• 1

    Centers for Disease Control and Prevention: National Diabetes Fact Sheet 2007, Centers for Disease Control and Prevention Atlanta, GA. ,2008. .

  • 2

    World Health Organization: Diabetes Fact Sheet, World Health Organization, Geneva, Switzerland. ,2009. .

  • 3

    Boulton AJ, Vileikyte L: The diabetic foot: the scope of the problem. .J Fam Pract 49: (suppl):S3. ,2000. .

  • 4

    Van Houtum WH, Lavery LA: Outcomes associated with diabetes-related amputations in The Netherlands and in the state of California, USA. .J Intern Med 240::227. ,1996. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    van Houtum WH, Lavery LA, Harkless LB: The impact of diabetes-related lower-extremity amputations in The Netherlands. .J Diabetes Complications 10::325. ,1996. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Lavery L, Ashry HR, van Houtum W, et al: Variation in the incidence and proportion of diabetes-related amputations in minorities. .Diabetes Care 19::48. ,1996. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Lipsky BA, Berendt AR, Deery HG, et al: Diagnosis and treatment of diabetic foot infections. .Clin Infect Dis 39::885. ,2004. .

  • 8

    Galer BS, Gianas A, Jensen MP: Painful diabetic polyneuropathy: epidemiology, pain description, and quality of life. .Diabetes Res Clin Pract 47::123. ,2000. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Lavery LA, Armstrong DG, Murdoch DP, et al: Validation of the Infectious Diseases Society of America’s diabetic foot infection classification system. .Clin Infect Dis 44::562. ,2007. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Armstrong DG, Lipsky BA: Diabetic foot infections: stepwise medical and surgical management. .Int Wound J 1::123. ,2004. .

  • 11

    Boulton AJ, Meneses P, Ennis WJ: Diabetic foot ulcers: a framework for prevention and care. .Wound Repair Regen 7::7. ,1999. .

  • 12

    Eneroth M, Larsson J, Apelqvist J: Deep foot infections in patients with diabetes and foot ulcer: an entity with different characteristics, treatments, and prognosis. .J Diabetes Complications 13::254. ,1999. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Frykberg RG, Wittmayer B, Zgonis T: Surgical management of diabetic foot infections and osteomyelitis. .Clin Podiatr Med Surg 24::469. ,2007. .

  • 14

    Grodinsky M: A study of the fascial spaces of the foot and their bearing on infections. .Surg Gynecol Obstet 49::739. ,1929. .

  • 15

    Loeffler RD Jr, Ballard A: Plantar fascial spaces of the foot and a proposed surgical approach. .Foot Ankle 1::11. ,1980. .

  • 16

    Childers BJ, Potyondy LD, Nachreiner R, et al: Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. .Am Surg 68::109. ,2002. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Wieman TJ: Principles of management: the diabetic foot. .Am J Surg 190::295. ,2005. .

  • 18

    Attinger CE, Bulan E, Blume PA: Surgical debridement: the key to successful wound healing and reconstruction. .Clin Podiatr Med Surg 17::599. ,2000. .

  • 19

    Steed DL, Donohoe D, Webster MW, et al; Diabetic Ulcer Study Group: Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. .J Am Coll Surg 183::61. ,1996. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Badia JM, Torres JM, Tur C, et al: Saline wound irrigation reduces the postoperative infection rate in guinea pigs. .J Surg Res 63::457. ,1996. .

  • 21

    Howell JM, Stair TO, Howell AW, et al: The effect of scrubbing and irrigation with normal saline, povidone iodine, and cefazolin on wound bacterial counts in a guinea pig model. .Am J Emerg Med 11::134. ,1993. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Parcells JP, Mileski JP, Gnagy FT, et al: Using antimicrobial solution for irrigation in appendicitis to lower surgical site infection rates. .Am J Surg 198::875. ,2009. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Giovinco NA, Bui TD, Fisher T, et al: Wound chemotherapy by the use of negative pressure wound therapy and infusion. .Eplasty 10::e9. ,2010. .

  • 24

    Zgonis T, Stapleton JJ, Roukis TS: A stepwise approach to the surgical management of severe diabetic foot infections. .Foot Ankle Spec 1::46. ,2008. .

  • 25

    Fisher DF Jr, Clagett GP, Fry RE, et al: One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study. .J Vasc Surg 8::428. ,1988. .

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Fisher TK, Wolcott R, Wolk DM, et al: Diabetic foot infections: a need for innovative assessments. .Int J Low Extrem Wounds 9::31. ,2010. .

A Stepwise Approach for Surgical Management of Diabetic Foot Infections

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  • 1 Southern Arizona Limb Salvage Alliance, Department of Surgery, University of Arizona College of Medicine, Tucson, AZ.
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Diabetic foot disease frequently leads to substantial long-term complications, imposing a huge socioeconomic burden on available resources and health-care systems. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common underlying pathways that lead to skin breakdown, often setting the stage for limb-threatening infection. Individuals with diabetes presenting with foot infection warrant optimal surgical management to affect limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. In addition, the initial surgical intervention or series of interventions must be coupled with appropriate systemic metabolic management as part of an integrated, multidisciplinary team. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health-care systems. This article presents a stepwise approach to the diagnosis and treatment of diabetic foot infections with emphasis on the appropriate use of surgical interventions and includes the following key elements: incision, wound investigation, debridement, wound irrigation and lavage, and definitive wound closure. (J Am Podiatr Med Assoc 100(5): 401–405, 2010)

Corresponding author: David G. Armstrong, DPM, MD, PhD, Southern Arizona Limb Salvage Alliance, Department of Surgery, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724. (E-mail: armstrong@usa.net)