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1. A Step-wise Approach for Surgical Management of Diabetic Foot Infections dr. Khusnul Rahman

2. Introduction

3. Introduction Diabetes is a global health issue with significant economic and healthcare impacts , affecting 23.6 million people in the US alone. It is a leading cause of lower-extremity amputations due to complications like diabetic peripheral neuropathy , which leads to the loss of protective foot sensation . Diabetic foot infections , often preceded by neuropathic foot ulcers, contribute to 85% of non-traumatic limb amputations in the US. Effective management of diabetic foot infections requires a multidisciplinary approach , involving various specialties such as internal medicine, infectious disease, surgery, podiatry, and others for optimal diagnosis dan treatment .

4. Stepwise approach to management

5. Stepwise approach to management

6. Diabetic foot infection classification schemes

7. Many diabetic foot infections are superficial but can sometimes penetrate deeper, forming a deep space abscess . Surgical intervention is required to drain abscess , remove necrotic tissue , and prevent further spread . Key steps :

8. Incision Fascial spaces and surgery  crucial for foot incision and drainage , especially in complex infections requiring multiple procedures. Grodinsky identified three major plantar spaces and recommended a medial approach , while Loeffler and Ballard advocated for plantar-based incision . Many modern diabetic foot units now prefer a distal-to-proximal approach for severe infections  starting the most affected area and extending proximally until healthy tissue is found  minimizes unnecessary incision length. Complete drainage of necrotic tissue are essential, further infections or exposed bone must be addressed.

9. Incision The Loeffler-Ballard is a single incision method that exposes all five central plantar spaces, following natural anatomical structures. A suggested modification involves extending the incision into affected interspaces for better infection management.

10. Example of modifications to a standardized plantar incision for inspecting, draining, and debriding diabetic foot infections.

11. Investigation Wound evaluation should assess the size , soft tissue involvement , and presence of foreign bodies , abscesses , or sinus tracts . Surgical exploration must follow proper tissue planes to examine compartments and clear any remaining infections. The need for further exploration depends on the surgeon’s understanding of compartmental anatomy . Tissue planes should be manually or instrumentally examined , as easy separation may indicate necrotizing fasciitis requiring debridement.

12. Debridement After assessing the wound and affected compartments, all non-viable tissue and bone must be debrided , regardless of size  including removing sloughed, ischemic (purple), and necrotic (black, gray) tissue. Exposed tendons should also be excised to prevent infection from spreading along them. A tourniquet is avoided to ensure proper identification of viable tissue and prevent excessive debridement.

13. Debridement Once soft tissue debridement is complete, exposed bone should be removed to aid future soft tissue coverage. Multiple debridements are often necessary in a diabetic foot infections, as thorough removal of nonviable tissue leads to faster healing and better outcomes .

14. Wound lavage Wound lavage after surgical debridement is a useful complement to antibiotics in reducing infection risk . There is no consensus on the best irrigation solution due to a lack of human studies, leaving the choice to surgeon preference . Animal studies suggest saline is effective in lowering bacterial counts and performs well compared to povidone iodine and cefazolin.

15. Wound lavage Parcells et al.: Compared normal saline (0.9%), Dakin’s (0.25%), and Imipenem (1 mg/ml) in 1063 appendectomy sites. Antibiotic irrigation significantly reduced infection rates in appendectomy wounds  a potential benefit for diabetic foot infections. Further research is needed to determine the most effective irrigation method.

16. Closure Once infection is eliminated, would closure is performed , though contaminated wounds or amputation sites may require revisions. Three closure methods: Primary closure  immediate closure Secondary closure  left open to heal naturally Delayed-primary closure  initially left open, then closed later once infection is cleared

17. Closure Delayed closure, often combined with wet-to-dry dressings or negative pressure wound therapy (NPWT)  reduces complications. Skin grafts, local and muscle flaps, and other reconstructive options may be used. The closure method depends on the remaining viable tissue , drainage levels , and any residual infection .

18. Conclusion

19. Diabetic foot infections often lead to amputations, creating a significant socioeconomic burden . Identifying the infecting pathogens is crucial for selecting appropriate antibiotics, but standard microbiological methods are slow, necessitating broad-spectrum antibiotics until culture results are available. Advanced diagnostics may help reduce healthcare costs in the future.

20. For surgical management, a stepwise approach improves patient care , especially for moderate to severe infections. A coordinated, interdisciplinary team —combining podiatry and vascular surgery—plays a vital role in preventing amputations by addressing both infection and ischemia. Integrating these specialties into a single service enhances treatment outcomes .

21. Thank You