46 Foot & Ankle Specialist February 2008

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

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

Copyright 2008 Sage Publications

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vol. 1 / no. 1
Figure 1.
Limb-threatening infection (A) treated with an emergent surgical proximal foot
amputation (B).
of noninvasive and invasive vascular
studies is delayed until infection is
adequately controlled through urgent
surgical debridement. It is imperative
that the surgeon along with the diabetic
foot team not delay initial surgical
intervention for a severe diabetic foot
infection to further evaluate the patients
vascular status. Vascular surgery and/
or endovascular intervention is not
feasible or beneficial to the patient with a
severe life- or limb-threatening infection
until the infection is controlled through
surgical debridement.1,2 Surgery to
control infection should not be delayed
because of the risk for a more proximal
amputation.3 However, vascular surgery
should be consulted as soon as possible,
especially in the face of ischemia,
to reach consensus on the treatment
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Foot & Ankle Specialist 47
plan and to perform any needed
revascularization early after the initial
surgical debridement (Figure 1A,B).4
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
and not placed on the surgical field at
the start of the case. Likewise, once
the cultures are obtained, they should
be immediately placed into the culture
tubes, labeled, and sent for analysis.
Cultures taken in this manner provide the
most reliable information to define the
causative pathogens.8 Swab cultures may
be taken initially, but there is debate in
regard to their usefulness.9-13
48 Foot & Ankle Specialist
Collaboration between the medical and
surgical disciplines of the diabetic foot
care team determines if the patient is
medically stable for the operating room
for urgent or emergent surgery to control
a severe diabetic foot infection. Emphasis
is placed on preexisting conditions
such as renal insufficiency, coronary
artery disease, peripheral vascular
disease, congestive heart failure, and
immunosuppression in conjunction with
readily assessable clinical and laboratory
findings when making this decision. Most
important among these are the severity
of infection based on specific tissue
involvement and the presence of systemic
toxicity and/or metabolic instability.
Categorizing the severity of the infection
is made difficult because more than 50%
of limb-threatening infections do not
manifest systemic signs or symptoms.14
For this reason, communication between
the surgeon and the medical team is
paramount to determine the stability of
the patient and the risk the infection
poses to the patient and the limb to
establish the venue of management.
Stabilizing the Patient
The goal of medical management
for the patient with a severe diabetic
foot infection is to support the
metabolic and hemodynamic state of
the patient.15,16 In severe diabetic foot
infections, considerable metabolic
decompensation may occur. This
may necessitate intravenous fluids
with electrolytes and tight sliding-
scale insulin coverage to correct for
hyperglycemia, hyperosmolality,
azotemia, and acidosis.17 Measures need
to be taken by the medicine team to
protect against a cardiovascular event
and further renal insufficiency. Critically
ill patients who require surgery for a
life- or limb-threatening infection should
be transferred to the operating room
after being stabilized.14,17,18 However,
surgery should not be delayed for more
than 48 hours after presentation to
the hospital.14,17,18 Conditions such as
gas gangrene and necrotizing fasciitis
are surgical emergencies.19,20 A delay
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in emergent surgery is associated
with patient mortality and morbidity.19
Necrotizing fasciitis is associated with
a mortality rate of 24% to 33%.19 The
diabetic foot team needs to appreciate
and foster the notion that easier
metabolic control of the patient is
apparent after surgical control of the
infection, as infection is the cause
of the metabolic disturbance.14 It is
important to proceed with surgical
debridement as soon as possible. The
anesthesiologist plays a critical role in
the initial management of metabolic and
hemodynamic instability. For this reason,
the anesthesiologist must be informed of
the patients condition and the necessity
for surgical intervention. It should
go without saying, but unfortunately
is regularly ignored, that all patients
presenting to the emergency room with
a possible diagnosis of a diabetic foot
infection should be kept NPO (nothing
by mouth) until evaluated by the surgical
team. Nothing is more preventable, but
nothing will delay an emergent incision
and drainage more than feeding a
patient in the emergency room prior to
evaluation by the surgical team.
An infectious disease specialist
dedicated to the treatment of the diabetic
foot may be beneficial to provide
optimal antibiotic therapy. Antibiotic
selection combined with early surgical
debridement is imperative in controlling
severe infection and stabilizing the
patient. Antibiotic treatment started
initially is empirical and based on history,
clinical appearance, and odor along
with antibiotic susceptibility results to
anticipated organisms at that hospital.
For severe diabetic foot infections, initial
antibiotic therapy should commence with
parenteral broad-spectrum antibiotics
that have activity against gram-positive
cocci as well as gram-negative and
obligate anaerobic organisms.21-24 In
addition, agents with activity against
methicillin-resistant Staphylococcus
aureus (MRSA) should be considered
for patients at risk for MRSA infection,
given its association with poor clinical
outcomes.25,26 Definitive antibiotic therapy
is based on culture and sensitivity results
February 2008
from the deep intraoperative cultures
along with the patients clinical response
to the empirical antibiotic therapy.
Consideration should also be made in
choosing the safest antibiotic that is
most convenient to administer given that
treatment may last for 6 weeks or longer.
Performing Adequate
Surgical Debridement
Severe diabetic foot infections
require surgical intervention to control
infections that may be life or limb
threatening to the patient. The surgeon
operating on severe diabetic foot
infections must be knowledgeable of
the anatomy of the foot along with
the pathophysiology of ulceration and
infection.27 In most instances, the surgeon
should be experienced in the surgical
management of diabetic foot infections
to prevent failure of surgery and higher
amputation.28 Wong et al28 have shown
in a retrospective study on minor foot
amputations performed for diabetic foot
infections that there are fewer failed
surgeries when surgery was performed
by surgeons with experience in the
diabetic foot.
Surgery should usually be performed
without the use of a tourniquet. The
surgeon should be confident operating
under these conditions as it is needed
to determine tissue viability. During
surgery, it is important to begin with a
detailed wound exploration that includes
the removal of all sloughed skin and
the opening of sinus tracts to establish
the tissue planes and the compartments
of the foot that are violated. The
finger test is a clinical test performed
intraoperatively to determine the extent
of violated tissue planes. The tissue
planes, particularly the subcutaneous
tissue off the deep fascia, should not be
easily separated with a gentle forward
pushing of the index finger along the
anatomic tissue planes. A positive finding
indicates possible necrotizing fasciitis.19
The surgeon can now determine
the portion of the foot that needs to
be amputated or widely excised to
adequately control the infection. This
vol. 1 / no. 1
may include open ray resections or a
proximal pedal amputation if needed.
Limited incisions and drains should be
avoided because infected tissue is left
behind despite decompression of the
infected area. All nonviable and infected
soft tissue and bone, regardless of size
and quantity, needs to be excised during
the initial debridement to enable wound
healing.29-32 Removal of exposed tendons
should be excised to prevent further
tracking of the infection. A portion of the
deep infected tissues should be sent to
microbiology for culture and sensitivity.
Infected soft tissue and bone should
not be left behind with the belief that
compromised tissues will eventually
appear healthy. Surgical debridement and
excision of nonviable tissue has been
associated with a decreased
healing time.29,30
After adequate surgical debridement,
the wound is then irrigated with copious
amounts of saline to reduce the number
of bacteria present in the wound.
Irrigation can be carried out with a
pulse lavage using 3 liters or more of
saline. Saline irrigation has been shown
to significantly decrease aerobic and
anaerobic bacterial counts compared
with untreated controls.33 It is not
known whether adding antibiotics to the
irrigation is beneficial in the management
of severe diabetic foot infections. After
wound irrigation is performed, the
surgeons change their outer pair of
gloves to reduce contamination. The
open wound is then packed with a moist
dressing followed by a dry dressing.
The goal is to maintain a moist wound-
healing environment. Dressings usually
are changed daily, beginning 24 to
48 hours after the initial debridement.
Repeat debridement should be performed
as needed to control infection as well
as the use of negative pressure therapy
to control tissue edema and help in the
wound bed preparation.
Vascular Intervention
Most patients with life- or limb-
threatening diabetic foot infections
will need to be considered for
revascularization to achieve limb salvage
(Figure 2). Soon after the initial surgical
debridement is when noninvasive and
invasive vascular studies are performed.
For a patient with a severely infected
dysvascular foot, it is preferable to
perform revascularization within 1
to 2 days after the initial surgical
debridement.18,31 Determining the need
for revascularization begins with the
intraoperative assessment of arterial
perfusion to the tissues after adequate
debridement. Noninvasive vascular
studies that include the ankle brachial
index, toe brachial index, pulse volume
recordings, and transcutaneous oxygen
pressures are performed initially to
determine the need for invasive vascular
studies. The Ankle Brachial Index
(ABI) is a screening test for peripheral
vascular disease and may not be very
useful in the diabetic patient because it
underestimates the severity of arterial
insufficiency.34 The ABI is affected by
incompressible calcified vessels, which
are common in the diabetic population.
This leads to falsely elevated values.34
Despite the shortcomings associated
with the ABI, a decreased value is still
clinically significant because it represents
both decreased peripheral vascular flow
to the foot and an increased incidence
of coronary artery disease, which should
prompt further evaluation and treatment.
Qualitative waveforms and the toe
brachial pressure index have been shown
to be more efficacious in screening for
arterial insufficiency in high-risk limbs
among the diabetic population when
compared with the ABI.35 Transcutaneous
oxygen pressure measurements(TCPo2)
may be useful in predicting the wound-
healing capability.36-38 The wound is
expected to heal if values are greater
than 30 mm Hg.36-38 Noninvasive
vascular studies in conjunction with the
extremitys clinical appearance depict the
need for further vascular intervention.
Angioplasty, various forms of stenting,
and endovascular atherectomy are
valuable means of minimally invasive
forms of revascularization that can be
followed, if unsuccessful, by distal arterial
bypass.1,39 Angioplasty with or without
stent placement is usually successful in
the treatment of short arterial occlusions
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Foot & Ankle Specialist 49
and stenosis in the iliac and superficial
femoral artery, whereas atherectomy
can be used at these levels as well as
below the knee and below the ankle.39
Peripheral arterial bypass has been
shown to be a beneficial procedure for
salvage of the ischemic diabetic limb with
considerable tissue loss.40,41 Peripheral
bypass is usually needed to treat long
arterial occlusions not amenable to
angioplasty.1,40,42 Reperfusion is essential
before soft tissue reconstruction can
take place. If revascularization is not
successful and limb ischemia permits,
then a proximal amputation should be
performed.
Soft Tissue Reconstruction
Obtaining long-lasting wound closure
after radical surgical debridement to
control infection is one of the most
challenging aspects in the surgical
management of the diabetic foot.
Extensive soft tissue loss is usually
present. The goal is to create a
functional limb that is resistant to further
breakdown and higher amputation.
Limb preservation is paramount in
preventing the morbidity and mortality
associated with higher amputations.43-45
However, soft tissue reconstruction
can only take place when infection is
eradicated, nonviable soft tissue and
bone are completely excised, and
arterial perfusion is sufficient. Numerous
techniques are used to obtain wound
closure in the diabetic foot, and the
procedure chosen must be tailored to
each patient and circumstance to obtain
soft tissue coverage that is durable and
mechanically sound. The simplest and
least invasive modalities should be
used first when feasible. The surgeon
first has to decide if primary wound
closure with minimal tension is possible
after revision debridement or limited
pedal amputation. Wounds that are not
suitable for primary closure, particularly
those with continued drainage or
extensive soft tissue loss, are usually
managed with wet to dry dressings
in tandem with negative pressure
therapy to facilitate granulation tissue.
In many complex wounds, plastic and
50 Foot & Ankle Specialist
Figure 2.
A clinical picture of an infected dysvascular diabetic foot that needed an emergent
surgical and vascular intervention.
reconstructive surgical techniques are
later used to achieve wound closure.
These include split thickness skin
grafting, local flaps, muscle flaps,
pedicle flaps, and/or musculotendinous
balancing. Split thickness skin grafts
after appropriate wound bed preparation
are useful to obtain closure of large non-
weight-bearing soft tissue defects (Figure
3A,B).46 Local flaps are often used for
wound coverage on the weight-bearing
plantar aspect of the foot.47-51
Local flaps comprise a segment of
skin and underlying tissues raised
adjacent to the wound and rotated,
advanced, or transposed to provide
wound coverage.49,50 The surgeon
has to appreciate the angiosomes
of the foot along with location and
size of the soft tissue defect when
choosing the appropriate local flap
for soft tissue coverage.52-54 All local
flaps obtain their vascular supply from
septofasciocutaneous perforating vessels
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that enter the flap from either its base
(transposition and rotation flaps) or
undersurface (advancement flaps).50
V-Y advancement flaps are reliable for
soft tissue coverage to the plantar aspect
of the foot and are relatively easy to
mobilize.48
Muscle flaps are useful to obtain
adequate vascularized coverage over
exposed bone. The abductor hallucis,
abductor digiti minimi, flexor digitorum
brevis, and the extensor digitorum brevis
are the most common muscle flaps used
in the foot.55-58 These muscle flaps are
classified as type 2, with 1 dominant
pedicle at the origin and several minor
perforators throughout the muscle
belly.55-58 Isolated muscle flaps provide an
excellent vascular base for the application
of a split thickness skin graft.59,60 Using
a muscle flap in conjunction with a
split thickness skin graft avoids the
large donor defect associated with a
musculocutaneous flap.
February 2008
Pedicle flaps around the foot and
ankle require surgical dissection often
with loupe magnification to isolate
the neurovascular bundle supplying
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
congestion.62-64 Despite the potential for
complications, pedicle flaps have been
shown to be useful to obtain soft tissue
coverage in the diabetic patient.64-68
Large cleft defects after central ray
resections may be difficult to close
primarily or with flap closure secondary
to the size of the defect, location of
the defect, and/or wound contraction.
External fixation devices can reduce the
size of large cleft wounds to facilitate
long-lasting wound closure and a more
functional limb.69,70 External fixation
to achieve reduction of the remaining
intermetatarsal space can be combined
with either delayed primary closure or
split thickness skin grafting to obtain
long-lasting wound closure.
Discussion
A stepwise approach to the surgical
management of life- or limb-threatening
diabetic foot infections is essential
vol. 1 / no. 1
Figure 3.
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).
for limb salvage and patient survival.
A multidisciplinary diabetic foot care
team consisting of surgical and medical
disciplines is needed to adequately
manage the severe diabetic foot
infection. The surgeon should have
experience and knowledge to evaluate
the diabetic foot with infection to
determine when and how to intervene.
The basic tenets in order are patient
stabilization, adequate surgical
debridement combined with intravenous
antibiotics, comprehensive vascular
assessment and revascularization
if needed, and delayed plastic and
reconstructive surgery. When these
tenets are followed, the surgeon can
optimize the likelihood of limb salvage.
The goal of limb salvage is to provide
the patient with a limb that is stable,
mechanically sound, and resistant to
further skin breakdown while resuming
an ambulatory status. Custom shoes,
inserts, and/or bracing are used
postoperatively to assist in achieving this
long-term goal.
Finally, the patient has to be better
educated on his or her disease to prevent
further diabetes-associated complications.
Unfortunately, a severe foot infection is
often the wakeup call to the diabetic
patient who did not comprehend
previously the severity of the disease.
This scenario should be used as an
opportunity to educate the patient on
his or her necessary role in the overall
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Foot & Ankle Specialist 51
management of diabetes to prevent
future problems.
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