debridement is done to a level of viable tissue based on absence of hyperkeratosis at the epidermal level. Furthermore the depth of operative debridement of the neuropathic foot ulcer is defined by the pathological analysis of absence of scar and infection.