A stepwise approach to the surgical management of severe diabetic foot infections

Foot infections are common 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 infection to achieve limb salvage and survival. Critical limb ischemia, neuropathy, and an impaired host complicate the treatment of a severe diabetic foot infection. A severe diabetic foot infection carries a 25% risk of major amputation. For this reason, surgery should be coordinated with a well-functioning 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 disciplines managing the diabetic patient with a limb-threatening infection. The overall strategy for surgically managing a severe diabetic foot infection is as follows: the first step is infection control through aggressive and extensive surgical debridement, the second step is a comprehensive vascular assessment with possible vascular surgery and/or endovascular intervention, and the final step is soft tissue and skeletal reconstruction after infection is eradicated to obtain wound closure and limb salvage. A consistent stepwise surgical approach combined with sound surgical principles is paramount for successful management of the severe diabetic foot infection. The authors discuss their stepwise surgical approach to reduce the mortality, morbidity, psychological distress, and length of hospitalization associated with life- or limb-threatening diabetic foot infections.