Classifying diabetic foot surgery: toward a rational definition

Abstract

The purpose of this manuscript was to describe a classification of diabetic foot surgery performed in the absence of critical limb ischaemia. The basis of this classification is centered on three fundamental variables which are present in the assessment of risk and indication: 1) the presence or absence of neuropathy (loss of protective sensation); 2) the presence or absence of an open wound; 3) the presence or absence of acute, limb-threatening infection. The conceptual framework for this classification is to define distinct classes of surgery in an order of theoretically increasing risk for high-level amputation. These classes include: Class I: Elective Diabetic Foot Surgery (procedures performed to treat a painful deformity in a patient without loss of protective sensation); Class II: Prophylactic (Procedure performed to reduce risk of ulceration or reulceration in person with loss of protective sensation but without open wound); Class III: Curative (Procedure performed to assist in healing open wound) and Class IV: Emergent (Procedure performed to limit progression of acute infection). The presence of critical ischaemia in any of these classes of surgery should prompt a vascular evaluation to consider a) the urgency of the procedure being considered and b) possible revascularization prior or temporally concomitant with the procedure. It is our hope that this system begins a dialogue amongst physicians and surgeons which can ultimately facilitate communication, enhance perspective, and improve care.

Challenges in the Treatment of Chronic Wounds

“…49,95 Surgical offloading is a term that (as its name implies) refers to the surgical management of foot deformities causing high pressures resulting in chronic ulcerations. [96][97][98] While not generally considered a primary treatment for most neuropathic DFUs, those that prove to be recalcitrant to standard wound bed preparation and effective offloading should be considered for surgical internal decompression. Many such procedures have been reported as effective over the last several decades.…”

Diagnosis and Treatment of Diabetic Foot Infections

“…Many infections require surgical procedures that range from drainage and excision of infected and necrotic tissues to revascularization of the lower extremity and reconstruction of soft-tissue defects or mechanical misalignments [164][165][166][167][168]. Unfortunately, surgical treatment of diabetic foot infections is based on even less-structured evidence than that for antibiotic therapy [169]. Seek urgent surgical consultation for life-or limb-threatening infections, such as those presenting with necrotizing fasciitis, gas gangrene, extensive soft-tissue loss, or evidence of compartment syndrome, or those in limbs with critical ischemia (A-II) [170,171].…”

How long to treat with antibiotics following amputation in patients with diabetic foot infections? Are the 2012 IDSA DFI guidelines reasonable?

“…2 There are currently no data to support using antibiotics to treat wounds after evidence of infection resolution in an attempt to either hasten healing or to prevent recurrent infection. 2,9 Unfortunately, evidence-based treatment recommendations for patients who require amputations are based on poorer quality of evidence than patients who just 17 This is especially evident when trying to determine the duration of antibiotic treatment after amputation. Therefore, our objective is review the literature evaluating antibiotic treatment in DFI to determine if the IDSA guideline recommendations are reasonable.…”