Diabetic Foot

The International Journal of Lower Extremity
Wounds
http://ijl.sagepub.com/
Seminar Review: A Review of the Basis of Surgical Treatment of Diabetic Foot Infections
Javier Aragón-Sánchez
International Journal of Lower Extremity Wounds 2011 10: 33
DOI: 10.1177/1534734611400259
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Seminar Review
The International Journal of Lower
A Review of the Basis of Surgical Extremity Wounds

10(1) 33–65
© The Author(s) 2011
Treatment of Diabetic Foot Infections Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1534734611400259
http://ijlew.sagepub.com
Javier Aragón-Sánchez, MD, PhD1
Abstract
Infection is an extremely challenging complication of foot ulcers in patients with diabetes. Surgery as part of a multidisciplinary
approach is key in the management of many types of diabetic foot infections (DFIs). Unfortunately, the surgical treatment
of DFIs is based more on clinical judgment and less on structured evidence, which leaves unresolved doubts. The clinical
presentation of DFIs is varied. This review examines the basis of nonvascular surgical treatment of DFIs, emphasizing the
importance of the anatomic concepts of the foot, the variety of its clinical presentations, and the concepts of timing surgery.
Recent evidence and case reports based on the author’s experience are presented in 2 parts.The first part examines clinical
presentation of infections, whereas the second part deals with imaging, foot anatomy, and some case reports.
Keywords
diabetic foot, diabetic foot infections, osteomyelitis, bone infection, foot ulcer, necrotizing soft tissue infections, lower limb
amputation, peripheral vascular disease, critical ischemia
Part A However, no classification exists to determine either the

point at which surgery becomes absolutely necessary or when
Background
surgery is likely to produce a better outcome than further
Infection is a worrying event when it complicates a foot prolonged treatment with antibiotics. When a clinician is
wound in diabetic patients. Approximately two thirds of faced with a patient with diabetes and foot infection, the
lower extremity amputations are the result of an infected key questions are the following: Does the patient need sur-
ulcer.1 Diabetic foot infections (DFIs) have a heterogeneous gery? Should the patient be operated on as an emergency?
clinical presentation, and the outcomes of treatment vary It is the aim of this work to review the basis of nonvascular
according to the type of infection,2 the presence of isch- surgical treatment of DFIs.
emia, and its depth.3 It is generally recognized that surgery
may be necessary in the treatment of many types of foot
infections.4-6 Unfortunately, there is little structured evi- Initial Evaluation
dence to inform the surgical treatment of DFIs.7 Deep foot A thorough clinical evaluation is crucial in the management
infections rarely respond to antimicrobial therapy alone and of DFIs. However, it has been reported that the acutely
generally require surgical procedures to evacuate pus, remove infected diabetic foot is not adequately evaluated in patients
necrotic tissue, and minimize the risk for further spread.4,8 who require hospitalization.12 The first step is to perform a
Vascular evaluation and prompt revascularization, whether physical evaluation of the patient. Clinical signs of infec-
open or endovascular, are often required to save the infected tion are pus draining, erythema, foul smell, edema, warmth,
foot. Delay in the implementation of appropriate surgery lymphangitis, regional lymphadenitis, crepitus, skin blister-
may be responsible for the high percentage of amputations, ing, and pain. The presence of pus draining is per se conclusive
because it allows the infection to proliferate and destroy evidence of infection.13 The characteristics of the pus might
tissue.9-11 The goal of the team treating DFIs should be to
conserve as much of the foot as possible, to make the foot 1
La Paloma Hospital, Las Palmas de Gran Canaria, Spain
stable, and restore its function and avoid re-ulceration. Non
vascular surgical interventions due to acutely infected diabetic Corresponding Author:
Javier Aragón-Sánchez, MD, PhD, Hospital La Paloma,
foot are classified as class III (curative) or class IV Diabetic Foot Unit, C/Maestro Valle, 20, 35005 Las Palmas de Gran
(emergency) diabetic foot surgery.7 They include drainage, Canaria, Canary Islands, Spain
debridement, bone resections, and minor or major amputations. Email: javiaragon@telefonica.net

34 The International Journal of Lower Extremity Wounds 10(1)
Figure 1. Interdigital ulcer with the area of cellulitis marked Figure 3. Long-standing neuropathic plantar ulcer beneath the
with felt-tip pen third metatarsal head
Figure 4. Severe destruction of the third metatarsal head

Figure 2. The foot of the patient in Figure 1 after resolution of
the infection with antibiotics
diagnostic tests must be considered if the tissue is slow to res
pond to treatment.
suggest what type of infection is present. Dense and white In such cases pedal edema of the foot is common, and
pus is more common in Gram-positive infections. Dishwater other causes of limb edema, cardiac or renal failure, deep
and foul smelling drainage is more typical of mixed infections venous thrombosis, or acute neuroarthropathy should be ruled
and anaerobes, including necrotizing soft tissue infections. out bearing in mind that systemic diseases generally mani-
Due to peripheral neuropathy, diabetic patients do not often fest as bilateral edema. Aggressive edema reduction after
report the pain that would normally be associated with this debridement of foot infection has been associated with
condition. However, when a patient with a previously pain- improved healing.14 In Figure 3, a plantar ulcer beneath the
less neuropathic ulcer begins to feel pain, a deep infection third metatarsal head is shown. In this case, probe-to-bone
should always be suspected. test was positive, and the x-ray (Figure 4) showed destruc-
Cellulitis and erythema around the wound are clinical tion of the third metatarsal head. In Figure 5, severe edema
signs of infection. It is good practice to mark the border of of the dorsum of the foot is apparent.
cellulitis with a felt-tip pen (Figures 1 and 2). In this way, The presence of skin necrosis is another clinical sign.
the variation of the extension of the cellulitis can objec- Necrosis can be produced by critical lower limb ischemia,
tively be evaluated. A change in antibiotic regime and further but the appearance of necrosis in a patient with palpable

Aragón-Sánchez 35
Figure 6. Necrotizing fasciitis. Necrosis of the big toe and

spreading to the dorsum of the foot was apparent
Figure 5. Important edema of the dorsum of the foot. More

noticeable edema was found in the third toe
distal pulses should be considered a sign of infection. In such

cases, infection can trigger the thrombosis of smaller end-
arteries and arterioles,15 causing the destruction of local
vascularization with secondary necrosis in the different layers
involved.16 Figure 6 shows the foot of a patient with a nec-
rotizing fasciitis. Toe necrosis, swelling, and necrosis of the
dorsum of the foot were found. After undergoing a “guillo-
tine amputation,” the part of the foot that was to be removed Figure 7. Surgical specimens after dissecting skin and
was dissected. In Figure 7, one can see the thrombosis of subcutaneous tissue. Arrows show endovascular thrombosis
the subcutaneous vessels.
Gangrene is generally agreed to be a criterion that defines
foot infections as moderate or severe,6,17 but the type of
infection or the depth of the necrotizing process that may be
prognostic factors are not currently considered in the clas-
sifications of DFIs.18 The typical signs of necrotizing soft
tissue infections are foul smell, extensive cellulitis, skin
necrosis, bluish patches, and hemorrhagic bullae (Figure 8).
During the surgical operation in the case that is shown in
Figures 8 and 9, we found that only subcutaneous tissue was
involved in the infection. Fifth toe amputation and exten-
sive debridement were performed to control the infection
(Figure 10). Total healing was achieved by secondary inten-
tion in 82 days (Figure 11).
The clinician should always look for a point of entry of the
infection regardless of the duration of a foot ulcer. Despite the
fact that 58% of the patients suffering foot ulcers may pres-
ent clinical signs of infection,19 the ulcer must be considered Figure 8. Typical findings of necrotizing soft tissue infections

Figure 9. Intraoperative photo showing that only subcutaneous Figure 12. Plantar ulcer with proximal cellulitis and deep
tissue (arrows) was involved in the infection abscess
Figure 10. Photo taken after the surgical procedure Figure 13. Pus draining from a plantar ulcer with osteomyelitis.
No plantar cellulitis was found
as the port of entry of the infection and not as a type of

infection itself as has been suggested.20 Ulcers can be com-
plicated by 1 or more of a great variety of infections, and the
treatment and prognosis may therefore vary considerably.
Figure 12 shows a plantar ulcer complicated by a deep abscess.
In Figure 13, the same type of plantar ulcer is complicated
by osteomyelitis. The x-ray (Figure 14) shows bone destruc-
tion in the third metatarsophalangeal joint. The prognosis is
different from that of the infected ulcer, which is shown in
Figure 15.
Abnormal granulation tissue that is dark red, brown, or
grey and increased in fragility with the presence of contact
bleeding suggests the presence of wound infection.21 In
such cases, a thorough exploration, including imaging stud-
ies, should be made to detect the origin of the infection. In
Figure 11. Total healing of the postoperative wound Figure 16, there is abnormal granulation tissue in a wound

Aragón-Sánchez 37
Figure 14. X-ray showing osteomyelitis of the third Figure 16. Abnormal granulation tissue shows change in color
metatarsophalangeal joint and increased fragility
Figure 17. X-ray showing the spread of the infection to the

adjacent metatarsal heads. Arrows show bone fragments
diabetic patients undergoing puncture wounds has been

Figure 15. Plantar ulcer with necrosis of the third and fourth
toes reported.22
A secondary suppurating wound may appear near the
main ulcer. In such cases, fistulization of the main source
undergoing healing following amputation of the third toe, of infection is the most probable cause. In our experience,
and the arrows on the x-ray (Figure 17) show bone frag- when a fistula is found, it is almost always as a result of
ments due to the spreading of the infection into the adjacent bone infection. Figure 21 shows a plantar ulcer in the big
metatarsal heads. toe of a patient. No off-loading had been implemented by
Interdigital ulcers easily penetrate into the deep tissues of the team that had been treating the patient, and a second
the toe. Figures 18 and 19 show an example of this type of wound appeared on the internal side of the toe. Osteomy-
ulcer, which has caused severe destruction of the bone and elitis was detected from the x-ray (Figure 22). Since the
soft tissue. Figure 20 shows the associated x-rays. Trauma, plantar surface of the big toe was exposed to high pressure
a foreign body, or nail puncture should be investigated as the during walking, spontaneous draining of the pus occurred
possible point of entry of the infection. High morbidity in at a low-pressure site.

Figure 18. Severe involvement of soft tissues of the fourth toe Figure 21. Plantar ulcer in the big toe and secondary fistula
Figure 19. Ulcer in the lateral side of the toe with bone Figure 22. X-ray showing bone destruction of the distal
exposed phalanx
Deep ulcers may expose fascia, tendons, joint, and/or

bone. Osteomyelitis is almost always present if the bone
can be seen at the bottom of the ulcer. In our experience, the
bone was exposed in 31% of cases of osteomyelitis and was
demonstrated to be related to the failure of conservative
surgery by the logistic regression model.23
After initial inspection, the foot should be carefully pal-
pated. Distal pulses might be difficult to palpate because of
the presence of edema. Sometimes, spontaneous pus drain-
age is not observed but the palpation and pressure on the
periphery of the wound will expel some pus from the cavi-
ties. In some cases, a toe may have an unusual range of motion
(Figure 23) as a result of pathological fracture (Figure 24)
due to bone infection.
Both plantar and dorsal surfaces should be palpated.
Figure 20. X-ray showing pathological fracture of the head of Dorsal erythema and swelling in a patient suffering from a
proximal phalanx plantar ulcer is suggestive of an infection that has spread

Aragón-Sánchez 39
Figure 23. Unusual medial range of motion of the first Figure 25. Plantar ulcer under the third metatarsal head
metatarsophalangeal joint with proximal cellulitis. Pus under the fascia should always be
suspected
Figure 24. Severe destruction of the hallux joint Figure 26. Plantar ulcer in the big toe with surrounding callus.
The callus should be removed to detect the depth of the ulcer
inward through the foot. Bone could be affected. In such the treatment of foot ulcers.3 However, it has been reported
cases, pressure over the dorsum might produce draining of that nearly 90% of the wounds in one series were not eval-
pus through the plantar ulcer. Crepitus while palpating the uated for involvement of underlying structures.12 The evaluation
surfaces is due to free gas in soft tissue. It should be borne of the depth of both ulcer and infection is recommended
in mind that clostridial myonecrosis (“gas gangrene”) is not by the International Consensus on the diabetic foot. The
the only cause of free gas in soft tissue. However, crepitus and depth of an ulcer can be difficult to determine because of
the appearance of gas in soft tissue should warn the clinician the presence of overlying callus or necrosis. Therefore,
of the severity of the infection. It is very important to palpate ulcers with callus and necrosis should be debrided as soon
the plantar surface. Plantar swelling is usual when the infec- as possible24 (Figures 26 and 27) to facilitate determina-
tion spreads inside the compartments. Pain while palpating tion of the depth.
the plantar compartments is a sign that is related to the sprea Lack of adequate evaluation of the depth of the infection
ding of the infection through the foot. Plantar erythema, may lead clinicians to suspect that the infection is mild. Since
swelling, and pain during palpation are a triad that should deep tissue infections rarely respond to antimicrobial therapy
cause one to suspect deep plantar infection (Figure 25). alone and generally require surgical procedures,25 any delay
The evaluation of the depth of the infection is important in diagnosis might have disastrous consequences for the
because this has been a significant factor in the outcome in patient. Studies into deep infections2,23 have demonstrated

Figure 27. After debridement, the clinician can confirm that the Figure 29. After examination, the depth of the ulcer can be
ulcer is superficial checked
Figure 28. Probe-to-bone test Figure 30. Foreign body partially removed from inside the foot
that osteomyelitis is the most frequent type of infection and it standard reported a predictive value of 0.95.29 In our experi-
must always be considered. Besides the well known clinical ence treating high-risk patients, PTB has a sensitivity of 0.95,
signs, the probe-to-bone (PTB) test is important and is to be a specificity of 0.93, positive predictive value of 0.97,
recommended. This test was originally described using a and a negative predictive value of 0.83.30 According to the
sterile, blunt, 14.0-cm, 5-F, stainless steel eye probe.26 We use author, other expensive tests are not required to diagnose
metal forceps (Halsted-mosquito). The surgical instrument osteomyelitis when treating patients who require admission
is gently introduced through the wound, and the PTB is because of moderate or severe foot infection.
considered “positive” if bone (a hard or gritty surface) is touched The Halsted-mosquito is also very useful for detecting
(Figure 28). In addition, this maneuver permits confirmation fistulous tracks, cavities, and paths of spreading of the infec-
of the depth of the lesion (Figure 29). tion through the foot though unexpected findings may result
When first described 15 years ago, this test showed a posi- when evaluating a wound. The patient whose foot is shown
tive predictive value of 0.89 in detecting bone involvement Figure 30 presented with a black spot on the plantar aspect
in patients with limb-threatening infections.26 In subsequent of the foot. A hard object under the wound could be pal-
studies,27,28 the positive predictive values of PTB were con- pated. Figure 30 shows the object (a fragment from a broken
siderably lower (0.50 and 0.62). One recent study performed ceramic vase) extracted (Figure 31). Patients with diabetes
in an outpatient setting using histopathology as the criterion should not be encouraged to walk barefoot.

Aragón-Sánchez 41
What Type of Infection

Does the Patient Have?
The severity of the infection should not be the only criterion
taken into account when choosing the most appropriate sur-
gical treatment since other variables also affect the outcome
of the treatment.33 In the context of DFI, poor outcomes are
often related to delayed diagnoses and consequent extensive
destruction of the soft tissue.9 These factors also depend on
the type of infection that should be determined, and only then
can one decide whether treatment is to be medical or surgi-
cal. This may be especially important in cases of moderate
infections. There is a need for a widely accepted classification
to determine the validity of this approach taking outcomes
into account.
A classification of foot infections has recently been sug-
Figure 31. The foreign body was a piece of broken vase
gested, making use of ICD-9-CM codes.20 However, of 61 007
charts reviewed, 20 142 (33%) were classified as “ulcer,”
General symptoms, such as fevers and chills, general 18 944 (31%) as “other” infections, and 11 666 (19.1%) as
malaise, nausea, and vomiting, may suggest a more serious “gangrene.” In the author’s view, this classification is suf-
infection, but ≥50% of patients with a limb-threatening ficiently specific to deal with the complications encountered
infection do not manifest systemic signs or symptoms.13 in the infected diabetic foot.
Noninfectious causes of inflammation, such as acute Char- An alternative is to divide DFIs into soft tissue and bone
cot joint changes, superimposed gouty arthritis, inappropriate infections. Soft tissue infections are then classified as cel-
footwear, and excessive weight bearing on an area, can cause lulitis, abscesses, tenovagynitis, and necrotizing soft tissue
localized changes that mimic infection.31 infections (necrotizing cellulitis, necrotizing fasciitis, and
myonecrosis).18,23 Soft tissue and bone infections are often
found together. Very similar clinical presentations of DFIs
Classifying the Severity of the Infection have been used by other authors.2,34 We currently include
The second step is to evaluate the severity of the infection. necrotizing tenosynovitis as a separate class, but it is some-
Classically, DFIs have been classified into 3 types: non– times difficult to differentiate tenosynovitis and fasciitis,
limb threatening, limb threatening, and life threatening.32 because when the tendons are involved in the necrotizing
This well-accepted scheme is simplistic but provides the process, the fascia has already been affected. Presented in
essentials in determining severity and subsequent treat- Table 2 is a proposed clinical-pathological classification that
ment.5 Recently, the Infectious Diseases Society of America remains to be validated.
(IDSA) proposed a classification. DFIs are classified acc Cellulitis is a diffuse inflammation of the skin and sub-
ording to their severity as mild, moderate, and severe,13 and cutaneous tissue. Figure 32 shows the foot and toes of a patient
this classification has now been validated.17 The Interna- with a small point of entry in the dorsum of the big toe and
tional Working Group on Diabetic Foot has proposed the extensive cellulitis of the dorsum of the foot.
PEDIS scheme (Perfusion, Extent, Depth, Infection and The term abscess should be used with care when describing
Sensation) for classifying foot ulcers. Infection is divided foot infections in diabetic patients. Abscesses are purulent
into 4 types. Classification of the severity of the infections collections in soft tissue, beneath the epidermis, in subcuta-
according to IDSA and the International Consensus is neous tissue, or beneath the fascia. An abscess is formed
shown in Table 1.13 These 2 classifications are similar and because the body’s defenses act to contain the infections in
are very useful for the clinicians to decide the need for hos- a capsule that prevents its spread. However, in our opinion
pitalization and the route of administration of antibiotics it is not typical to find such well-defined collections in the
but do not indicate clearly the need for surgical treatment. feet of diabetic patients. It is possible that damage to host
Mild and severe infections are clearly defined, but defining defenses by chronic hyperglycemia35,36 has a role. Sub-
infections as “moderate” poses the greatest difficulty, because epidermal abscesses should be considered as mild infections.
this term covers a broad spectrum of wounds, some of A case of subepidermal abscess is shown in Figures 33 to 35.
which can be quite complicated, even limb threatening.13 Paronichia should also be considered as a mild infection
Furthermore, this type of infection may get deteriorate rap- (Figure 36). Minor debridement, oral antibiotics, and local
idly becoming severe. wound care achieve healing in such cases.

Table 1. Classification of Diabetic Foot Infections According to Their Severity
IDSA PEDIS Grade (IWGDF)

Wound without purulence or any manifestations of inflammation Uninfected 1
≥2 Manifestations of inflammation (purulence or erythema, pain, tenderness, warmth, Mild 2
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
illness
Infection in a patient who is systemically well and metabolically stable but has ≥1 of the Moderate 3
following: cellulitis extending ≤2 cm, lymphangitis, spread beneath fascia, deep tissue
abscess, gangrene, and muscle, tendon, joint, or bone involvement
Infection in a patient with systemic toxicity or metabolic instability (eg, fever, chills, Severe
tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, hyperglycemia, or
azotemia)
Any foot infection, in the presence of a systemic inflammatory response manifested by 4
at least 2 of the following characteristics:
• Temperature >38°C or <36°C
• Pulse >90 bpm
• Respiratory rate >20 per minute
• Paco2 <32 mm Hg
• Leukocytes >12 000 or <4000 per mm3
• 10% of immature (band) forms
Abbreviations: IDSA, Infectious Diseases Society of America; PEDIS, Perfusion, Extent, Depth, Infection, Sensation; IWGDF, International Working Group
on the Diabetic Foot.
Table 2. Clinical-Pathological Classification Of Diabetic Foot

Infections
Soft tissue infections • Cellulitis
• Abscesses
 Subepidermal abscess
 Subcutaneous abscess
 Deep tissue abscess
• Tenosynovitis
• Necrotizing soft tissue infections
 Necrotizing cellulitis
 Necrotizing fasciitis
 Necrotizing tenosynovitis
 Myonecrosis
Joint infections • Septic arthritis

Bone infections • Osteitis
• Osteomyelitis
Figure 32. Extensive cellulitis of the dorsum of the foot
Abscesses may be confined to subcutaneous tissue. In

such cases, the infection is not deep, but in some cases if it in color of the first interdigital space were found. Urgent
is not adequately treated, it may become limb threatening. drainage of the abscess was indicated (Figure 40). Instru-
The patient whose foot is shown in Figure 37 presented mental exploration showed a track between the point of entry
limb edema, pain in the heel, occasional suppuration, and (plantar ulcer) and the dorsum of the foot (Figure 41).
fever for 1 month. He had been treated exclusively with anti- Necrotizing soft tissue infections are associated with ext
biotics. Surgery was planned and the subcutaneous abscess ensive tissue destruction. Necrotizing cellulitis is diagnosed
drained. Figure 38 shows the incision while undergoing when the necrotizing changes only involve the skin and sub-
healing. cutaneous tissue. A case of necrotizing cellulitis is shown
A deep abscess should be treated an emergency as it is in Figures 8 and 9. Figure 42 demonstrates another patient
limb threatening. Figure 39 shows a patient who had a plantar with palpable pulses with necrosis of the fifth toe and the
ulcer for some length of time. Extensive cellulitis and change skin. After the amputation of the fifth toe and debridement,

Aragón-Sánchez 43
Figure 33. Subepidermal abscess Figure 36. Paronichia
Figure 37. Subcutaneous abscess on the heel. Extensive

Figure 34. Pus draining after incision cellulitis
Figure 35. Epidermis has been removed and the wound is

prepared for undergoing healing Figure 38. Incision performed to drain the abscess

Figure 42. Necrotizing soft tissue infection in a patient with

palpable pulses on the foot
Figure 39. Deep abscess. Cellulitis of the dorsum of the foot

and change in color in the first interdigital space
Figure 43. After debridement one can see that the deep tissues
were not involved in the necrotizing process
Figure 40. Drainage of the pus
it was found that deep tissue was not involved in the necro-
tizing changes (Figure 43). Total healing was achieved without
complications (Figure 44).
Necrotizing fasciitis is diagnosed when there is involve-
ment of the fascia, necrotizing tensynovitis when there is
involvement of the tendons or their sheaths, and myonecro-
sis when the muscle is affected by the necrotizing process.
These 3 clinical presentations of necrotizing soft tissue
infections are more severe. Figure 45 presents the ill-cared-
for foot of a patient. The plantar ulcer was the point of entry
of the infection, which caused necrosis of the forefoot. The
patient was admitted with fever, leucocytosis, confusion,
and tachycardia. The infection had become life threatening
and emergency surgery was carried out. A Chopart guillotine
amputation was done initially (Figure 46) though an above-
Figure 41. Track between the plantar ulcer and the dorsum of knee amputation was needed since the infection had spreading
the foot through the limb (Figure 47).

Aragón-Sánchez 45
Figure 44. Total healing Figure 47. After Chopart guillotine amputations, ascending
necrotizing fasciitis was found
In other reports, the term fetid foot has been used as a

variation on the theme of necrotizing soft tissue infections
in the feet of patients with diabetes. Even though fetid smell
is a classical sign of these infections and it was found in
78.6% of patients in our series, we think that this term, only
related to a subjective clinical parameter, is not sufficiently
objective in defining these foot infections.18
In cases of osteomyelitis, bacteria gain access to bone by
contiguous spread, entering from overlying soft tissue and
penetrating the cortex before involving the marrow.37 The
first layer affected by the infection is the periostium (peri-
ostitis). Subsequently, the cortical bone may be affected (ie,
osteitis), and then if the infection progresses into the medul-
lar bone the infection is defined as osteomyelitis. It must
be borne in mind that some bones in the foot have a small
medullar cavity or none at all.
Figure 45. Plantar ulcer with necrosis of the forefoot The clinical presentation of osteomyelitis varies consid-
erably and is frequently associated with soft tissue infection.
In the author’s series, 72.2% of the infected patients had
osteomyelitis, of which 21.8% had both osteomyelitis and
soft tissue infection, and this complicating factor should be
taken into account when dealing with osteomyelitis. There
is currently a debate about in which circumstances medical,
surgical, or combined treatment is appropriate for diabetic
patients with bone infections in their feet. Although it may
be possible to develop a comprehensive and coherent proto-
col describing the treatment of DFIs, it is probable that
the treatment will have to be tailored to individual patients
because diabetic foot osteomyelitis presents variedly. To
illustrate this, we are going to analyze 4 cases of osteomy-
elitis of the big toe. The patient in Figure 48 had an ulcer in
the big toe for 6 months, which had been treated by a differ-
ent clinical team using antibiotics (amoxicillin clavulanate)
Figure 46. Necrosis of the forefoot with extensive plantar bulla and wound care. Another typical ulcer can also be seen near

Figure 48. Ulcer in the big toe. Probe-to-bone test was positive. Figure 50. Total healing of the point of entry of the bone
One can see another ischemic ulcer infection. Ischemic ulcer undergoing healing
Figure 51. Ulcer on the big toe and another one in the dorsum
of the second toe. Probe-to-bone test was positive in both cases
second toe (Figure 51). The PTB test was positive in both
Figure 49. Osteomyelitis of the base of the distal phalanx ulcers. The x-ray showed signs of osteomyelitis of the
(arrow) interphalangeal joint of the big toe and at the proximal
interphalangeal joint of the second toe (arrows in Figure 52).
The patient underwent conservative surgery, and the amount
the point of entry of the infection to the bone (Figure 48). At of bone removed can be seen in the x-ray taken during the
the initial evaluation, no distal pulses were detected, and postoperative period (Figure 53). Healing was achieved in
noninvasive vascular tests indicated the presence of critical 46 days (Figure 54) and there has been no recurrence after
ischemia. The PTB test was positive, and the x-ray shows 2 years of follow-up.
signs of osteomyelitis (Figure 49). The patient underwent Another patient (Figure 55) had a very different outcome.
angioplasty, and after a period of 20 days with endovenous He had had an ulcer for 3 months, which had been treated
amoxicillin clavulanate, the ulcer healed (Figure 50) without with antibiotics and local wound care. No x-ray had been
the need for bone surgery. Improving perfusion to the tissues taken during this period. After admission, an x-ray was taken
was key to successful management in this case. that showed bone destruction in the interphalangeal joint
The second case of osteomyelitis is shown in Figure 51. The (Figure 56). During the surgical procedure, spreading of the
woman had a long-standing ulcer over the interphalangeal infection along the tendons was found, and we had to perform
joint of the big toe and another one over the dorsum of the a transmetatarsal big toe amputation (Figure 57).

Aragón-Sánchez 47
Figure 52. X-ray showing the osteomyelitis Figure 55. Ulcer in the big toe.You can see the slough in the
bed of the ulcer
Figure 56. X-ray showing osteomyelitis of the interphalangeal

joint
Figure 53. Postoperative x-ray showing the bone resection
Figure 54. Total healing of the wound of the second toe and
almost total healing of the surgical wound of the big toe
Figure 57. Open hallux amputation

The final illustration of the variety of clinical presentations

of bone infection is another patient whose case is presented
in Figure 58. She had had an ulcer in the top of the big toe
for 6 months. She was referred with fever, chills, leucocyto-
sis, and necrosis, which had been apparent for 7 days. In the
x-ray (Figure 59), one can see osteomyelitis (arrow) and
gas in soft tissues (circled). She underwent an open trans-
metatarsal amputation because necrotizing tenosynovitis
was found in the operating theatre.
With such varied outcomes, it is easy to understand
why osteomyelitis in the feet of diabetic patients is such a
controversial issue. Researchers dealing with diabetic foot
osteomyelitis should take into account such differences.
The nature of DFIs is complex, and clinicians need to keep
an open mind when diagnosing and treating them. It is
essential to avoid simplistic preconceptions when evaluat- Figure 58. Ulcer at the top of the big toe with bone exposed
ing DFIs. and necrotizing soft tissue infection
The patient in Figure 61 had been diagnosed with
“paronychia,” A sample was sent for culture and antibiotics
were prescribed. Figure 62 shows the foot 20 days after this
treatment. It is common to find spontaneous serous draining
from the nails in cases of severe ischemia, and a diagnosis
of “paronychia” instead of indicating an urgent vascular
examination is a dangerous oversimplification.
Another example is shown in the next case (Figure 63).
The diagnosis of the doctor attending this patient was
“polymicrobial infection,” and silver-based dressings and
antibiotics were prescribed. No x-rays were done, and no
surgical consultation was sought. A polymicrobial nature
is a common characteristic of DFIs,38 and the results of
cultures are very important in choosing the optimal antibi-
otic treatment. However, in this case this diagnosis is
another oversimplistic approach to managing DFIs. The
patient had a plantar ulcer in the big toe with 2 dorsal fis-
tulizations. The bone could be probed through the wound Figure 59. X-ray showing osteomyelitis in the top of the distal
and there was a severe cavitation around the bone. In the phalanx (arrow) and gas in soft tissues (encircled)
x-ray performed in the author’s unit (Figure 64), one can
see destruction of the proximal phalanx. This patient had
osteomyelitis with severe destruction of the soft tissue and
fistulization, which should have been diagnosed at the
outset. In our opinion, this type of infection should be reg
arded as limb threatening and surgery should be carried out
as soon as possible.39
Part B
What Imaging Studies Do I Need
to Plan Surgery?
The basic imaging study for treating diabetic patients with foot
infections is the simple x-ray in 2 standard planes or views.
Three important signs that should be looked for in the simple
x-ray: free gas in the soft tissues, bone destruction, and the
Figure 60. Open transmetatarsal amputation

Aragón-Sánchez 49
Figure 61. Critical ischemia misdiagnosed as “paronychia”

Figure 64. X-ray showing severe destruction of the
interphalangeal joint
presence of a foreign body. Gas in soft tissues may be a sign

of gas gangrene, which is myonecrosis caused by Clostridia,
a specific type of infection. Gas is produced by the metabo-
lism of bacteria, and there are other anaerobic bacteria or
combinations of bacteria which produce gas. This situation
is most frequent in diabetic foot syndrome. The presence of
gas in an x-ray alerts the clinician to the presence of a severe
limb-threatening infection, which should be treated imme-
diately with surgical intervention.40 Appropriate deroofing
and aggressive debridement of the compartments exposes
the cavities to atmospheric air and creates adverse condi-
tions for the growth of anaerobic bacteria.41 The second
sign that the clinician should look for is bone abnormalities.
In cases of osteomyelitis, x-rays show cortical disruption,
Figure 62. Advanced ischemia of the foot
periosteal elevation, a sequestrum or involucrum or gross
destruction of bone. However, these radiological changes
do not appear until 10 to 14 days after the onset of the bone
infection.13,40 The reported sensitivity of plain radiography
in the diagnosis of osteomyelitis is usually low, especially
in early stages of infection.42,43 This may be attributable to
factors such as how positive signs are defined, the timing
of the x-rays in relation to the duration of the ulcer, the
radiographic technique used, and the skill of the radiolo-
gist reading the films.42 The radiological diagnosis of
bone infection in diabetic patients is difficult because of
complications due to neuroarthropathy, previous bone
and/or soft tissue infections, previous bone trauma, and
bone deformities.44,45 The author has reported a sensitivity
of 0.82, specificity of 0.93, positive predictive value of
0.97, negative predictive value 0.65, positive likelihood
ratio of 12.71, and negative likelihood ratio of 0.18
for plain x-rays.30 When no positive findings are found,
Figure 63. Plantar ulcer with 2 fistulizations and severe
destruction of soft tissue follow-up radiography is usually done 2 to 6 weeks later,

although there is no agreed best interval. If the diagnosis

remains in doubt, further investigations may be needed.21
Other imaging studies have been proposed for studying
DFIs, especially when dealing with osteomyelitis. Magnetic
resonance imaging (MRI) has been suggested as the most
useful imaging study to evaluate soft tissue and bone-
related infections, especially in the early stages.40,46,47 As has
been stated concerning studies of PTB tests,27 when evalu-
ating studies in MRI, it should be borne in mind that selected
populations were studied and there was high pretest proba-
bility of the disease. A meta-analysis selected 17 high-quality
studies to determine the performance of MRI in diagnosis
of foot osteomyelitis.46 One of these studies was performed
on patients with leprosy. The average of prevalence of
osteomyelitis in the remaining 16 studies was 54.6%. Ten
of them presented a prevalence of osteomyelitis >50%. It is
Figure 65. Plantar wound with suppuration and extensive
necessary to remember that the prevalence of osteomyelitis
cellulitis
in the original study in which the PTB test was described
was 66%.26 Furthermore, the enrolment criteria used in the
studies included in the meta-analysis varied greatly. Some
of these studies were restricted to advanced cases: patients
scheduled for partial amputations,48 patients admitted
with foot infections,49-51 or patients with advanced disease,
≥Wagner 3.52 Additionally, in many studies the clinical cri-
teria used for suspecting osteomyelitis were not reported.53-55
Bone biopsies in cases in which MRI was negative were not
performed in the majority of cases. Bearing these reserva-
tions in mind, the evidence in support of MRI to diagnose
early osteomyelitis may not be as conclusive as some
authors believe. Abscesses associated with osteomyelitis,56
necrosis,55 and tendon involvement57 are also identified effec-
tively using MRI.
The ability of imaging to detect the presence of osteo-
myelitis does not imply that it should be offered to all Figure 66. X-ray showing a triangle-shaped foreign body. In detail
one can see a piece of glass that was removed from the foot
patients.58 Costs should be considered; also, microbiologi-
cal examination of bone tissue specimens showed higher
sensitivity and the same specificity value as MRI in one
study.52 In some cases, it may play a role in surgical plan- a foreign body was detected. He underwent surgery, and a
ning,58 but no studies have yet proved its usefulness. MRI piece of glass was removed from inside the foot (Figure 66).
has also been used for guiding the duration of antibiotics in Extensive debridement was necessary. Unnoticed punctures
cases of forefoot osteomyelitis in diabetic patients,59 but or trauma are frequent in patients with neuropathy.
the cost-effectiveness of this approach should be evaluated
taking into account that the PTB test was used as a sign
suggestive of bone infection and to indicate the MRI.59 Does This Diabetic Patient With Foot
Radionuclide imaging used in the diabetic foot includes Infection Really Need Surgical Treatment?
triple-phase bone scan, gallium scan, and indium-labeled A crucial issue when dealing with foot infection is to decide
leukocyte scan. Of the 3 radionuclide imaging studies, the whether the patient needs surgical debridement to remove
indium scan is the most sensitive and specific for diagnos- extensive infected tissue.60 Little evidence exists about the
ing diabetic foot osteomyelitis.40 impact of surgical treatment on these worrying infections,
A foreign body may be found when evaluating diabetic and surgery is sometimes described as “adjunctive therapy”61
patients with foot infections. The patient whose foot is shown or its role is not well-defined.62 This author18,63,64 and others
in Figure 65 was admitted with a plantar wound, suppuration, take the view5,65,66 that surgery should be the mainstay of
extensive cellulitis, edema, and fever. An x-ray was taken and treatment of life- or limb-threatening infections. Despite the

Aragón-Sánchez 51
importance of surgical treatment as part of the management diabetic foot osteomyelitis in an extensive review.63 One
of patients with diabetes and foot infections, which has significant example in the confusion that may exist when
been strongly emphasized in guidelines and consensus, a dealing with bone infections is reported in one series dealing
delay in appropriate treatment frequently takes place and is with medical management of diabetic foot osteomyelitis.74
associated with amputation.10 This mismanagement can be In this report, the authors reported their technique for per-
found even in hospitalized patients.10,67 forming per-wound bone biopsy as follows: when the bone
According to the severity of the infection, patients who testing revealed a fragilized adulterated infected bone or
have mild infections (as classified using PEDIS 2) can be sequestra, these were harvested at bed site until the healthy
treated as outpatients with oral antibiotics, off-loading, and bone was reached. When the bone testing was positive with
appropriate wound care. In such cases, minor debridement a bone that was not felt to be adulterated, a small sample
may be necessary. Removing callus, debridement of wound was harvested.74 Clearly, this is an interesting approach with
bed to remove necrotic tissue, pus draining, and opening the advantages but it is not merely medical management.
sinus tracks by means of sharp debridement of the wound A combination of soft tissue and bone infection indi-
is recommended. Evidence is lacking in cases of chronic cate that the patient needs a surgical debridement.2 The
noninfected foot ulcers,68,69 but in cases of mild infections, author is of the view that conservative surgery defined as
minor sharp debridement is essential. Treatment can be done healing without any amputation was more frequently suc-
in an outpatient setting, but in cases in which diagnostic test- cessful in patients with exclusively bone infection. All
ing, consultations, or surgical intervention is needed, a brief types of amputation were more frequent when soft tissue
hospitalization is preferable.9 infection was present. In the logistic regression model, the
There is agreement that when the infection is potentially presence of necrotizing soft tissue infection was associ-
life threatening (severe or PEDIS 4), immediate surgery ated with amputation.23
should be indicated,5 because deep tissue infections rarely
respond to antimicrobial therapy alone and generally require
surgical procedures.25 Aggressive surgery of foot infections When Should I Operate?
and prompt revascularization, if needed, can result in good The timing for performing surgery is not well defined, but
rates of limb salvage.10,70 Diagnosis of moderate infections it has been reported that prompt surgical treatment includ-
(PEDIS 3) present problems. Moderate infections show a ing extensive use of revascularization may reduce the need
great range of clinical presentations and much experience is for above-ankle amputations.11,70,75,76 Conservative man-
needed to decide if and when surgery should be offered to agement with only antibiotics has been reported but without
the patient. The author has experience of patients with mod- specifying the optimal time or criteria used for surgical
erate infections presenting a necrotizing soft tissue infection intervention.33 Most publications have not attempted to spec-
that was limb threatening. Table 2 presents a clinicopatho- ify the optimal time for surgical intervention. Some authorities
logical classification. state that when the infection is potentially life threatening,
Deep tissue abscesses2,5,10 and necrotizing soft tissue immediate surgery should be indicated.5 Any delay in surgi-
infections18 require emergency surgery. Necrotizing soft cal debridement allows the infection to spread and is
tissue infections are associated with significant tissue des associated with higher levels of amputation.10 Some author
truction and can be classified according to the depth of argue that surgical treatment should be considered only
the necrotizing changes. In cases of necrotizing soft tissue when antibiotics have failed to control the infection. How-
infections, the definitive classification of the infection can ever, extensive surgical debridement is always preferable to
often not be made before the operation because the external extensive tissue loss due to uncontrolled proximal spread-
appearance of the 3 types of infection may be similar. The ing of an infection. The surgeon performing the procedure
surgeon should not consider a major amputation merely on and eliminating pus and infected tissue creates the best con-
the external appearance of the foot. Some authors regard DFIs ditions in the foot for antibiotics to work.
and necrotizing soft tissue infections in diabetic patients as The author advocates early surgery as the best way of
2 different entities.71 From a surgical perspective, there treating necrotizing soft tissue infections in the feet of dia-
should not be any difference in the management of a peri- betic patients.18 These infections produce destruction of
neal necrotizing soft tissue infection (Fournier’s gangrene) local microcirculation and antibiotics cannot penetrate to
and a necrotizing soft tissue infection in the foot of a dia- the site of the infection.77 Surgery reduces pressure in the
betic patient. It is the same type of infection but on a different affected compartments of the foot,9 and aggressive debride-
site but both requiring urgent surgery. ment allows the surgeon to establish which layers are affected
The treatment of osteomyelitis in the foot of patients with by the necrotizing process and the extent of infection.18
diabetes continues to be debated.13,37,72,73 We have recently Guidelines for treatment of diabetic foot osteomyelitis sug-
dealt with the controversies around the surgical treatment of gest that urgent surgery is indicated for necrotizing fasciitis,

deep soft tissue abscesses, or gangrene accompanying

osteomyelitis.72 Nonurgent surgery may be necessary if there
is a significant compromise of the soft tissue envelope.
We have reported 18.6% of major amputations in a series
of necrotizing soft tissue infections, 24.8% of which were
fasciitis and myonecrosis.18 All patients were operated on
within the first 12 hours of their admission to the surgery
department.18 Although the impact of early surgery cannot
be evaluated from this study on account of its retrospective
nature, the findings suggest that in severe infections emer-
gency surgery is essential.
How Should I Operate? Anatomy of

the Compartments of the Foot
The term debridement is widely used in the literature about Figure 67. Subepidermal abscess
foot ulcers and infections referring to many very different
procedures.10,69,78-86 Elimination of the surrounding hyper-
keratosis in plantar ulcers is sometimes defined as
debridement. Debridement also includes treatments such
as removing slough, minor skin necrosis, and nonviable tis-
sues of the wound. Sometimes, the term bone debridement
has been used in reports about diabetic foot oste
omyelitis.87,88 For the sake of clarity, the term debridement
should only be used when referring to the removal of infected,
devitalized, or necrotic skin or soft tissue. Generally, minor
debridement in outpatients will be necessary in cases of
noninfected and mildly infected foot ulcers (Figures 67
and 68). Surgical debridement includes procedures per-
formed in the operating theatre to drain pus and remove
necrotic and infected tissue as part of the treatment of the
infection (Figure 69).
The use of defined terminology will permit meaningful
comparisons between the reports.23,63 The surgical treat- Figure 68. Subepidermal abscess after debridement
ment of DFIs is based on 3 principles: having thorough
knowledge of the compartments of the foot,89 the ability to
identify how infection spreads, and the surgical skills to
detect and solve postoperative complications.
Knowledge of the anatomy of the foot, which is divided
into several rigid compartments, may help explain the clini-
cal characteristics of the infection and the spreading of
infection through the foot. In the sole of the foot, the plantar
aponeurosis is the outermost fascia. Its central portion is the
thickest and is attached to the calcaneous. The fascia then
spreads fanlike distally. The plantar aponeurosis forms the
inferior boundary of the 3 plantar compartments. These 3
compartments in the foot are medial, central, and lateral
(Figure 70).
Figure 71 presents a transmetatarsal cross section of the
compartments of the foot. The septum transversum is located
in the central compartment, and it has been argued that the
central compartment has 2 subcompartments—superficial
and deep or “calcaneal” section90—though this subdivision Figure 69. Surgical debridement in the operating theatre

Aragón-Sánchez 53
relieve the raised compartmental pressure and hence the

danger of necrosis.
Knowledge of the structure of the fascial compart-
ments of the foot permit understanding of how infections
of the big toe spread through the internal compartment
(Figures 72-74).
The infections of the second, third, and fourth toe spread
through the central compartment (Figures 75-77), and the
infections of the fifth toe spread through the external com-
partment (Figures 78-80).
The fascial planes do not contain the infection in the
forefoot as has been reported using MRI.92 It is very impor-
tant to detect the spreading of the infection through the
compartments. The spreading in some cases of forefoot
infections forces the surgeon to perform a transmetatarsal
amputation. The plantar aponeurosis spreads fanlike in the
forefoot and there are many attachments between the fibrous
septa and the subcutaneous tissue then forming loculations.
Between the superficial transverse metatarsal ligament
(deeper) and the superficial layer of the digital band of apo-
Figure 70. Compartments of the foot
neurosis, a virtual plantar space exists through which infections
can spread (Figure 81). The author considers this type of
spreading of the infection as “transversal spreading” because
it is transverse to the major axis of the foot.
An example of this type of spreading is shown in Figure 82.
The patient had had a neuropathic foot ulcer for 3 months.
She was referred for pain, fever, bad metabolic control, and
extensive redness (Figure 83) over the previous 15 days.
Oral antibiotics and immersion baths had been prescribed
by her surgeon. There was spontaneous suppuration through
the ulcer and pain while palpating the plantar and dorsal
surfaces. Fistula with abundant suppuration was seen in the
fourth toe. We suspected osteomyelitis of the fifth metatar-
sal head and transversal spreading of the infection and indicated
urgent surgery.
The first step was to check the path of spreading of the inf
Figure 71. I, II, II, IV,V: Metatarsal bones. (a) Medial ection and the transversal plantar space was opened (Figure 84).
compartment, (b and c) Central compartment, (d) Lateral Total healing was achieved after surgery (Figure 85).
compartment, (e) interosseus compartment We have observed this type of spreading of the infec-
tions in 9 cases. The fifth ray was the point of entry of the
infection 7 times, the third metatarsal head in one, and the
was not recognized by other authors.91 The structures that third toe in another. These ways of spreading are shown in
are included in each compartment are shown in Table 3. the Figure 86. This type of transversal spreading when the
When infection penetrates into a compartment, there is point of entry of the infection was the hallux has not been
an increase of the compartmental pressure. The pressure experienced in the author’s unit.
in the compartments in neuropathic patients may also be Infection often spreads through the foot via tendons and
increased because of edema caused by the sorbitol pathway their sheaths. Tendons and their sheaths are poorly vascu-
and increase in the capillary permeability.89 When compart- larized structures that pass through the compartments. This
mental pressure exceeds the capillary pressure, necrosis type of spreading is a “longitudinal spreading” because the
occurs. This creates the ideal conditions for bacteria to spread tendons are placed in the longitudinal axis of the foot. In
through the compartment. Bacterial growth, toxins, and leu- this case (Figure 87), one can see the spreading of the infec-
cocyte response may also cause and increase the necrosis. tion along the flexor tendons that pass through the central
The infected compartment should be opened quickly to compartment.

Table 3. Compartments of the Foot and Its Contents

Interosseus
Medial (Figure 71a) Central (Figure 71b and c) Lateral (Figure 71d) (Figure 71e)
Flexor hallucis brevis Section b Flexor digiti minimi Interossei muscles
brevis
Abductor hallucis Flexor digitorum brevis Abductor digiti minimi
Flexor hallucis longus tendon (under the Lumbrical muscles
head of first metatarsal head the tendon is
located between the sesamoid bones)
Flexor digitorum longus
tendons
Section c
Quadratus plantae
Figure 74. The total healing of the postoperative wound
Figure 72. Necrotizing soft tissue infections. Arrows show

the way of spreading of the infection through the medial
compartment
Figure 75. Ulcer under the fourth metatarsal head. Arrows

show the spreading of the infection through the central
compartment. In the lateral view one can see the redness near
the ankle
Another case presented in Figure 88 showed necrosis of

the fourth toe and midfoot. When the central compartment
was opened, necrotizing tenosynovitis and mionecrosis
Figure 73. The medial compartment was opened widely were observed.

Aragón-Sánchez 55
Figure 76. Central compartment opened widely
Figure 79. Extensive debridement of the external compartment

was carried out
Figure 77. Total healing. Foot saved
Figure 80. Total healing
Figure 89 shows how the infection spreads through the

dorsal surface along the extensor hallucis longus tendon. In
the cross section of the specimen we can observe skin and
subcutaneous necrosis, necrosis of the extensor tendon, and
healthy bone and plantar soft tissue (Figure 90).
Extensor tendons are commonly involved in cases of
spreading of infections through the dorsum of the foot
(Figure 91).
Figure 78. Spreading infection through the external Figure 92 shows the case of a patient who had a trauma
compartment. The point of entry was a plantar ulcer. Muscle over the external side of his foot and had been admitted with
necrosis was found during surgical treatment fever, chills, leukocytosis, and confusion. The point of entry

Figure 83. Extensive cellulitis of the dorsum of the foot
Figure 81. Distal spreading of the plantar aponeurosis and

superficial transverse metatarsal ligament in the forefoot
Figure 84. Transverse spreading of the infections. The track is
detected introducing the forceps gently. The compartment was
opened widely
Figure 82. Neuropathic ulcer under the fifth metatarsal head
of the infection over the tuberosity of the base of the fifth

metatarsal and the extensive skin necrosis can be seen.
Figure 93 shows the presence of free gas in soft tissue. He
underwent an emergency guillotine transtibial amputation. Figure 85. Total healing of the postoperative wound

Aragón-Sánchez 57
Figure 86. Several types of transversal spreading found in our

experience
Figure 89. Necrotizing soft tissue infection with involvement of
the dorsum of the big toe. Cellulitis. Spreading along the extensor
hallucis longus should be taken into account in such cases
Figure 87. Spreading of the infection along the flexor tendons

that are included in the central compartment
Figure 90. Cross-section of the big toe
Figure 88. Necrotizing tenosynovitis and mionecrosis through

the central compartment
Figure 91. Severe involvement of the extensor tendons
In Figure 94, the spreading of this infection is analyzed: tendon of the peroneus brevis is attached to the tuberosity of
along the peroneus tendons. Necrotizing tenosynovitis along the base of the fifth metatarsal and the tendon of the pero-
these tendons and myonecrosis were found in this case. The neus longus is close to the peroneus brevis (Figure 95).

Figure 92. Necrotizing soft tissue infections. The point of entry Figure 94. Analysis of the specimen. Necrotizing tenosynovitis
was located in the tuberosity of the base of fifth metatarsal along these peroneus brevis and longus tendons and
myonecrosis was found in this case
Figure 95. Diagram showing the running of the peroneus

tendons
Figure 93. X-ray showing gas in soft tissues
Necrotizing changes are not always found when the ten-

dons are involved. The case in the Figures 96 to 98 was
treated for osteomyelitis of the tuberosity of the base of the
fifth metatarsal with proximal spreading along the peroneus
tendons. In this case, the spreading of the infection along the
peroneus but without any necrotizing changes (Figure 96)
may be observed; the foot was saved (Figures 97 and 98).
The surgeon should take into account other ways of
spreading of the infection. Infections can also spread to the Figure 96. Peroneus longus with nonnecrotizing tenosynovitis
adjacent bone in cases of forefoot infections. If the infection before removal

Aragón-Sánchez 59
Figure 97. Postoperative wound Figure 99. Wound deterioration and necrosis of the forth toe
appeared 20 days after the fifth toe amputation. X-ray shows the
spreading of the infection to the fourth metatarsal head

Figure 100. Analysis of the specimen. Fourth metatarsal head
is encircled and green arrows show the path of spreading of the
is not completely eliminated, infectious foci may complicate infection. White arrow show the gross destruction of the bone
the postoperative period. Figure 99 shows a postoperative
wound following a little toe amputation. Twenty days later,
the wound had deteriorated and areas of skin necrosis had
appeared. The x-ray shows the spreading of the infection to
the fourth metatarsal head (Figure 99). The patient under-
went an open transmetatarsal amputation (Figure 100).
Arrows show the path of spreading of the infection. Gross
destruction of the fourth metatarsal head may be observed.
Figure 101 shows the open transmetatarsal amputation that
healed (Figure 102). In our experience, antibiotics and local
wound care alone are inadequate to control this type of
spreading of the infection.
Outcomes of Surgical Treatment of DFIs

Little is know about long-term outcomes after foot surgery
for limb salvage,9 and this statement is especially true in Figure 101. Open transmetatarsal amputation

management of foot infections. Other authors have also

reported high short-term limb salvage with aggressive treat-
ment of invasive foot infection during a period of less than
48 hours from admission followed by autogenous bypass.76
Eneroth et al2 reported that 43% of their patients healed
after an amputation (major or minor). The total rate of major
amputations was 10.7%.2 These good results in patients with
ischemia contrast with the outcomes of digit amputations in
diabetic patients with presumed adequate circulatory status.
Complete healing was achieved in only 34%, and infection
persisted in 36% of the operated limbs.97 Twenty-four per-
cent of the patients underwent a major amputation.97 A higher
rate is found in 1 study in which life-threatening infections
were excluded; 33% of the patients underwent amputations
although the level where these were performed is not
stated.98 The timing at which the surgical treatment was car-
ried out was not reported either. Despite peripheral vascular
disease being the cause of nearly all the wounds, a bypass
cases of bone infection. The relapse of osteomyelitis after was performed in only 1 of the 26 patients who underwent
treatment is a worrying complication in the treatment of amputation (3.8%) and in only 2 of the 52 patients who did
these patients. A high rate of nonhealing wounds compli- not undergo amputation.98 In the multivariate analysis, the
cated with osteomyelitis has been reported in a predominantly peripheral vascular disease (diagnosed as an obstruction by
surgical series.93 Wide excision of necrotic and infected a Doppler study) increased the risk of amputation by 12.5
bone with 5 mm or greater of clearance has been shown to times.98 These results highlight the importance of appropri-
reduce the risk for recurrence in cases of chronic osteomy- ate vascular treatment. Faglia et al10 reported that when
elitis,94 but in this study only 7 out of 50 patients (14%) had aggressive revascularization was carried out, deep foot
chronic osteomyelitis that had spread from an overlying infections in ischemic patients had the same prognosis as in
ulcer. It is difficult to extract any conclusion from this study nonischemic patients. Early surgical debridement of deep
for the treatment of bone infection in the feet of patients foot abscesses and revascularization are the keys to achiev-
with diabetes. Osteomyelitis of the digits is usually treated ing good results.10 Only 4.7% in a group of 106 patients
by amputation of the affected toe.95 The approach adopted with deep foot infections underwent major amputation.
by some including this author87,96 is to perform conservative Revascularization was performed in 60.3% of the patients.
surgery in cases of diabetic foot osteomyelitis.23,63 In our Eighty-nine percent of the procedures were carried out
previously reported series, after excluding the patients for using an endovascular approach.10 Another group of authors
whom conservative surgery was found on admission not to using extensive angioplasty in patients with critical ischemia
be possible, 111 patients underwent conservative surgeries as and severe foot ulcers reported 15.7% of major amputations
the first choice. Of those, only 20 (18%) required subsequent and 60.8% of wound healing after 4.9 ± 0.9 and 9.4 ± 0.5
amputations: 13 minor (11.7%) and 7 major amputations months of follow up, respectively.99 Hartemann-Heurtier
(6.3%).23,63 However, we have data about recurrence of the et al96 reported the outcomes of specialized treatment of
bone infection and midterm follow-up with our approach. severe foot ulcers. Although this work is not specifically
This remains a key question when treating these patients. dedicated to infections, the authors included 114 patients,
Another group of authors included in their series 114 51 of whom had osteomyelitis. The limb salvage rate was
diabetic patients who underwent emergency surgery for 97.5% (3 major amputations), and the minor amputation
indications of infection, gangrene, or infected neurotrophic rate was 31% (n = 37). Ten patients (8.5%) died before
ulcers.70 Surgery was always performed within 48 hours of healing was achieved. There were no deaths in the intraop-
admission in the operating room under regional (never local) erative or immediate postoperative period.96
anesthesia. Forty-seven percent of those patients underwent Amputation rates may depend on the particular local
2 or more surgical procedures. The authors stated that early approach of the surgeons,98 but the experience and skills of
aggressive drainage, debridement, and local foot amputa- the surgeon should also be taken into account.9 Diabetic
tions combined with liberal use of revascularization resulted foot surgery must not be considered a “minor procedure”
in cumulative limb salvage of 74% at 5 years.70 This aggres- that can be performed by anyone. It has been reported that
sive policy in this series was safe since only 1 patient died the level of experience of the surgeon conditions the out-
due to myocardial infarction. We agree with this aggressive comes after amputations due to DFIs.100 Taylor and Porter70

Aragón-Sánchez 61
Figure 104. Severe deformity of the foot for residual

osteomyelitis after undergoing the amputation of the second toe
by a doctor without surgical experience
Figure 103. Multiple holes made as debridement. No anatomic

planes and ways of spreading of the infection were taken into
account
were aware of this issue, and they stated in their report that
senior surgeons carried out the procedures and the operations
were not delegated to unsupervised junior house officers.70
The consequences of performing diabetic foot surgery with-
out experience and appropriate training may be disastrous
for the patient. Because inadequate “debridement” rarely
achieves the resolution of the problem, the patient should
quickly be referred to a specialized unit. Previous proce-
dures may condition the proper surgery that the patient
should undergo. One can see in Figure 103 a patient who
had undergone “debridement” for foot infection. Debride-
ment had been performed by a doctor without surgical
training. Multiple holes were made in the foot when new
sites of necrosis appeared during a 1-month stay in another
hospital. Appropriate treatment of the infection was not per-
formed in this case and the patient had to undergo a below
the knee amputation. In Figure 105 one can see another Figure 105. X-ray showing pathological fracture of the base of
illustrative case. A patient who had undergone amputation the second metatarsal, osteolisis of the second metatarsal, and
of the “infected second toe” was referred to our unit after destruction of the third metatarsophalangeal joint
7 months of antibiotic treatment and wound care. Amputa-
tion had been performed by a doctor without surgical training.
The patient had severe edema, suppuration, deformity, and debridement in a patient who should have undergone a clin-
an unhealed wound (Figure 104). An x-ray was taken on ical evaluation to rule out severe ischemia. Surgeons who
admission (Figure 105) showing pathological fracture of have to treat patients with diabetic foot problems must be
the base of the second metatarsal, osteolisis of the second aware that debridement should not be done before knowing
metatarsal, and destruction of the third metatarsophalangeal the etiology of the ulcer. Debridement in a foot suffering
joint. The limb was able to be saved in this case. In Figure 106, from critical ischemia should only be done in cases of severe
one can see the consequences of performing inappropriate infections and when revascularization has been scheduled.

when the debridement must be performed by a specialist

surgeon. Referring the patient to a center with experience of
diabetic foot problems may be the best way to achieve limb
salvage. The outcome of surgery largely depends on the
skill and experience of the surgeon and the degree of care
taken.9 Specialized teams in acute diabetic foot problems
may result in a reduction of lower limb amputations.96,101
In conclusion, DFI is a dramatic event that can threaten
the limb in many cases. The clinical presentation of DFIs is
extremely varied, and the clinician should know the keys to
deciding when the surgery is absolutely essential. In severe
cases and many cases of moderate infections surgical treat-
ment is required. Advanced imaging studies can help the
clinician make a decision but in most cases a comprehen-
sive clinical evaluation and plain x-ray are sufficient to
diagnose the patient. If surgery has been indicated, the best
outcomes are obtained if the procedure is done early. Prompt
revascularization whether using bypass or endovascular
approach is necessary to achieve the best results. The surgeon
involved in the care of these patients should have a com-
prehensive knowledge of the anatomy of the foot besides
knowing perfectly the difficult physiopathology of the dia-
Figure 106. Extensive necrosis after debridement in a foot betic foot. The surgeon who looks after these challenging
suffering from critical ischemia
patients must perform aggressive debridement but be con-
servative when amputation is required.
Acknowledgments
The author would like to acknowledge Neil Rutishauser for review-
ing the English and for his technical support and friendship.
Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interests with respect
to the authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research and/or
authorship of this article.
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The International Journal of Lower Extremity

The online version of this article can be found at:

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>> Version of Record - Mar 28, 2011

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A Review of the Basis of Surgical Extremity Wounds

Javier Aragón-Sánchez, MD, PhD1

Part A However, no classification exists to determine either the

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Figure 4. Severe destruction of the third metatarsal head

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Figure 6. Necrotizing fasciitis. Necrosis of the big toe and

Figure 5. Important edema of the dorsum of the foot. More

distal pulses should be considered a sign of infection. In such

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as the port of entry of the infection and not as a type of

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Figure 17. X-ray showing the spread of the infection to the

diabetic patients undergoing puncture wounds has been

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Deep ulcers may expose fascia, tendons, joint, and/or

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What Type of Infection

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Table 1. Classification of Diabetic Foot Infections According to Their Severity

IDSA PEDIS Grade (IWGDF)

Table 2. Clinical-Pathological Classification Of Diabetic Foot

 Deep tissue abscess

Joint infections • Septic arthritis

Abscesses may be confined to subcutaneous tissue. In

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Figure 33. Subepidermal abscess Figure 36. Paronichia

Figure 37. Subcutaneous abscess on the heel. Extensive

Figure 35. Epidermis has been removed and the wound is

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Figure 42. Necrotizing soft tissue infection in a patient with

Figure 39. Deep abscess. Cellulitis of the dorsum of the foot

Figure 40. Drainage of the pus

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In other reports, the term fetid foot has been used as a

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Figure 56. X-ray showing osteomyelitis of the interphalangeal

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The final illustration of the variety of clinical presentations

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Figure 61. Critical ischemia misdiagnosed as “paronychia”

presence of a foreign body. Gas in soft tissues may be a sign

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although there is no agreed best interval. If the diagnosis

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deep soft tissue abscesses, or gangrene accompanying

How Should I Operate? Anatomy of

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relieve the raised compartmental pressure and hence the

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Table 3. Compartments of the Foot and Its Contents

Figure 74. The total healing of the postoperative wound

Figure 72. Necrotizing soft tissue infections. Arrows show

Figure 75. Ulcer under the fourth metatarsal head. Arrows

Another case presented in Figure 88 showed necrosis of