WOUND MANAGEMENT

Diabetic foot and foot

debridement technique

with diabetic foot sepsis. In addition the neutrophil count and

C-reactive protein may be normal, even in the face of life threatening sepsis, and derangement of capillary blood glucose should
be assessed as the most sensitive marker of foot sepsis. It is
essential to achieve metabolic and haemodynamic stability in
septic patients with administration of IV fluids, parenteral antibiotics and correction of electrolyte imbalance, acidosis and hyperglycaemia. Chronic anaemia could complicate intraoperative
blood loss and may require preoperative blood transfusions.
Delay to surgery could increase morbidity and mortality.
Appropriate antibiotic selection is imperative and consultation
with an infectious disease specialist or microbiologist in conjunction with surgical intervention is essential.
It is vital that there is good communication between the surgical and medical teams in planning whether the patient requires
immediate or delayed surgical intervention. In some patients
diabetic foot infection is the first presentation of diabetes and
they will require diabetology input into the initial blood glucose
control and ongoing diabetes management.
A thorough vascular examination is required to determine
arterial insufficiency. A detailed history should be taken to assess
for intermittent claudication, rest pain and previous arterial
surgery. Peripheral pulses should be examined and ankle
brachial index pressure (ABPI) or toe brachial pressure index
(TBPI) should be measured. In an ischaemic limb the severity of
infection and the risk of subsequent limb loss increases, and
therefore early arterial imaging to plan revascularization should
be considered. However in the presence of severe infection the
priority is infection control.

Soroush Sohrabi
David Russell

Abstract
Surgical foot debridement is widely practised in diabetic foot care.
Although minor debridement could be done at the bedside with or
without local anaesthesia, more extensive debridement would require
regional or general anaesthesia in operating theatres. Delayed surgery
could increase the risk of limb loss and mortality. The International Working Group of the Diabetic Foot (IWGDF) or the Infectious Diseases Society
of America classifications could be used to assist management of the diabetic foot sepsis. A detailed knowledge of the anatomy of the foot is
required to achieve the best outcome. Complications of diabetes and
any amputation further disrupts the biomechanics of the diabetic foot
and increases the risk of transfer ulceration. Foot biomechanics should
be considered while debridement and reconstructive techniques
employed, although adequate debridement shouldnt be compromised.

Keywords Debridement technique; diabetic foot; foot biomechanics;

foot sepsis

Introduction
Debridement is the removal of devitalized, contaminated or
foreign material from within or adjacent to a wound, until surrounding healthy tissue is exposed. Foot debridement, which is
widely practised in diabetic foot care, may consist of removal of
skin, soft tissue, tendon and bone, which could include digit or
ray amputations.
The ultimate goal of debridement is to remove pathogens and
devitalized tissue, which can serve as a reservoir for potential
pathogens.
Minor debridement can be done as a clinic/bedside procedure
without the use of local anaesthesia. However local, regional or
general anaesthesic techniques are necessary for sensate patients
or those requiring more extensive debridement. In more extensive infections, serial debridement may be necessary to achieve a
healthy wound bed.1
Pre-existing conditions such as congestive cardiac failure,
coronary heart disease, obesity, peripheral neuropathy, peripheral
vascular disease and renal insufficiency, along with nutritional
status, should all be evaluated at the time of examination. In
addition, evaluation of clinical and laboratory findings is paramount in determining risk stratification and timing of surgery.
Many diabetic patients do not have a sufficient immune
response to manifest systemic signs and symptoms of infection

Wound assessment
An understanding of the anatomy of the foot is fundamental to
accurately assess the extent of the soft tissue and bone involvement. This will guide further surgical planning on the site of
incision and potential amputations. Physical examination should
include the entire limb rather than just the foot. Diabetic patients
commonly have a history of pre-existing neuropathic or neuroischaemic ulceration. Ulcers may be masked by hyperkeratotic
skin or calluses or hidden within the inter-digital web spaces.
Therefore any hyperkeratotic skin should be sharply debrided
and elevated to evaluate the underlying tissue and the web
spaces carefully examined. The wound should be assessed for its
size, depth, margins, and potential involvement of the deeper
structures such as tendon, joint capsule and bone, including a
probe-to-bone test. Pain on palpation, especially in the presence
of neuropathy, could indicate a deep collection. X-rays can be
helpful in identifying evidence of osteomyelitis, gas in the soft
tissue, fractures and foreign bodies. Further imaging modalities
such as CT scan and MRI may be required to assess the extent of
infection and plan surgical drainage.

Timing
The timing of debridement in diabetic foot infection is influenced
by both the severity of infection and the degree of ischaemia. In
diabetic foot ulceration it is not uncommon for tissue necrosis
and infection to coincide and as consequence rapidly progress
along the tendons and fascial planes. Tissue debridement and
drainage in these cases should be regarded as a medical/surgical

Soroush Sohrabi MD PhD MRCS is a Specialist Registrar in Vascular

Surgery at Hull Royal Infirmary, Hull, UK. Conflict of interest: none.
David Russell MB ChB MD PG Dip Clin Ed FRCS(Gen.Surg) is a Consultant
Vascular Surgeon and Honorary Senior Lecturer, Leeds Vascular
Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK.

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emergency. By contrast superficial tissue infection (cellulitis)

arising from an ulcer or necrotic digit might be best managed
with intravenous antibiotics until urgent revascularization has
been performed to give the debrided wound bed the optimal
chance for healing.
Box 1 summarizes indicators of potentially immediate or longterm limb-threatening tissue damage and/or infection. Persistent
foot pain and tenderness on examination could be a sign of deepspace infection even in the absence of high temperature and
leucocytosis.
The most common site for a severe foot infection is the plantar
surface. A plantar wound accompanied by dorsal erythema or
fluctuance suggests that the infection has passed through fascial
compartments and is likely to require surgical drainage. The
development of an abscess in the foot especially in the presence
of ischaemia, can rapidly lead to irreparable tissue damage.1
Although a trial of conservative medical management and
delaying surgery may be appropriate in an early and evolving
infection, urgent debridement could prevent progression of a
deep plantar space infection.
Several factors are responsible for rapid deterioration of an
infected diabetic foot. Oedema as a consequence of infection and
cellulitis can result in compartment syndrome. Microvascular
circulation is impaired and the compartment pressure exceeds
the hydrostatic pressure in the compartment. As diabetics have
raised compartment pressures due to increased in the concentration of sorbitol molecules and their split products, rapid
deterioration can occur with minor tissue oedema and infection.
Furthermore, the greater affinity of glycated haemoglobin (haemoglobin A1c) to oxygen compared to normal haemoglobin may

reduce tissue oxygenation. The end result would be thrombosis

of the small arteries and veins even in a well-vascularized tissue.
Therefore emergency surgery is of paramount importance to
decompress and drain the involved compartment. If soft tissue
infection is accompanied by osteomyelitis of one or more metatarsal bones, a ray amputation may be needed, although osteomyelitis alone is not an indication for surgical intervention. It is
extremely important that urgent surgical debridement, if required
for sepsis control, should not be delayed for diagnostic tests or
revascularization procedures.2
Patients may be classified according to the International
Working Group of the Diabetic Foot (IWGDF) or the Infectious
Diseases Society of America (Table 1).
PEDIS 2 patients can often be treated with oral antibiotics and
offloading in an outpatient setting. Most of the minor debridement could be done in an outpatient setting. However presence
of any of the criteria in Box 2 could necessitate hospitalization.
PEDIS 4 patients would require immediate surgical intervention
and debridement. Arterial insufficiency should be assessed and
revascularization should be performed soon after sepsis control if
necessary.
In PEDIS 3 patients it could be difficult to decide whether the
patient requires surgical debridement or not. While many diabetic foot infections are considered superficial because they do
not extend beneath the superficial fascia, the infection will not
uncommonly penetrate more deeply into underlying soft tissue
and create a deep-space abscess. In such cases, surgical intervention is mandated to evacuate the abscess, remove necrotic
tissue, and minimize the risk of further spread. Therefore it is
advisable that the treating physicians should have a low
threshold for hospitalization and aggressive surgical and medical
treatment in patients in PEDIS 3 group.3 MRI imaging may be
useful in guiding management in this group.

Indicators of immediate or long-term limb-threatening

tissue damage/infection

Technical considerations

Infection
C
Evidence of systemic inflammatory response
C
Worsening metabolic control
C
Rapid progression of infection
C
Spreading cellulitis or lymphangitis
C
Extensive ecchymoses or petechiae
C
Bullae, especially haemorrhagic
C
Failure of infection to respond to appropriate therapy

Grodisnky (1929) identified three major plantar spaces in the

foot; medial, central (superficial and deep) and lateral spaces
(Figures 1 and 2). He recommended a medial surgical approach
due to potential discomfort of a plantar incision. However Loeffler and Ballard demonstrated that with a plantar-based incision
and careful tissue dissection and handling, a plantar incision can
drain infection without a sensitive scar.4 The original description
was of a plantar based incision starting posterior to the medial
malleolus, extend distally and laterally toward the midline, and
ending between the heads of the first and second metatarsals.
Understanding the anatomy of the fascial compartments in
diabetic foot infections is essential. This will help the clinician to
understand how infections of the first toe spread through the
medial compartment. The infections of the second, third, and
fourth toe spread through the central compartment and the infections of the fifth toe spread through the lateral compartment.
In most units a distal approach is adopted for PEDIS 4
wounds. In this approach, the starting point of the incision is the
most distal area of infection or ulceration and it is extended
proximally. The incision is continued until healthy and viable
tissue is observed, extending posterior to the medial malleolus
(in the line of the flexor tendons) and into the calf if necessary.
This approach eliminates the need for unnecessarily long

Neurological
C
Recent or progressive acute loss of neurological function
C
Onset of wound anaesthesia
C
Pain out of proportion to clinical findings
Perfusion
C
Extensive necrosis or gangrene
C
Critical limb ischaemia
Tissue
C
Extensive soft tissue loss
C
Especially loss of weight-bearing plantar skin
C
Bony destruction especially if involves mid or hind foot
C
Pre-existing significant structural abnormalities within the foot
including Charcot
Box 1

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Diabetic foot infection classification schemes

Clinical manifestation

Infectious Diseases
Society of America

(PEDIS grade) International

Working Group on the
Diabetic Foot

Wound without pus or any clinical presentation of inflammation

There is no local complication or systemic illness, however there are equal or more than two
presentations of inflammation (pus, erythema, pain, tenderness, warmth, or swelling); any
cellulitis or erythema that extends less than 2 cm around ulcer, and infection is limited to skin
or superficial tissues
A patient who is systemically well, but has more than one of the following; cellulitis larger
than 2 cm, lymphangitis, extending beneath the fascia, deep tissue collection, gangrene or
any muscle, tendon, joint or bone involvement
Toxic or metabolically unstable patients

Uninfected
Mild

1
2

Moderate

Severe

Table 1

incisions that could pose future problems, particularly in a patient with vascular insufficiency. The wound should thoroughly
be explored and all necrotic and infected issue should be
removed. All sinuses should be opened to assess if any additional
foot compartments have been affected. The deep fascial tissue
should not be easily separated by pushing a finger along tissue
planes. All of the necrotic and devitalized tissue should be
removed regardless of the size and quantity, preserving all
healthy tissue for future reconstructive strategies (Figure 3).
Regular use of a tourniquet is not encouraged as it could
prevent identifying viable tissue through bleeding and lead to
over-debridement. However, it should be kept in mind that
bleeding is not always a reliable indicator of viable subcutaneous
tissue as it has a decreased concentration of the blood vessels
compared to the skin, and tissue appearance may be more useful.
The basic tools for debridement include forceps, blades,
scissors, curettes, and rongeurs.
Toothed forceps have a better grasp with reduced tissue
trauma. A number 15 blade is used for dissection around bone,
while a number 10 or 20 blade is used on soft tissue to slice thin
layer after thin layer until healthy tissue is reached.5
Curettes with sharp edges are very useful in removing the
proteinaceous coagulum accumulation; which contains proteases
and bacteria that inhibit healing. Rongeurs are useful for removing

hard-to-reach indurated soft tissue and for debriding bone. Electrical saw is useful for sawing off bone slices until normal cortex
and marrow is reached and reduces the risk of bone fragmentation
and residual bone spikes at resection margins.
A callus is a non-viable hyperkeratotic tissue, which could
cover an infected area in the foot. Furthermore it could create
unbalanced pressure onto the soft tissue in the foot resulting in
further ulceration. The callus should be debrided and adjacent
soft tissue be assessed.
Non-blanching, insensate and blistered skin should be debrided. Inadequate skin debridement could result in liquefaction
necrosis in which dead skin separates from the underlying
healthy tissue and may lead to functional loss, scarring, deeper
tissue damage, and disseminated infection. If non-viable skin is

The plantar surface of the foot

Factors suggesting hospitalization of a patient with

diabetic foot may be necessary
C
C
C
C
C
C
C
C

Severe infection
Metabolic instability
Intravenous therapy necessary
Inpatient diagnostic tests required
Critical foot ischaemia
Inpatient surgical procedures are necessary
Failure of outpatient management
Inability or unwillingness of the patient to comply with outpatient
treatments
Complex dressing changes are required
Figure 1 (1) Lateral compartment; (2) central compartment; (3) medial
compartment.

Box 2

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Transverse section of the foot

2
4

Figure 2 (1) Lateral compartment; (2) central deep compartment; (3)

central superficial compartments; (4) medial compartment.

demarcated, incision would be at the border of demarcation. If

there is no demarcation, the incision starts at the centre of the
wound and progressed until viable bleeding skin is reached.
Thrombosed venules in the skin are a sign of interrupted
microcirculation and mandate further debridement.
Non-viable fascia with a soft and stringy appearance should
be debrided. Healthy viable fascia has a white, glistening and
hard appearance.
Viable healthy muscle has a bright red and shiny appearance
and contracts with diathermy or when grasped with forceps. Nonviable muscle should be debrided. Exposed tendons could act as a
pathway for spreading infection and should always be debrided.
Infected tendons have a dull, soft and grainy appearance.
However over-debridement of the tendons could result in loss
of functional anatomy of the foot and increase the risk of future
ulceration due in imbalanced pressure areas. Minimum
debridement of large tendons such as Achilles and tibialis anterior tendon is encouraged. Leaving the hard, shiny tendon, if it is
healthy, provides reconstruction options for the future.
Healthy subcutaneous fat has a shiny yellow colour compared
to grey, hard and non-elastic non-viable tissue. Undermining
could affect the blood supply and should be avoided. Excessive
diathermy could cause tissue damage and create nidus for bacterial proliferation. If sutures were used, absorbable monofilament would be preferable to minimize facilitation of further
infection. If nerves are sacrificed, it should be cut under tension
to allow retraction back into the tissue to minimize neuroma
formation. If they are to be preserved, it should be covered with
adequate tissue to keep them moist. Neuroma formation can be
prevented by burying it in underlying tissue (muscle or bone) or
by sowing the epineurium over the nerve fascicles with fine
monofilament suture.5
Non-viable/infected bone is soft, does not bleed at the cortex
and is discoloured. Damage to the healthy bone should be
avoided when cutting the dead bone segments. Sending infected
bone segments for culture and sensitivity is essential in the
treatment of osteomyelitis.
The sesamoid bones are to be removed in plantar foot ulceration if exposed by debridement.
Following debridement, wound irrigation helps reduce the
bacterial count and removal of free tissue from the wound.
Although saline irrigation will be effective many centres use

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Figure 3 Patient presenting with plantar space collection (a) and dorsal
lateral forefoot cellulitis (b), and appearance 5 days following Loeffler
Ballard incision with debridement, fourth toe amputation and VAC (c and
d).

antibacterial solutions. Hydrogen peroxide has been found to be

a useful irrigation solution by some. Clean tissue and bone
should be sent for microbiology, and bone for histology, to guide
ongoing antibiotic therapy.1
Depending of the extent of the debrided area and the severity
of the infection, primary, secondary or tertiary wound closure
techniques could be applied. Topical negative pressure therapy
has gained popularity in recent years. Skin grafts, dermal substitutes, musculo-tendinous flaps could are techniques to achieve
wound closure.

Biomechanical considerations
The foot is a versatile organ which is malleable enough to adapt
to uneven surfaces yet able to act as a rigid lever for toe off. It is
able to do this through interactions between the subtalar and
midtarsal joints which allow three planes of movement, culminating in supination and pronation of the foot. During heel strike
the foot is supinated, as pressure is placed on the lateral aspect of

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the heel with the leg outstretched. In the supinated position the
foot is flexible. As the weight of the body moves over the foot in
stance phase of the gait cycle, weight is transferred from the
lateral heel across to the first metatarsal as the foot moves into
pronation. In the pronated position the foot is a rigid lever and
weight is passed down the first metatarsal and onto the hallux
during toe off.
Complications of diabetes alter the biomechanics of the foot.
Motor neuropathy causes wasting of the intrinsic muscles of the
foot, leading to claw toes and retrograde posterior plantar
movement of the metatarsal heads due to unopposed long
extensor tendon action. Reduced joint movement and Achilles
tendon contracture due to glycosylation exacerbate this.
Destruction of the bony architecture of the mid-foot secondary to
Charcot neuroarthropathy leads to the classic rocker-bottom foot.
All of these changes cause focal areas of peak pressures in excess
of 1000 kPa. This repetitive pressure insult, combined with shear
forces, leads to tissue breakdown and ulceration.
Any minor amputation further disrupts the biomechanics of
the diabetic foot and increases the risk of further transfer ulceration. Such changes must be considered in the choice of
debridement and reconstructive techniques employed, although
adequate debridement shouldnt be compromised.
Hallux and first ray amputations increase the pressure placed
on the second and third metatarsal heads and shafts. Transfer
ulceration leading to further amputation occurs in over 70% of
patients and stress fractures are also seen. Risk can be minimized
by maintaining the proximal 1 cm of proximal phalaynx, which
maintains the Windlass mechanism and therefore preserves the
medial longitudinal arch. Lesser digit amputation has less affect
on biomechanics but does lead to lateral drift of the medial toes.
Preservation of a stump of second toe will buttress the hallux and
prevent secondary hallux valgus deformity.
The first and fifth metatarsals have independent axes of
rotation to the central three metatarsals (which act as a functional unit). Loss of two central rays, with or without an adjacent
outer ray, will lead to loss of stability of the forefoot, high
pressures on the residual metatarsal heads and is an indication
for transmetatarsal amputation to minimize risk of future ulceration. When performing a transmetatarsal amputation, maximizing length preserves best function. The bone ends should be

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cut in tri-planar fashion such that the dorsal edge is longer than
the plantar edge (all rays), and lateral edge longer than medial
edge (first and second rays) or medial edge longer than lateral
edge (fourth and fifth rays). Effort should be made to preserve
the natural metatarsal parabola where possible. Loss of long
extensor function with transmetatarsal amputation causes equinovarus deformity and plantar ulceration over the end of the
residual fifth metatarsal in up to 50%. This can be reduced by
synchronous percutaneous achilles tendon lengthening.
The insertions of tibialis anterior into the base of the first
metatarsal and peroneus brevis into the base of the fifth metatarsal need to be preserved. If these bones need to be resected
fully then the tendons should be transferred, usually a secondary
procedure when sepsis control has been achieved.

Conclusion
Foot debridement is an essential part of diabetic foot care. In the
presence of sepsis emergency debridement prior to revascularization could prevent progression of the infection and potential
limb loss or life endangering sepsis. Multidisciplinary teams
involving vascular surgery, plastic surgery, orthopaedics, diabetology and orthotics are an integral part of maintaining a
functional foot after debridement.
A
REFERENCES
1 Lipsky BA, Berendt AR, Cornia PB, et al. Infectious Diseases Society of
America clinical practice guideline for the diagnosis and treatment of
diabetic foot infections. Clin Infect Dis 2012; 54: 1679e84.
2 van Baal JG. Surgical treatment of the infected diabetic foot. Clin Infect
Dis 2004; 39: S123e8.
3 Fisher TK, Scimeca CL, Bharara M, Mills JL, Armstrong DG. A step-wise
approach for surgical management of diabetic foot infections. J Vasc
Surg 2010; 52: 72Se5.
4 Loeffler Jr RD, Ballard A. Plantar fascial spaces of the foot and a
proposed surgical approach. Foot Ankle 1980 Jul; 1: 11e4.
5 Attinger CE, Janis JE, Steinberg J, Schwartz J, Al-Attar A, Couch KA.
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