Surgical Management of Diabetic Foot Infections and Amputations

THOMAS ZGONIS, DPM; JOHN J. STAPLETON, DPM; VALERIE A. GIRARD-POWELL, RN; RYAN T. HAGINO, MD

2.6

he incidence of diabetes with foot complications has risen significantly during the past decade.1-6 Severe diabetic foot infections include, but are not limited to, necrotizing fasciitis, gas gangrene, ascending cellulitis, compartment syndrome, and infection with systemic toxicity or metabolic instability. A severe diabetic foot infection has approximately a 25% risk of ultimately requiring a major lower extremity amputation.1-13 For this reason, surgery should be coordinated among an established multidisciplinary team whose members are knowledgeable in diabetic foot care.14-16 The timing of surgery and the strategies employed should be understood and agreed upon by all team members. The first step in the overall strategy for surgically managing a diabetic foot infection is infection control through adequate surgical debridement and proper antibiotic selection. The second step consists of a comprehensive vascular assessment and timed intervention when necessary. The final step includes soft-tissue coverage through adjunctive wound therapy modalities, plastic surgery techniques, or pedal amputations. This coordinated surgical approach combined with comprehensive medical management of the patient is vital for overcoming the morbidity and mortali-

ty associated with a diabetic foot infection.17 This article presents a rational approach for reducing the morbidity, mortality, psychological distress, and lengthy hospitalizations associated with the management of patients with complicated diabetic foot infections.

INITIAL PATIENT EVALUATION

Communication and collaboration between the medical and surgical disciplines of the diabetic foot-care team is necessary to determine whether the patient requires immediate or delayed surgical intervention. For many patients, a diabetic foot infection may be the first indication that the patient has diabetes mellitus. These patients initially may experience denial when presented with the prognosis of their infection or the recommendation that amputation is required to further prevent the

ABSTRACT
THE INCIDENCE OF DIABETES with severe foot infections (eg, necrotizing fasciitis, gas gangrene, ascending cellulitis, infection with systemic toxicity or metabolic instability) has risen significantly during the past decade. FOOT INFECTIONS are a major cause of hospitalization and subsequent lower extremity amputation among patients with diabetes mellitus who have a history of a preexisting ulceration. SURGICAL MANAGEMENT often is required to address severe diabetic foot infections because they can be limb- or life-threatening. Critical limb ischemia, neuropathy, and an immunocompromised host, which often are associated with diabetic foot infections, complicate treatment and are associated with a poorer prognosis. AORN J 87 (May 2008) 935-946. AORN, Inc, 2008.

indicates that continuing education contact hours are available for this activity. Earn the contact hours by reading this article and taking the examination on pages 947948 and then completing the answer sheet and learner evaluation on pages 949950. You also may access this article online at http://www.aornjournal.org.

AORN, Inc, 2008

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spread of the infection. This may unnecessarily delay surgical treatment. Family support in conjunction with a multidisciplinary team approach addressing the devastating complications associated with diabetes mellitus are necessary throughout the patients treatment to help the patient accept the diagnosis and remain compliant with the treatment care plan. The clinician performs a thorough history and physical examination with an emphasis on evaluating preexisting conditions, such as congestive heart failure, coronary artery disease, morbid obesity, peripheral neuropathy, peripheral vascular disease, and renal insufficiency. In addition, the clinician carefully evaluates clinical and laboratory findings to determine risk stratification and the timing of surgery. Most importantly, the team must address, in a timely fashion, the severity of the patients infection, particularly in the presence of systemic toxicity or metabolic instability. Categorizing the severity of the infection is difficult because more than 50% of patients with limb-threatening infections do not mount a sufficient immune response to manifest systemic signs or symptoms.18 For this reason, an understanding between the surgeon and the medical team is paramount in determining the patients medical stability as well as defining the risk that the infection poses to the patient and his or her lower extremity. Significant metabolic and hemodynamic instability may occur in patients with severe diabetic foot infections. This may necessitate administration of IV fluids with electrolytes and IV insulin to correct for hyperglycemia, hyperosmolality, azotemia, and acidosis.2 Chronic anemia can compound blood loss intraoperatively, and the patient may need blood transfusions before and during surgery. Furthermore, team members should take clinical measures to protect the patient from experiencing a cardiovascular event. A critically ill patient with multiple comorbidities who requires urgent or emergent surgery usually is transferred to the OR after he or she has been stabilized.2,18 Surgery should

not be delayed for more than 48 hours after presentation to the health care facility, however, because conditions such as gas gangrene and necrotizing fasciitis mandate emergent surgical intervention (Figure 1).2,18-21 A delay in emergent surgery is associated with a high rate of patient morbidity and mortality. Necrotizing fasciitis has been associated with a mortality rate of 24% to 33%.20 Often, immediate medical optimization is not feasible until surgery is performed and the anesthesia care provider has managed the high-risk patient with diabetes mellitus and a limb-threatening infection. For this reason, the anesthesia care provider must be informed of the patients emergent condition and the necessity for surgical intervention so that a plan of care can be developed for the type of anesthesia required and can be implemented in a timely fashion to avoid any further delay of surgical intervention. Appropriate antibiotic selection combined with early surgical intervention is imperative in controlling the extent of the infection and stabilizing the patient. An infectious disease

Figure 1 A severe diabetic foot infection with gas gangrene, ascending cellulitis, and calcaneal osteomyelitis.

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specialist who can determine optimal antibiotic therapy also is an essential team member. Determining the initial antibiotic therapy required is empirical and based on the patients history, clinical appearance, and antibiotic susceptibility results to anticipated organisms at the particular hospital. For severe diabetic foot infections, initial antibiotic therapy may commence with parenteral, broad-spectrum antibiotics that have activity against gram-positive and gram-negative cocci and anaerobic organisms.13,22-24 In addition, agents with activity against methicillin-resistant Staphylococcus aureus (MRSA) may be considered for patients at risk of acquiring an MRSA infection, given its association with poor clinical outcomes.25,26 Definitive antibiotic therapy is based on culture and sensitivity results from deep intraoperative specimen collection along with the patients clinical response to the antibiotic therapy. Selection, route of administration, and dosage of antibiotics are confirmed with the infectious disease team to ensure the safest, easiest to administer, and most effective antibiotic regimen.

The infectious disease team confirms the selection, route of administration, and dosage of antibiotics to ensure the safest, easiest to administer, and most effective antibiotic regimen.

chemia is present or at the time of the initial emergent surgical debridement.12,27,28

WOUND ASSESSMENT
Knowledge of the diabetic foot and clinical suspicion is vital to help clinicians avoid unnecessarily delaying surgical intervention. The extent of soft-tissue and bone involvement must be determined to decide the level of amputation required or the feasibility of diabetic limb salvage. Physical examination of the entire lower extremity, not simply the foot, is essential in determining the proximal extent of the infection. Patients with diabetic foot infections almost always have a history of preexisting neuropathic ulcerations.29 Diabetic foot ulcers often are masked by an overlying callous or are located within the interdigital web spaces. For this reason, the clinician may sharply debride any hyperkeratotic tissue to evaluate for an underlying foot ulcer in a patient with diabetes mellitus who has dense peripheral neuropathy. The clinician should inspect interdigital web spaces as possible portals for bacterial entry, particularly when an obvious foot ulcer is not present but the patient is exhibiting clinical signs of infection. When the wound is identified, the clinician should closely examine it to determine its size, depth, and surrounding margins and then inspect the wound for exposed deep structures such as tendon, joint capsule, or bone. If the patient complains of pain on palpation in the
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VASCULAR ASSESSMENT
A thorough vascular examination is needed to determine if arterial insufficiency and limb ischemia may be complicating the infection. The clinician should assess the patient for limb ischemia, which is demonstrated by decreased or absent pedal pulses, necrosis, or gangrene. The clinician should closely evaluate the patient and document the severity of the infection and the risks that threaten limb survival. If the diabetic patients foot is dysvascular, the severity of the infection and subsequent rate for major limb amputation increases. Despite the significance of revascularization for limb survival when arterial insufficiency is present, initial emergent surgical intervention to eradicate infection may not be delayed just to further evaluate the patients vascular status.12 Emergent diabetic foot surgery in the presence of a severe infection is of primary importance. A vascular surgery consult should be initiated immediately when critical limb is-

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presence of neuropathy, the clinician should culture tubes, supplies, and paperwork; consider abscess formation and deep underly a minimum of one 3 L bag of normal saline ing infection.30 The clinician then should obtain irrigation; and appropriate wound and blood culture speci hemostatic agents as requested by the surgeon. mens in a sterile manner to determine the The circulating nurse ensures that a tournicausative organism and to further evaluate the quet and appropriately sized cuffs are availextent of the infection when bacteremia and able at the surgeons request. If the patient septicemia are suspected. has been on a course of antibiotics before surThe clinician should obtain gery, the circulating nurse enx-rays to determine the absures that the next scheduled sence or presence of osteodose is available for adminismyelitis, gas in the soft tistration after intraoperative sues, and foreign bodies. If gas soft-tissue and bone cultures The circulating nurse is seen or clinically suspected, have been obtained or when x-rays should include the next it is requested by the surgeon. ensures the availability proximal joint to ensure that The circulating nurse also enthe infection has not migrated sures the availability of a gluof a glucometer and is proximally and to determine cometer and is prepared to the level of emergent amputaperform multiple blood sugar prepared to perform tion to reduce the chance of tests intraoperatively; the morbidity and mortality. nurse provides insulin to the multiple blood sugar The clinician may order adanesthesia care provider as ditional imaging and laboratorequested. tests intraoperatively; ry studies to further confirm the diagnosis and treatment PREOPERATIVE AREA the nurse provides insulin plan. The clinician initially orWhen the patient arrives in ders a complete blood count the preoperative area, the preto the anesthesia care with differential, sedimentaoperative nurse helps the pation rate, and C-reactive protient change into a surgical provider as requested. tein. Computed tomography gown; starts an IV; organizes (CT) scans with contrast or the medical record; and intermagnetic resonance imaging views the patient, confirming can assist in the diagnosis of that the patient is aware of his deep abscess that is not clinior her condition and the procally apparent. The clinician should use caution posed procedures. To avoid misconceptions, all when waiting for further imaging results to members of the team must relay consistent inconfirm the diagnosis, which may unnecessariformation to the patient and his or her family ly delay urgent surgery. members regarding the patients condition and proposed procedures. The preoperative nurse OR PREPARATION confirms the proposed procedure with the paThe circulating nurse and scrub person pretient, the patients medical record and informed pare the OR for the procedure by gathering reconsent form, and the surgery schedule. If an quired instruments, supplies, and equipment, amputation is to be performed, the nurse enincluding sures that this is clearly stated on the consent form along with the level of amputation. a basic orthopedic instrumentation tray; At times, amputations may need to be per a pneumatic reciprocating sagittal saw and appropriate blades with battery or power source; formed more proximally than was initially a pulse lavage or debridement irrigation sys- anticipated because of the extent of the infectem, depending on the severity of the diabettion identified intraoperatively. The consent ic foot infection and the surgeons preference; form, therefore, always should include details

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regarding the possibility of a more proximal amputation in the presence of a diabetic limbor life-threatening infection. This prepares the patient preoperatively and lessens further psychosocial distress postoperatively. The preoperative nurse obtains the patients history and performs a physical examination, focusing on identifying a systemic response to the infection (eg, presence of fever, rigors, nausea, vomiting, hypotension, unexplained hyperglycemia, tachycardia). The preoperative nurse continues close observation and documentation of any changes in the patients systemic response to the infection and relays any changes from the initial history and physical examination to the medical and surgical team managing the patient. The nurse reviews all test results (eg, serum chemistry analyses, hematological testing) as well as the time they were obtained to determine the current metabolic state and stability of the patient. The preoperative nurse reports the results of abnormal laboratory studies to the other team members. The nurse ensures that appropriate blood typing and cross matching has been completed and that two or more units of packed red blood cells are available for later use if needed. In addition, the nurse confirms and documents the patients NPO status, identifying when the patient last had something to eat or drink. The surgeon arrives in the preoperative area and answers any questions that the patient and his or her family members may have. While completing the informed consent and surgical site marking processes, the surgeon and patient cooperatively identify the correct lower extremity, and the surgeon and patient both initial the correct extremity before the patient is transferred to the OR. The circulating nurse goes to the preoperative area to meet and assess the patient. After reviewing the medical record, the nurse verifies that the consent is complete and that the surgical extremity has been initialed by the patient and surgeon. The nurse ensures that the patient is able to verbalize the proposed procedures and that it is consistent with what is on the surgical consent form and surgery schedule. After assessing the patient and answering

An amputation may need to be performed more proximally than was initially anticipated; therefore, the consent form always should include details regarding the possibility of a more proximal amputation in the presence of a diabetic limb- or life-threatening infection.

any questions that the patient and family members may have, the nurse prepares a nursing care plan specific to this patient (Table 1).

INTRAOPERATIVE PHASE
The circulating nurse and anesthesia care provider transport the patient to the OR on a stretcher and assist the patient in moving to the OR bed and into a supine position. The circulating nurse pads and secures all nonsurgical extremities and remains with the patient throughout induction of anesthesia. The anesthesia care provider induces anesthesia (eg, general, regional) or IV sedation and monitors the patient throughout the procedure. The surgeon administers a local anesthetic block using 0.5% bupivicaine plain. The circulating nurse initiates a surgical time out to confirm the correct patient; surgery; surgical sites and laterality; and availability of all required instruments, equipment, and supplies before the procedure is started. If the patient presents with an open and infected draining wound, the circulating nurse isolates the infected wound by covering the site with an antiseptic-soaked sponge. The nurse then cleanses the extremity from the clean to dirty areas (ie, areas of high microbial counts within the surgical site are prepared last). The circulating nurse uses gentle
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TABLE 1

Nursing Care Plan for Patients With Diabetes Undergoing Surgery

Diagnosis
Risk for anxiety related to the stress of surgery and knowledge deficit of the diabetic disease process

Nursing interventions

Interim outcome criteria

The patient verbalizes understanding of the procedure and expected outcomes before anesthesia induction and demonstrates decreased anxiety and increased ability to cope throughout the perioperative period. The patient reports pain in a timely fashion and demonstrates adequate pain management throughout the perioperative period.

Outcome statement
The patient demonstrates appropriate psychological response to the procedure and knowledge of potential side effects.

Risk for acute or chronic pain related to the surgical procedure and medical condition

Determines knowledge level related to the diabetic disease process and need for surgical intervention, assesses readiness to learn, and identifies barriers to communication. Provides instruction (ie, verbal, written) for treatment options, surgical procedure, sequence of events, and discharge based on age and identified need. Ensures availability of a support group. Communicates patient concerns to the appropriate surgical team members. Evaluates response to instruction. Assesses the patients preoperative pain, previous experiences of pain, and cultural and value components related to pain and pain management. Identifies the patients acceptable postoperative pain level. Provides pain management instruction and pain scale to assess pain control. Implements pain management guidelines by administering adequate quantities of pain medication and alternative pain management therapies. Evaluates the patients response to pain management interventions. Assesses the patient preoperatively for susceptibility to infection (eg, presence of comorbidities, weight not within normal limits, deviations in laboratory values, alterations in skin integrity). Implements, monitors, and maintains aseptic technique throughout the perioperative period (eg, traffic control, wound dressings). Anticipates the need to culture the surgical wound and classifies the surgical wound. Administers prescribed prophylaxis (eg, antibiotic therapy) at appropriate times. Prepares separate instruments, back tables, and glove changes for different surgical sites to prevent cross contamination. Reports signs and symptoms of wound infection (eg, elevation in body temperature with increased pulse and blood pressure, incisional redness or tenderness, purulent drainage, odor, abnormal laboratory results). Evaluates the patients response to infection prevention and management interventions.

The patients clinical and nonverbal signs remain stable, indicating adequate pain control.

Increased potential for wound infection related to multiple sites for organism invasion secondary to the surgical procedure, presence of external fixation, and complications of impaired circulation and impaired sensation

The patients surgical wound remains free of signs of infection, the patients blood glucose levels remain within the acceptable range, and the patient remains normothermic throughout the perioperative period. The patient is able to state adverse signs and symptoms that need to be reported immediately.

The patient is free of signs and symptoms of infection.

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preparation techniques because diabetic patients often have fragile skin.31 The scrub person and surgeon then drape the patient for surgery. Surgery usually is performed without the use of a tourniquet. In certain circumstances, a tourniquet is required; if so, the tourniquet is released immediately after the surgical debridement to determine tissue viability and need of further surgical debridement. A surgeon who operates on a patients diabetic foot infection must have sound knowledge of foot and lower extremFigure 2 An open partial calcanectomy and aggressive incision and drainage are ity anatomy because meticuperformed immediately. lous surgical debridement is necessary to prevent further postoperative complications or proximal amputations.32 The surgeon begins by thoroughly exploring the wound (Figure 2) and removing all necrotic, fibrotic, and infected tissue (Figure 3). He or she opens sinus tracts to identify the tissue planes and compartments of the foot that have been violated. The surgeon performs the finger-test technique intraoperatively to determine the extent of affected tissue planes. Deep fascial tissue should not be easily separated with a gentle forward pushing Figure 3 Vascular consult and intervention is initiated immediately before the of the index finger along the anatomic tissue planes. A posi- subsequent revisional debridement. tive finding indicates rapidly disseminating infection and possible necrotiz a midfoot, rearfoot, or ankle disarticulation, ing fasciitis.20 if needed. After exploring the wound, the surgeon deMaking limited incisions to drain a wound termines the portion of the foot that needs to be should be avoided because infected tissue reamputated or widely excised to adequately con- mains despite decompression of the infected trol the infection. This may include area. The surgeon should excise all nonviable and infected soft tissue and bone, regardless of an open toe or ray (ie, toe and part of the metatarsal) resection; size and quantity, during the initial debridement to improve wound healing and chances of a transmetatarsal amputation; or
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limb survival.33-36 The surgeon excises exposed course depends on the patients healing capabilitendons to prevent further tracting of the inties, ability to cope psychologically, and ability to fection. He or she then obtains a portion of comply with the postoperative regimen.38 the deep infected tissues or bone and sends The postoperative phase consists of the care the specimen to the microbiology and histoprovided during hospitalization and preparation pathology departments for reliable culture and of the patient for additional surgery that might be sensitivity results.33,34 required. The medical/surgical unit nurse assessAfter the surgeon is satisfied with the surgies the patients vital signs, laboratory studies, and cal debridement, he or she irriclinical status on a daily basis. A gates the patients wound with multidisciplinary team apcopious quantities of saline, proach continues throughout which reduces the wounds the postoperative period to enbacterial count. The surgeon sure a successful outcome. The It is not known may choose to use pulse lavage vascular surgeon determines irrigation with 3 L of saline. the need for further vascular whether adding Saline irrigation has been studies or vascular intervention. shown to significantly decrease An infectious disease specialist antibiotics to the aerobic and anaerobic bacterial determines the appropriate secounts compared with untreatlection, route, and duration of irrigation is beneficial ed controls.37 It is not known, antibiotic therapy. Wound care however, whether adding annurses perform necessary local in the management tibiotics to the irrigation is benwound care and adjunctive eficial in the management of modalities after surgery. A foot of severe diabetic severe diabetic foot infections, and ankle specialist determines and this practice remains a surthe need for serial debridefoot infections. geons preference. ments, level of amputation, and After wound irrigation is definitive soft-tissue closure. Alperformed, the circulating though medical management of nurse helps the scrubbed surgia patient with diabetes mellitus cal team members change their who has a foot infection is paouter pair of gloves; equipment is not reused tient-specific, includes various specialties, and is from this point forward to reduce contamination. dependent on the patients comorbidities, the The surgeon and scrub person pack the open overall goal is to provide specialized care to opwound with a wet-to-dry dressing to provide a timize the patients health and prevent further moist, wound-healing environment. Dressings diabetic-related complications. usually are changed daily beginning 24 to 48 hours after the initial surgery. Serial surgical deVASCULAR INTERVENTION bridements also may be performed as necessary Most patients with limb- or life-threatening to further eradicate any remaining localized indiabetic foot infections will need to consider fection. Advanced healing modalities and dressvascular intervention to achieve limb salvage. ings usually are initiated after the first dressing Soon after the initial surgical debridement, the change and inspection of the surgical wound. surgeon requests that invasive and noninvasive vascular studies be performed. The vascular POSTOPERATIVE PHASE surgeon may prefer to perform revascularizaAfter surgery for a diabetic foot infection, the tion within one to two days of the initial surgipatient is faced with additional challenges, multi- cal debridement for a patient who has a severeple concerns, anxiety, and depression that should ly infected, dysvascular foot.19,35 be addressed and efficiently managed immediDetermining the need for revascularization ately and long after surgery.38 Ultimately, the sucbegins with comparing the preoperative perfusion with the intraoperative assessment of cess of surgery throughout the postoperative

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arterial tissue perfusion after adequate deing but not limited to endovascular and arteribridement. Noninvasive vascular studies that al bypass techniques, is not successful, a proxiinclude the ankle-brachial index, toe-brachial mal amputation may need to be performed if index, pulse-volume recordings, and transculimb ischemia persists and if team members taneous oxygen pressures are performed iniagree on this course of action. tially to determine whether there is a need for invasive vascular studies. SOFT-TISSUE CLOSURE AND RECONSTRUCTION The ankle-brachial index is a screening test Obtaining long-lasting wound closure after specifically for peripheral vascular disease, but it radical surgical debridement to control infection may not be very useful in the diabetic patient beis one of the most challenging aspects in the surcause the index underestimates the severity of argical management of diabetic foot infections.48 39 terial insufficiency. The ankle-brachial index is Extensive soft-tissue loss usually is present. Sucaffected by uncompressible calcified vessels, cessful soft-tissue reconstruction can be achieved which are common in diabetic patients. This leads only if persistent localized infection and arterial to falsely elevated values.39 Despite the shortcominsufficiency have been resolved. Numerous ings associated with the ankle-brachial index, a techniques may be used to obtain wound closure decreased value still is considered clinically sigin the diabetic foot after the initial surgical denificant. Qualitative wave forms and toe-brachial bridement. The procedure chosen is based on the pressure index have been shown to be more effipatients overall medical and clinical status. The cacious compared to the ankle-brachial index in simplest and least invasive modalities should be screening for arterial insufficiency in high-risk ex- attempted first, when feasible. The surgeon must tremities among the diabetic population.40 decide if a delayed primary wound closure with Transcutaneous oxygen pressure measureminimal tension is possible after revisional dements may be useful in predicting wound bridement or limited pedal amputation. Wounds healing capability.41-43 The wound is expected to that are not suitable for delayed primary closure, heal if values are greater than 30 mmHg.41-43 particularly those with continued drainage or exNoninvasive vascular studies in conjunction tensive soft-tissue loss, usually are managed with the extremitys clinical appearance may with advanced local wound care dressings in indicate the need for further vascular interven- tandem with negative pressure wound therapy tion. Angioplasty is a reasonable initial means (Figure 4). This facilitates development of granuof revascularization for anatomically favorable lation tissue and helps eliminate wound bacterial vascular disease, followed by distal artery bycount. In the most complex wounds, advanced pass if the angioplasty is unsuccessful.12,44 Angioplasty usually is successful in treating short arterial occlusions and stenosis.44 Peripheral artery bypass has been shown to be a beneficial procedure for salvage of the ischemic diabetic limb that has undergone considerable tissue loss.45,46 Peripheral bypass usually is needed to treat long arterial occlusions that are not amenable to angioplasty.12,45,47 Re-perfusion is essential before soft-tissue reFigure 4 Negative pressure wound therapy is applied at the second revisional construction can take place. If surgery and after appropriate bone and soft tissue cultures are obtained. vascular intervention, includAORN JOURNAL

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plastic surgical techniques eventually are required to achieve wound closure. These include split thickness skin grafting (Figure 5), local flaps, muscle flaps, pedicle flaps, and free-tissue transfer.48 In addition, external fixation techniques may be used alone or in conjunction with plastic surgery techniques to off-load or position the extremity, correct underlying osseous deformities, and assist in the closure of large cleft defects while permitting easy access for clinical assessments and local wound care when indicated (Figure 6).48-50 Finally, custom-molded shoes, inserts, or braces are used postoperatively to prevent future breakdown after soft-tissue coverage is achieved.

OPTIMIZING CHANCES
Figure 5 A hybrid, off-loading external fixator is applied in conjunction with negative pressure wound therapy before the patient is discharged from the hospital.

FOR

LIMB SURVIVAL

A rational approach to the surgical management of diabetic foot infections is essential for limb salvage and patient survival (Figure 7). A

Figure 6 A split-thickness skin graft is applied 12 weeks after surgery.

Figure 7 A final clinical picture 20 weeks after diabetic limb salvage surgery.

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multidisciplinary diabetic foot-care team consisting of personnel from both surgical and medical disciplines is needed to adequately manage a diabetic foot infection. The surgeon should have experience and knowledge to evaluate the patient with a diabetic foot infection to determine when and how to intervene. The basic principles to be accomplished include, but are not limited to, patient stabilization; adequate surgical debridement combined with antibiotic administration; comprehensive vascular assessment and revascularization, if needed; delayed soft-tissue reconstruction; and postoperative medical and surgical education and intervention. When these principles are achieved, the surgeon can optimize the likelihood of limb salvage. Social and nutritional services as well as diabetic support groups are key components of the patients education about diabetes mellitus and its devastating complications. Unfortunately, a foot infection often is the first wakeup call for the patient with diabetes mellitus and dense peripheral neuropathy. This clinical scenario should be used as an opportunity to further educate the patient on the necessity of adhering to the overall management of diabetes mellitus to prevent future complications.

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presentation and surgical management of the acute diabetic foot. Eur J Vasc Endovasc Surg. 2006;31 (2):151-156. 26. Pellizzer G, Strazzabosco M, Presi S, et al. Deep tissue biopsy vs superficial swab culture monitoring in the microbiological assessment of limb-threatening diabetic foot infection. Diabet Med. 2001;18(10):822-827. 27. Roukis TS, Zgonis T. The management of acute Charcot fracture-dislocations with the Taylors spatial external fixation system. Clin Podiatr Med Surg. 2006;23(2):467-483,viii. 28. Zgonis T, Roukis TS, Frykberg RG, Landsman AS. Unstable acute and chronic Charcots deformity: staged skeletal and soft-tissue reconstruction. J Wound Care. 2006;15(6):276-280. 29. Zgonis T, Roukis TS, Lamm BM. Charcot foot and ankle reconstruction: current thinking and surgical approaches. Clin Podiatr Med Surg. 2007;24(3):505-517. 30. Zgonis T, Jolly GP, Buren BJ, Blume P. Diabetic foot infections and antibiotic therapy. Clin Podiatr Med Surg. 2003;20(4):655-669. 31. Jolly GP, Zgonis T, Blume P. Soft tissue reconstruction of the diabetic foot. Clin Podiatr Med Surg. 2003;20(4):757-781. 32. Kosinski MA, Joseph WS. Update on the treatment of diabetic foot infections. Clin Podiatr Med Surg. 2007;24(3):383-396. 33. Wallace GF, Stapleton JJ. Transmetatarsal amputations. Clin Podiatr Med Surg. 2005;22(3):365-384. 34. Roukis TS, Zgonis T. Skin grafting techniques for soft-tissue coverage of diabetic foot and ankle wounds. J Wound Care. 2005;14(4):173-176. 35. Levin LS. The reconstructive ladder. An orthoplastic approach. Orthop Clin North Am. 1993;24(3):393-409. 36. Donato MC, Novicki DC, Blume PA. Skin grafting. Historic and practical approaches. Clin Podiatr Med Surg. 2000;17(4):561-598. 37. Attinger C. Use of skin grafting in the foot. J Am Podiatr Med Assoc. 1995;85(1):49-56. 38. Roukis TS. The Doppler probe for planning septofasciocutaneous advancement flaps on the plantar aspect of the foot: anatomical study and clinical applications. J Foot Ankle Surg. 2000;39(5):270-290. 39. Zgonis T, Roukis TS. Off-loading large posterior heel defects after sural artery soft-tissue flap coverage with stacked taylor spatial frame foot plate system. Oper Tech Ortho. 2006;16(1):32-37. 40. Shmueli G, Nahlieli O, Baruchin A, Herold HZ. External fixation for fractures and pedicle flap immobilization: a convenient and inexpensive substitute. Plast Reconstr Surg. 1985;75(4):594-595. 41. Roukis TS, Landsman AS, Weinberg SA, Leone E. Use of a hybrid kickstand external fixator for pressure relief after soft-tissue reconstruction of heel defects. J Foot Ankle Surg. 2003;42(4):240-243. 42. Bickel KD, Lineaweaver WC, Follansbee S, Feibel R, Jackson R, Buncke HJ. Intestinal flora of the medicinal leech Hirudinaria manillensis. J Reconstr Microsurg. 1994;10(2):83-85. 43. Attinger CE, Ducic I, Zelen C. The use of local

muscle flaps in foot and ankle reconstruction. Clin Podiatr Med Surg. 2000;17(4):681-711. 44. Attinger CE, Ducic I, Cooper P, Zelen CM. The role of intrinsic muscle flaps of the foot for bone coverage in foot and ankle defects in diabetic and nondiabetic patients. Plast Reconstr Surg. 2002;110(4):1047-1054. 45. Roukis TS, Zgonis T. Modifications of the great toe fibular flap for diabetic forefoot and toe reconstruction. Ostomy Wound Manage. 2005;51(6):30-36. 46. Bhandari PS, Sobti C. Reverse flow instep island flap. Plast Reconstr Surg. 1999;103(7):1986-1989. 47. Jolly GP, Zgonis T. Soft tissue reconstruction of the foot with a reverse flow sural artery neurofasciocutaneous flap. Ostomy Wound Manage. 2004;50(6):44-49. 48. Costa-Ferreira A, Reis J, Pinho C, Martins A, Amarante J. The distally based island superficial sural artery flap: clinical experience with 36 flaps. Ann Plast Surg. 2001;46(3):308-313. 49. Price MF, Capizzi PJ, Watterson PA, Lettieri S. Reverse sural artery flap: caveats for success. Ann Plast Surg. 2002;48(5):496-504. 50. Noack N, Hartmann B, Kntscher MV. Measures to prevent complications of distally based neurovascular sural flaps. Ann Plast Surg. 2006;57(1):37-40.

Thomas Zgonis, DPM, is an assistant professor in the Department of Orthopaedics, Podiatry Division, and the director of the Reconstructive Foot and Ankle Fellowship at the University of Texas Health Science Center at San Antonio. Dr Zgonis has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. John J. Stapleton, DPM, is an associate of foot and ankle surgery at VSAS Orthopaedics, Allentown, PA, and a clinical assistant professor of surgery at Penn State College of Medicine, Hershey, PA. Dr Stapleton has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Valerie A. Girard-Powell, RN, is a perioperative nurse at the University Hospital, San Antonio, TX. Ms Girard-Powell has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article. Ryan T. Hagino, MD, is an associate professor in the Division of Vascular Surgery at the University of Texas Health Science Center at San Antonio. Dr Hagino has no declared affiliation that could be perceived as a potential conflict of interest in publishing this article.

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Examination
PURPOSE/GOAL

2.6

Surgical Management of Diabetic Foot Infections and Amputations

To educate perioperative nurses about caring for patients during surgical management of diabetic foot infections and amputations.

BEHAVIORAL OBJECTIVES
After reading and studying the article on surgical management of a patient with a severe diabetic foot infection, nurses will be able to

1. identify the risks involved with a severe diabetic foot infection, 2. explain signs or symptoms of diabetic foot infections, 3. discuss preoperative management of a patient with a severe diabetic foot infection, 4. describe intraoperative care of the patient undergoing surgery for management of a diabetic
foot infection, and

5. discuss the postoperative management of the patient who has undergone surgery for a diabetic foot infection.

QUESTIONS
1. A severe diabetic foot infection has a _______ risk of ultimately requiring a major lower extremity amputation. a. 15% b. 20% c. 25% 2. Signs of limb ischemia include 1. decreased or absent pedal pulses. 2. fever. 3. gangrene. 4. necrosis. 5. presence of severe claudicating pain. a. 1 and 5 b. 1, 3, and 4 c. 2, 3, and 5 d. 1, 2, 3, 4, and 5 3. If the patient complains of pain on palpation in the presence of neuropathy, the clinician should consider a. abscess formation and deep underlying infection. b. venous claudication. c. blood clot formation. d. intermittent claudication. 4. X-rays can help the clinician determine 1. whether osteomyelitis is present. 2. whether foreign bodies are present. 3. whether there is gas in the soft tissues. 4. the level of emergent amputation needed. 5. whether an infection has migrated proximally. a. 2 and 3 b. 1, 4, and 5 c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5 5. A systemic response to infection is indicated by the presence of 1. hypotension. 2. nausea and vomiting. 3. rigors. 4. tachycardia. 5. unexplained hyperglycemia. a. 1 and 5 b. 2, 3, and 4 c. 2, 3, 4, and 5
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MAY 2008, VOL 87, NO 5

Examination

d. 1, 2, 3, 4, and 5 6. If the patient presents with an open and infected draining wound, the circulating nurse cleanses the extremity circumferentially from the planned incision site outward. a. true b. false 7. Saline irrigation has been shown to significantly decrease aerobic and anaerobic bacterial counts. a. true b. false 8. The success of surgery during the postoperative course is dependent on the patients 1. ability to comply with the postoperative regimen. 2. ability to cope psychologically. 3. healing capabilities. a. 1

b. 3 c. 1 and 2 d. 1, 2, and 3 9. _________________________ may be useful in predicting wound healing capability. a. Toe-brachial pressure indices b. Ankle-brachial indices c. Transcutaneous oxygen pressure measurements d. Qualitative wave forms 10. External fixation may be used to 1. assist in the closure of large cleft defects. 2. correct underlying osseous deformities. 3. off-load or position the extremity. 4. permit easy access for clinical assessments and local wound care. a. 1 and 3 b. 2 and 4 c. 1, 2, and 3 d. 1, 2, 3, and 4

The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, director, Center for Perioperative Education. Ms Holm and Ms Bakewell have no declared affiliations that could be perceived as potential conflicts of interest in publishing this article.

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for acceptance of this activity for relicensure.

948 AORN JOURNAL

Answer Sheet
Surgical Management of Diabetic Foot Infections and Amputations
lease fill out the application and answer form on this page and the evaluation form on the back of this page. Tear the page out of the Journal or make photocopies and mail with appropriate fee to:

2.6
Event #08036 Session #1902

AORN Customer Service

c/o AORN Journal Continuing Education 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax with credit card information to (303) 750-3212.
Additionally, please verify by signature that you have reviewed the objectives and read the article, or you will not receive credit.

Signature ______________________________________ 1. Record your AORN member identification number in the appropriate section below. (See your member card.) 2. Completely darken the spaces that indicate your answers to examination questions 1 through 10. Use blue or black ink only. 3. Our accrediting body requires that we verify the time you needed to complete this 2.6 continuing education contact hour (156-minute) program. ______ 4. Enclose fee if information is mailed.
AORN (ID) #____________________________________________ Name__________________________________________________ Address ________________________________________________ City ___________________________________________________ Phone number __________________________________________ RN license #____________________________________________ Fee enclosed ___________________________________________ or bill the credit card indicated State __________ State __________ Zip __________

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Fee: Members $13 Nonmembers $26 Program offered May 2008 The deadline for this program is May 31, 2011 AORN, Inc, 2008

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answers. Each applicant who successfully completes this program will receive a certificate of completion.
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2.6

Learner Evaluation
Surgical Management of Diabetic Foot Infections and Amputations

his evaluation is used to determine the extent to which this continuing education program met your learning needs. Rate these items on a scale of 1 to 5.

PURPOSE/GOAL
To educate perioperative nurses about caring for patients during surgical management of diabetic foot infections and amputations.

OBJECTIVES
To what extent were the following objectives of this continuing education program achieved? 1. Identify the risks involved with a severe diabetic foot infection. 2. Explain signs or symptoms of diabetic foot infections. 3. Discuss preoperative management of a patient with a severe diabetic foot infection. 4. Describe intraoperative care of the patient undergoing surgery for management of a a diabetic foot infection. 5. Discuss the postoperative management of the patient who has undergone surgery for a diabetic foot infection.

CONTENT
To what extent 6. did this article increase your knowledge of the subject matter? 7. was the content clear and organized? 8. did this article facilitate learning? 9. were your individual objectives met? 10. did the objectives relate to the overall purpose/goal?

TEST QUESTIONS/ANSWERS
To what extent 11. were they reflective of the content? 12. were they easy to understand? 13. did they address important points?

1. the Journal I receive as an AORN member. 2. a Journal I obtained elsewhere. 3. the AORN Journal web site. 16. What factor most affects whether you take an AORN Journal continuing education examination? 1. need for continuing education contact hours 2. price 3. subject matter relevant to current position 4. number of continuing education contact hours offered What other topics would you like to see addressed in a future continuing education article? Would you be interested or do you know someone who would be interested in writing an article on this topic? Topic(s): __________________________________ __________________________________________ Author names and addresses: _______________ __________________________________________ __________________________________________
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LEARNER INPUT
14. Will you be able to use the information from this article in your work setting? 1. yes 2. no 15. I learned of this article via

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