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46 Foot & Ankle Specialist February 2008

A Stepwise Approach to
the Surgical Management of
Thomas Zgonis, DPM, FACFAS,
John J. Stapleton, DPM, and
Thomas S. Roukis, DPM, FACFAS

Severe Diabetic Foot Infections

Abstract: Foot infections are com- limb salvage. A consistent stepwise sur- with appropriate consultations provided
mon among diabetic patients with gical approach combined with sound if necessary. The physician observes for
ulceration and are a major cause of surgical principles is paramount for self-neglect, noncompliance, depression,
hospitalization and lower extremity successful management of the severe delirium, impaired cognition, and stupor.
amputation. Aggressive and emergent diabetic foot infection. The authors dis- Next, the surgeon determines if critical
surgical intervention is essential in the cuss their stepwise surgical approach limb ischemia is present in conjunction
face of life- or limb-threatening infec- to reduce the mortality, morbidity, psy- with infection. The presence of limb
tion to achieve limb salvage and sur- chological distress, and length of hospi- ischemia should be closely evaluated to
vival. Critical limb ischemia, neuropa- talization associated with life- or limb- categorize the severity of the infection
thy, and an impaired host complicate threatening diabetic foot infections. and the risk posed on limb survival. The
the treatment of a severe diabetic foot dysvascular diabetic foot increases the
infection. A severe diabetic foot infec- Keywords: diabetic foot infections; gas severity of the infection.1 The arterial
tion carries a 25% risk of major ampu- gangrene; osteomyelitis; diabetic neurop- supply to the lower extremities is
tation. For this reason, surgery should athy; diabetic foot surgery assessed and conveyed to the diabetic
be coordinated with a well-functioning

multidisciplinary team that specializes Initial Evaluation
in diabetic limb preservation. Timing
of surgery and strategies employed The initial assessment The goal of limb salvage is to
should be understood and agreed on includes a thorough history
by both the surgical and medical dis- and physical to determine
provide the patient with a limb that is
ciplines managing the diabetic patient the patients overall medical stable, mechanically sound, and
with a limb-threatening infection. The condition. The history and
overall strategy for surgically manag- physical focuses on evaluating resistant to further skin breakdown while
ing a severe diabetic foot infection is as for a systemic response to the
follows: the first step is infection con- infection by determining if resuming an ambulatory status.
trol through aggressive and extensive the patient has a fever, rigors,
surgical debridement, the second step nausea, vomiting, hypotension,
is a comprehensive vascular assess- unexplained hyperglycemia, and foot care team. The surgeon should
ment with possible vascular surgery tachycardia. Serum chemistry analysis palpate for the presence or absence of
and/or endovascular intervention, and and hematological testing are reviewed pedal, popliteal, and femoral pulses.
the final step is soft tissue and skeletal to access the metabolic state of the Clinical observation of ischemia,
reconstruction after infection is erad- patient. The psychosocial state of the necrosis, and gangrene should be noted.
icated to obtain wound closure and patient should be observed and assessed Further vascular workup consisting

DOI: 10.1177/1938640007312316. From the Department of Orthopedics/Podiatry Division and the Reconstructive Foot & Ankle Fellowship, University of Texas Health
Science Center, San Antonio, Texas (TZ); VSAS-Orthopaedics, Lehigh Valley Hospital, Allentown, Pennsylvania (JJS); and Limb Preservation Service, Department of Vascular
Surgery, Madigan Army Medical Center, Tacoma, Washington (TSR). Address for correspondence: Thomas Zgonis, DPM, FACFAS, Department of Orthopedics/Podiatry
Division and the Reconstructive Foot & Ankle Fellowship, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl DriveMSC 7776, San Antonio, TZ
78229; e-mail:

Copyright 2008 Sage Publications

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vol. 1 / no. 1 Foot & Ankle Specialist 47

plan and to perform any needed

Figure 1. revascularization early after the initial
Limb-threatening infection (A) treated with an emergent surgical proximal foot surgical debridement (Figure 1A,B).4
amputation (B). Determining the extent of tissue
involvement is paramount in deciding
if limb salvage is feasible. Ulcers are
the most frequent predisposing factor
in the development of a diabetic
foot infection.5 The presence of a
wound associated with a diabetic foot
infection should be closely examined
to determine its overall dimensions
and the degree of tissue involvement.
The surgeon should inspect, debride,
and probe the wound to determine the
presence of muscle, tendon, bone, and/
or joint involvement; sinus tracts; and
abscess. Deep tissue infections that can
be limb or life threatening may reveal
on inspection the development of
superficial bullae, petechia, ecchymosis,
fluctuance, and soft tissue crepitus.6,7
Pain on palpation in the presence of
neuropathy may indicate deep infection.7
Physical examination of the entire lower
extremity, not simply the foot, is essential
in determining the proximal extent of
the infection. Radiographs are obtained
to determine the absence or presence
of osteomyelitis, gas in the soft tissues,
and foreign body. Radiographs should
include the next proximal joint if gas is
seen or clinically suspected to ensure
that proximal migration of the infection
is not evident. Blood cultures should
be obtained on initial presentation to
evaluate for bacteremia or frank sepsis.
Wound cultures require special attention
to the technique used to obtain an
adequate specimen. Cultures taken in the
operating room allow the surgeon the
ability of obtaining deep tissue specimens
under sterile conditions. In this regard,
the culture tubes should be opened
immediately prior to obtaining the culture
of noninvasive and invasive vascular feasible or beneficial to the patient with a and not placed on the surgical field at
studies is delayed until infection is severe life- or limb-threatening infection the start of the case. Likewise, once
adequately controlled through urgent until the infection is controlled through the cultures are obtained, they should
surgical debridement. It is imperative surgical debridement.1,2 Surgery to be immediately placed into the culture
that the surgeon along with the diabetic control infection should not be delayed tubes, labeled, and sent for analysis.
foot team not delay initial surgical because of the risk for a more proximal Cultures taken in this manner provide the
intervention for a severe diabetic foot amputation.3 However, vascular surgery most reliable information to define the
infection to further evaluate the patients should be consulted as soon as possible, causative pathogens.8 Swab cultures may
vascular status. Vascular surgery and/ especially in the face of ischemia, be taken initially, but there is debate in
or endovascular intervention is not to reach consensus on the treatment regard to their usefulness.9-13

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48 Foot & Ankle Specialist February 2008

Collaboration between the medical and in emergent surgery is associated from the deep intraoperative cultures
surgical disciplines of the diabetic foot with patient mortality and morbidity.19 along with the patients clinical response
care team determines if the patient is Necrotizing fasciitis is associated with to the empirical antibiotic therapy.
medically stable for the operating room a mortality rate of 24% to 33%.19 The Consideration should also be made in
for urgent or emergent surgery to control diabetic foot team needs to appreciate choosing the safest antibiotic that is
a severe diabetic foot infection. Emphasis and foster the notion that easier most convenient to administer given that
is placed on preexisting conditions metabolic control of the patient is treatment may last for 6 weeks or longer.
such as renal insufficiency, coronary apparent after surgical control of the
artery disease, peripheral vascular infection, as infection is the cause Performing Adequate
disease, congestive heart failure, and of the metabolic disturbance.14 It is Surgical Debridement
immunosuppression in conjunction with important to proceed with surgical
readily assessable clinical and laboratory debridement as soon as possible. The Severe diabetic foot infections
findings when making this decision. Most anesthesiologist plays a critical role in require surgical intervention to control
important among these are the severity the initial management of metabolic and infections that may be life or limb
of infection based on specific tissue hemodynamic instability. For this reason, threatening to the patient. The surgeon
involvement and the presence of systemic the anesthesiologist must be informed of operating on severe diabetic foot
toxicity and/or metabolic instability. the patients condition and the necessity infections must be knowledgeable of
Categorizing the severity of the infection for surgical intervention. It should the anatomy of the foot along with
is made difficult because more than 50% go without saying, but unfortunately the pathophysiology of ulceration and
of limb-threatening infections do not is regularly ignored, that all patients infection.27 In most instances, the surgeon
manifest systemic signs or symptoms.14 presenting to the emergency room with should be experienced in the surgical
For this reason, communication between a possible diagnosis of a diabetic foot management of diabetic foot infections
the surgeon and the medical team is infection should be kept NPO (nothing to prevent failure of surgery and higher
paramount to determine the stability of by mouth) until evaluated by the surgical amputation.28 Wong et al28 have shown
the patient and the risk the infection team. Nothing is more preventable, but in a retrospective study on minor foot
poses to the patient and the limb to nothing will delay an emergent incision amputations performed for diabetic foot
establish the venue of management. and drainage more than feeding a infections that there are fewer failed
patient in the emergency room prior to surgeries when surgery was performed
Stabilizing the Patient evaluation by the surgical team. by surgeons with experience in the
An infectious disease specialist diabetic foot.
The goal of medical management dedicated to the treatment of the diabetic Surgery should usually be performed
for the patient with a severe diabetic foot may be beneficial to provide without the use of a tourniquet. The
foot infection is to support the optimal antibiotic therapy. Antibiotic surgeon should be confident operating
metabolic and hemodynamic state of selection combined with early surgical under these conditions as it is needed
the patient.15,16 In severe diabetic foot debridement is imperative in controlling to determine tissue viability. During
infections, considerable metabolic severe infection and stabilizing the surgery, it is important to begin with a
decompensation may occur. This patient. Antibiotic treatment started detailed wound exploration that includes
may necessitate intravenous fluids initially is empirical and based on history, the removal of all sloughed skin and
with electrolytes and tight sliding- clinical appearance, and odor along the opening of sinus tracts to establish
scale insulin coverage to correct for with antibiotic susceptibility results to the tissue planes and the compartments
hyperglycemia, hyperosmolality, anticipated organisms at that hospital. of the foot that are violated. The
azotemia, and acidosis.17 Measures need For severe diabetic foot infections, initial finger test is a clinical test performed
to be taken by the medicine team to antibiotic therapy should commence with intraoperatively to determine the extent
protect against a cardiovascular event parenteral broad-spectrum antibiotics of violated tissue planes. The tissue
and further renal insufficiency. Critically that have activity against gram-positive planes, particularly the subcutaneous
ill patients who require surgery for a cocci as well as gram-negative and tissue off the deep fascia, should not be
life- or limb-threatening infection should obligate anaerobic organisms.21-24 In easily separated with a gentle forward
be transferred to the operating room addition, agents with activity against pushing of the index finger along the
after being stabilized.14,17,18 However, methicillin-resistant Staphylococcus anatomic tissue planes. A positive finding
surgery should not be delayed for more aureus (MRSA) should be considered indicates possible necrotizing fasciitis.19
than 48 hours after presentation to for patients at risk for MRSA infection, The surgeon can now determine
the hospital.14,17,18 Conditions such as given its association with poor clinical the portion of the foot that needs to
gas gangrene and necrotizing fasciitis outcomes.25,26 Definitive antibiotic therapy be amputated or widely excised to
are surgical emergencies.19,20 A delay is based on culture and sensitivity results adequately control the infection. This

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vol. 1 / no. 1 Foot & Ankle Specialist 49

may include open ray resections or a (Figure 2). Soon after the initial surgical and stenosis in the iliac and superficial
proximal pedal amputation if needed. debridement is when noninvasive and femoral artery, whereas atherectomy
Limited incisions and drains should be invasive vascular studies are performed. can be used at these levels as well as
avoided because infected tissue is left For a patient with a severely infected below the knee and below the ankle.39
behind despite decompression of the dysvascular foot, it is preferable to Peripheral arterial bypass has been
infected area. All nonviable and infected perform revascularization within 1 shown to be a beneficial procedure for
soft tissue and bone, regardless of size to 2 days after the initial surgical salvage of the ischemic diabetic limb with
and quantity, needs to be excised during debridement.18,31 Determining the need considerable tissue loss.40,41 Peripheral
the initial debridement to enable wound for revascularization begins with the bypass is usually needed to treat long
healing.29-32 Removal of exposed tendons intraoperative assessment of arterial arterial occlusions not amenable to
should be excised to prevent further perfusion to the tissues after adequate angioplasty.1,40,42 Reperfusion is essential
tracking of the infection. A portion of the debridement. Noninvasive vascular before soft tissue reconstruction can
deep infected tissues should be sent to studies that include the ankle brachial take place. If revascularization is not
microbiology for culture and sensitivity. index, toe brachial index, pulse volume successful and limb ischemia permits,
Infected soft tissue and bone should recordings, and transcutaneous oxygen then a proximal amputation should be
not be left behind with the belief that pressures are performed initially to performed.
compromised tissues will eventually determine the need for invasive vascular
appear healthy. Surgical debridement and studies. The Ankle Brachial Index Soft Tissue Reconstruction
excision of nonviable tissue has been (ABI) is a screening test for peripheral
associated with a decreased vascular disease and may not be very Obtaining long-lasting wound closure
healing time.29,30 useful in the diabetic patient because it after radical surgical debridement to
After adequate surgical debridement, underestimates the severity of arterial control infection is one of the most
the wound is then irrigated with copious insufficiency.34 The ABI is affected by challenging aspects in the surgical
amounts of saline to reduce the number incompressible calcified vessels, which management of the diabetic foot.
of bacteria present in the wound. are common in the diabetic population. Extensive soft tissue loss is usually
Irrigation can be carried out with a This leads to falsely elevated values.34 present. The goal is to create a
pulse lavage using 3 liters or more of Despite the shortcomings associated functional limb that is resistant to further
saline. Saline irrigation has been shown with the ABI, a decreased value is still breakdown and higher amputation.
to significantly decrease aerobic and clinically significant because it represents Limb preservation is paramount in
anaerobic bacterial counts compared both decreased peripheral vascular flow preventing the morbidity and mortality
with untreated controls.33 It is not to the foot and an increased incidence associated with higher amputations.43-45
known whether adding antibiotics to the of coronary artery disease, which should However, soft tissue reconstruction
irrigation is beneficial in the management prompt further evaluation and treatment. can only take place when infection is
of severe diabetic foot infections. After Qualitative waveforms and the toe eradicated, nonviable soft tissue and
wound irrigation is performed, the brachial pressure index have been shown bone are completely excised, and
surgeons change their outer pair of to be more efficacious in screening for arterial perfusion is sufficient. Numerous
gloves to reduce contamination. The arterial insufficiency in high-risk limbs techniques are used to obtain wound
open wound is then packed with a moist among the diabetic population when closure in the diabetic foot, and the
dressing followed by a dry dressing. compared with the ABI.35 Transcutaneous procedure chosen must be tailored to
The goal is to maintain a moist wound- oxygen pressure measurements(TCPo2) each patient and circumstance to obtain
healing environment. Dressings usually may be useful in predicting the wound- soft tissue coverage that is durable and
are changed daily, beginning 24 to healing capability.36-38 The wound is mechanically sound. The simplest and
48 hours after the initial debridement. expected to heal if values are greater least invasive modalities should be
Repeat debridement should be performed than 30 mm Hg.36-38 Noninvasive used first when feasible. The surgeon
as needed to control infection as well vascular studies in conjunction with the first has to decide if primary wound
as the use of negative pressure therapy extremitys clinical appearance depict the closure with minimal tension is possible
to control tissue edema and help in the need for further vascular intervention. after revision debridement or limited
wound bed preparation. Angioplasty, various forms of stenting, pedal amputation. Wounds that are not
and endovascular atherectomy are suitable for primary closure, particularly
Vascular Intervention valuable means of minimally invasive those with continued drainage or
forms of revascularization that can be extensive soft tissue loss, are usually
Most patients with life- or limb- followed, if unsuccessful, by distal arterial managed with wet to dry dressings
threatening diabetic foot infections bypass.1,39 Angioplasty with or without in tandem with negative pressure
will need to be considered for stent placement is usually successful in therapy to facilitate granulation tissue.
revascularization to achieve limb salvage the treatment of short arterial occlusions In many complex wounds, plastic and

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50 Foot & Ankle Specialist February 2008

Pedicle flaps around the foot and

Figure 2. ankle require surgical dissection often
with loupe magnification to isolate
A clinical picture of an infected dysvascular diabetic foot that needed an emergent
the neurovascular bundle supplying
surgical and vascular intervention.
the tissue intended for transfer. Source
vessels or septofasciocutaneuos vessels
have to be identified and separated to
allow successful mobilization of the
pedicle flap. The medial plantar artery
flap and the sural artery flap are the
pedicle flaps most commonly used to
salvage midfoot and hindfoot soft tissue
defects, respectively. Complication rates
can be high for pedicle flaps in patients
with diabetes.61 Venous congestion
with subsequent flap necrosis is the
most common complication associated
with pedicle flaps around the foot and
ankle.61 Techniques can be employed
to reduce the high complication rates
associated with pedicle flaps such as the
utilization of external fixation to offload
and immobilize the flap.61 Preserving
the perivascular anastomosis around
the vascular pedicle by maintaining the
surrounding adipose tissue can decrease
the likelihood of venous congestion.
Sural artery flaps that are delayed and
fashioned with a cutaneous tail have
been shown to be more reliable and
have less risk of developing venous
reconstructive surgical techniques are that enter the flap from either its base congestion.62-64 Despite the potential for
later used to achieve wound closure. (transposition and rotation flaps) or complications, pedicle flaps have been
These include split thickness skin undersurface (advancement flaps).50 shown to be useful to obtain soft tissue
grafting, local flaps, muscle flaps, V-Y advancement flaps are reliable for coverage in the diabetic patient.64-68
pedicle flaps, and/or musculotendinous soft tissue coverage to the plantar aspect Large cleft defects after central ray
balancing. Split thickness skin grafts of the foot and are relatively easy to resections may be difficult to close
after appropriate wound bed preparation mobilize.48 primarily or with flap closure secondary
are useful to obtain closure of large non- Muscle flaps are useful to obtain to the size of the defect, location of
weight-bearing soft tissue defects (Figure adequate vascularized coverage over the defect, and/or wound contraction.
3A,B).46 Local flaps are often used for exposed bone. The abductor hallucis, External fixation devices can reduce the
wound coverage on the weight-bearing abductor digiti minimi, flexor digitorum size of large cleft wounds to facilitate
plantar aspect of the foot.47-51 brevis, and the extensor digitorum brevis long-lasting wound closure and a more
Local flaps comprise a segment of are the most common muscle flaps used functional limb.69,70 External fixation
skin and underlying tissues raised in the foot.55-58 These muscle flaps are to achieve reduction of the remaining
adjacent to the wound and rotated, classified as type 2, with 1 dominant intermetatarsal space can be combined
advanced, or transposed to provide pedicle at the origin and several minor with either delayed primary closure or
wound coverage.49,50 The surgeon perforators throughout the muscle split thickness skin grafting to obtain
has to appreciate the angiosomes belly.55-58 Isolated muscle flaps provide an long-lasting wound closure.
of the foot along with location and excellent vascular base for the application
size of the soft tissue defect when of a split thickness skin graft.59,60 Using Discussion
choosing the appropriate local flap a muscle flap in conjunction with a
for soft tissue coverage.52-54 All local split thickness skin graft avoids the A stepwise approach to the surgical
flaps obtain their vascular supply from large donor defect associated with a management of life- or limb-threatening
septofasciocutaneous perforating vessels musculocutaneous flap. diabetic foot infections is essential

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vol. 1 / no. 1 Foot & Ankle Specialist 51

management of diabetes to prevent

Figure 3. future problems.
An open partial first ray amputation after a severe diabetic foot infection (A) followed
by a delayed closure with a split thickness skin grafting technique (B).
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