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• W2131344356 abstract "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 effect 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 special 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. 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 effect 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 special 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. Diabetes is a global problem with significant socioeconomic and health care implications, both in developed as well as developing nations. In the United States alone, there are 23.6 million (7.8% of the population) people affected by diabetes and its attendant increased mortality.1Centers for Disease ControlNational Diabetes Fact Sheet, 2007. US Centers for Disease Control and Epidemiology, Atlanta, Georgia2007Google Scholar, 2World Health OrganizaitonWorld Health Organization Facts Sheet. World Health Organization, Geneva2009Google Scholar Diabetes continues to be the single most common underlying factor contributing to lower-extremity amputation in the US and Europe,3Boulton A.J. Vileikyte L. The diabetic foot: the scope of the problem.J Fam Pract. 2000; 49: S3-S8PubMed Google Scholar, 4Van Houtum W.H. Lavery L.A. Outcomes associated with diabetes-related amputations in The Netherlands and in the state of California, USA.J Intern Med. 1996; 240: 227-231Crossref PubMed Scopus (65) Google Scholar, 5van Houtum W.H. Lavery L.A. Harkless L.B. The impact of diabetes-related lower-extremity amputations in The Netherlands.J Diabetes Complications. 1996; 10: 325-330Abstract Full Text PDF PubMed Scopus (87) Google Scholar, 6Lavery L.A. Ashry H.R. van Houtum W. Pugh J.A. Harkless L.B. Basu S. Variation in the incidence and proportion of diabetes-related amputations in minorities.Diabetes Care. 1996; 19: 48-52Crossref PubMed Scopus (215) Google Scholar primarily due to the development of diabetic peripheral neuropathy and the resultant loss of protective sensation (LOPS) of the feet. A simple neuropathic foot ulcer is the major antecedent risk predisposing to diabetic foot infection7Lipsky B.A. Berendt A.R. Deery H.G. Embil J.M. Joseph W.S. Karchmer A.W. et al.Infectious Diseases Society of America Diagnosis and treatment of diabetic foot infections.Clin Infect Dis. 2004; 39: 885-910Crossref PubMed Scopus (835) Google Scholar and precedes 85% of all non-traumatic lower limb amputations in the US.8Galer B.S. Gianas A. Jensen M.P. Painful diabetic polyneuropathy: epidemiology, pain description, and quality of life.Diabetes Res Clin Pract. 2000; 47: 123-128Abstract Full Text Full Text PDF PubMed Scopus (481) Google Scholar We herein present a stepwise approach to the diagnosis and treatment of diabetic foot infections with special emphasis on appropriate and timely surgical intervention. Optimal management often involves a multidisciplinary team that integrates the complementary expertise of different specialties; these may include internal medicine, diabetology, infectious disease, medical microbiology, vascular surgery, podiatry, plastic surgery, emergency medicine, nursing, prosthetics/orthotics, and physical therapy. Determination of the presence and severity of infection is the first step in its treatment. The diabetic foot infection classification system (Infectious Diseases Society of America - International Working Group on the Diabetic Foot) displayed in the Table is a simple and clinically useful tool that has been validated by Lavery et al.9Lavery L.A. Armstrong D.G. Murdoch D.P. Peters E.J. Lipsky B.A. Validation of the Infectious Diseases Society of America's diabetic foot infection classification system.Clin Infect Dis. 2007; 44: 562-565Crossref PubMed Scopus (265) Google Scholar This system facilitates accurate risk classification and identifies high-risk patients that are prone to adverse outcomes and increased risk of major limb amputation.9Lavery L.A. Armstrong D.G. Murdoch D.P. Peters E.J. Lipsky B.A. Validation of the Infectious Diseases Society of America's diabetic foot infection classification system.Clin Infect Dis. 2007; 44: 562-565Crossref PubMed Scopus (265) Google ScholarTableDiabetic foot infection classification schemesClinical descriptionInfectious Diseases Society of AmericaInternational Working Group on the Diabetic FootWound without purulence or any manifestations of inflammationUninfected1≥2 Manifestations of inflammation (purulence or erythema, pain, tenderness, warmth, or induration); any cellulitis or erythema extends ≤2 cm around ulcer, and infection is limited to skin or superficial subcutaneous tissues; no local complications or systemic illnessMild2Infection in a patient who is systemically well and metabolically stable but has ≥1 of the following: cellulitis extending >2 cm; lymphangitis; spread beneath fascia; deep tissue abscess; gangrene; muscle, tendon, joint, or bone involvementModerate3Infection in a patient with systemic toxicity or metabolic instability (eg, fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, hyperglycemia, or azotemia)Severe4 Open table in a new tab While many diabetic foot infections are considered superficial because they do not extend beneath the superficial fascia,10Armstrong D.G. Lipsky B.A. Diabetic foot infections: stepwise medical and surgical management.Int Wound J. 2004; 1: 123-132Crossref PubMed Scopus (114) Google Scholar the infection will not uncommonly penetrate more deeply into underlying soft tissue and create a deep space abscess.11Boulton A.J. Meneses P. Ennis W.J. Diabetic foot ulcers: a framework for prevention and care.Wound Repair Regen. 1999; 7: 7-16Crossref PubMed Scopus (143) Google Scholar, 12Eneroth 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. 1999; 13: 254-263Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar In such cases, surgical intervention is mandated to evacuate the abscess, remove necrotic tissue, and minimize the risk for further spread. In this section, we discuss steps including incision, investigation, debridement, lavage, and considerations for closure. The concept of fascial spaces is of critical importance when performing an incision and drainage of the foot. All but the simplest infections may require staged procedures; thus, the initial skin incision and dissection should take into account future surgical plans.13Frykberg R.G. Wittmayer B. Zgonis T. Surgical management of diabetic foot infections and osteomyelitis.Clin Podiatr Med Surg. 2007; 24 (viii-ix): 469-482Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar Grodinsky identified three major plantar spaces: the medial, central (superficial and deep), and lateral spaces. He recommended a medial surgical approach due to potential discomfort of a plantar incision.14Grodinsky M. A study of the fascial spaces of the foot and their bearing on infections.Surg Gyencol Obstet. 1929; 49: 739-751Google Scholar However, Loeffler and Ballard described success with a plantar-based incision for drainage of foot infections.15Loeffler Jr, R.D. Ballard A. Plantar fascial spaces of the foot and a proposed surgical approach.Foot Ankle. 1980; 1: 11-14Crossref PubMed Scopus (42) Google Scholar They described it as beginning proximally, posterior to the medial malleolus, and extending distally and laterally toward the midline, ending between the heads of the first and second metatarsals. The current approach in many diabetic foot units, including the authors' own, reverses the proximal to distal approach as described by Loeffler and Ballard. We prefer a distal to proximal approach in class IV, emergency, diabetic foot infections. The starting point coincides with the distal most area of infection or ulceration and extends proximally. The incision continues until evidence of infection has been eradicated or until viable, healthy-appearing tissue is observed. This approach eliminates the need for unnecessarily long incisions that could pose future problems, particularly in a patient with vascular insufficiency. As stated above, plans for closure or future reconstruction should always be considered. In any case, the infected space(s) must be drained completely and all grossly necrotic tissue debrided. Following the incision, drainage, and debridement of all non-viable and necrotic appearing tissue, the wound should be thoroughly examined.10Armstrong D.G. Lipsky B.A. Diabetic foot infections: stepwise medical and surgical management.Int Wound J. 2004; 1: 123-132Crossref PubMed Scopus (114) Google Scholar The presence of further abscess, sinus tracts, or exposed bone should be sought and treated accordingly. When planning surgical intervention for deep diabetic foot infections, the Loeffler-Ballard incision utilizes a single-incision approach to diabetic foot infections of the plantar compartment to expose all five central plantar spaces. This incision begins at the distal aspect of the first intermetatarsal space and proceeds, as needed, proximally through the medial longitudinal arch toward the medial malleolus. This approach follows the natural anatomy of the flexor tendons and soft tissues. A suggested modification to this approach involves termination of the incision into each of the affected interspaces (see Fig). Wound evaluation should include the size and extent of soft tissue involvement and the presence of any foreign bodies, abscesses, or sinus tracts. Surgical exploration should then follow the appropriate tissue planes and enable the surgeon to examine the compartments and open all adjacent areas to remove any possible remaining infection. The surgeon must decide if additional exploration or blunt dissection is needed based on his or her knowledge of compartmental anatomy and the communications between each of these compartments. Tissue planes should also be investigated either manually or with instrumentation. If tissue planes are easily separated, this may be an indication of potential necrotizing fasciitis in need of debridement.16Childers B.J. Potyondy L.D. Nachreiner R. Rogers F.R. Childers E.R. Oberg K.C. et al.Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients.Am Surg. 2002; 68: 109-116PubMed Google Scholar Following wound investigation, and determination of any tissue planes and foot compartments that are violated, debridement of any and all non-viable tissue and bone should be completed regardless of size and quantity.17Wieman T.J. Principles of management: the diabetic foot.Am J Surg. 2005; 190: 295-299Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 18Attinger C.E. Bulan E. Blume P.A. Surgical debridement The key to successful wound healing and reconstruction.Clin Podiatr Med Surg. 2000; 17: 599-630PubMed Google Scholar This should commence with the removal of all sloughed, ischemic-appearing (purple) and grossly necrotic (black, gray) tissue. Following soft tissue debridement, exposed tendons should also be removed in order to reduce the spread of infection along these pathways (that serve as pus highways). We avoid use of a tourniquet in this situation because it obscures the identification of viable tissue, potentially leading to over-debridement. Once adequate soft tissue debridement has been completed, exposed bone is frequently evident. Removal of this exposed bone is recommended, as it will assist the surgeon in planning soft tissue coverage in the future. Multiple surgical debridements are common in the infected diabetic foot prior to wound closure, and it has been shown that the adequate removal of all nonviable tissue is associated with quicker healing times and better outcomes.17Wieman T.J. Principles of management: the diabetic foot.Am J Surg. 2005; 190: 295-299Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 19Steed D.L. Donohoe D. Webster M.W. Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers Diabetic Ulcer Study Group.J Am Coll Surg. 1996; 183: 61-64PubMed Google Scholar Wound cleansing following surgical debridement of infected tissue has been reported as a good complement to systemic antibiotics and appears to be safe in reducing the incidence of continued infection.10Armstrong D.G. Lipsky B.A. Diabetic foot infections: stepwise medical and surgical management.Int Wound J. 2004; 1: 123-132Crossref PubMed Scopus (114) Google Scholar However, there is no consensus regarding the most effective solution(s) to use due to the lack of appropriate randomized controlled human studies, and the irrigant selected has largely been left to surgeon preference. Animal studies suggest that the use of saline alone on infected wounds is effective in reducing the bacterial counts compared with untreated controls; saline has also performed favorably when compared with povidone iodine solution and cefazolin solution.20Badia J.M. Torres J.M. Tur C. Sitges-Serra A. Saline wound irrigation reduces the postoperative infection rate in guinea pigs.J Surg Res. 1996; 63: 457-459Abstract Full Text PDF PubMed Scopus (42) Google Scholar, 21Howell J.M. Stair T.O. Howell A.W. Mundt D.J. Falcone A. Peters S.R. 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. 1993; 11: 134-138Abstract Full Text PDF PubMed Scopus (34) Google Scholar Recently, Parcells et al reported a comparative study of irrigation with solutions of normal saline (0.9%), Dakin's (0.25%), and Imipenem (1 mg/mL) in a series of 1063 appendectomy sites. They found that the use of an antibiotic solution irrigation resulted in a wound infection rate of 0.5%, compared with 7.3% and 15.9% when using normal saline and Dakin's solution, respectively.22Parcells J.P. Mileski J.P. Gnagy F.T. Haragan A.F. Mileski W.J. Using antimicrobial solution for irrigation in appendicitis to lower surgical site infection rates.Am J Surg. 2009; 198: 875-880Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar While this study may not be directly applicable to diabetic foot wounds with pre-existing infections, it does suggest a potential use for irrigation with antibiotic solutions to assist in the complete eradication of infection and allow earlier wound closure.23Giovinco N.A. Bui T.D. Fisher T. Mills J.L. Armstrong D.G. Wound chemotherapy by the use of negative pressure wound therapy and infusion.Eplasty. 2010; 10: e9PubMed Google Scholar More investigation in this area is clearly necessary. Once clinical signs of infection have been eliminated in the infected diabetic foot wound, closure of the wound is usually conducted. However, it is common for heavily contaminated wounds and previous amputation sites to require revision or re-debridement to a higher level.10Armstrong D.G. Lipsky B.A. Diabetic foot infections: stepwise medical and surgical management.Int Wound J. 2004; 1: 123-132Crossref PubMed Scopus (114) Google Scholar There are three methods for wound closure: primary, delayed-primary, and secondary intention. In primary closure, the wound is closed at the time of the initial surgical intervention. In secondary closure, the wound is left open at the end of the surgical intervention to granulate and to contract. Delayed-primary closure refers to when the wound is left open at the time of the initial surgical intervention then closed at a later date, usually once the wound is free from any sign of infection. Such an approach is usually carried out in conjunction with wet-to-dry dressings and/or negative pressure wound therapy (NPWT) to facilitate granulation prior to closure and is associated with fewer wound complications than primary closure.24Zgonis T. Stapleton J.J. Roukis T.S. A stepwise approach to the surgical management of severe diabetic foot infections.Foot Ankle Spec. 2008; 1: 46-53Crossref Scopus (22) Google Scholar, 25Fisher Jr, D.F. Clagett G.P. Fry R.E. Humble T.H. Fry W.J. One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study.J Vasc Surg. 1988; 8: 428-433PubMed Scopus (42) Google Scholar Additionally, the use of split-thickness skin grafts, local flaps, muscle flaps, pedicle flaps, and musculotendinous flaps are options for achieving proper wound closure. Decisions regarding closure are ultimately dependent on the volume of viable soft tissue remaining after surgery, the amount of drainage, and the presence of any residual infection.10Armstrong D.G. Lipsky B.A. Diabetic foot infections: stepwise medical and surgical management.Int Wound J. 2004; 1: 123-132Crossref PubMed Scopus (114) Google Scholar Diabetic foot wounds complicated by infection all too commonly result in amputations, thereby imposing a major socioeconomic burden on available health care resources. Accurate identification of the infecting pathogens is the sine qua non in selecting the choice and duration of antimicrobial therapy. Because the standard, current microbiologic approach is lengthy and time-consuming, broad-spectrum antibiotics directed against the most likely pathogens are typically administered until tissue culture and sensitivity results are available. This approach has obvious inherent disadvantages, but these are outside the scope of current review and are discussed elsewhere.38 Improved, advanced diagnostic modalities are now or soon will be available that may further reduce the health care costs associated with diabetic foot infections.26Fisher T.K. Wolcott R. Wolk D.M. Bharara M. Kimbriel H.R. Armstrong D.G. Diabetic foot infections: a need for innovative assessments.Int J Low Extrem Wounds. 2010; 9: 31-36Crossref PubMed Scopus (37) Google Scholar" @default.
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