SLR - June 2018 - Candace Criscione
Reference: C. Setacci, P. Sirignano, G. Mazzitelli, F. Setacci, G. Messina, G. Galzerano, G. de Donato. Diabetic Foot: Surgical Approach in Emergency. International Journal of Vascular Medicine. 2013 Oct 23; 2013: 296169.Scientific Literature Review
Reviewed By: Candace Criscione, DPM
Residency Program: MetroWest Medical Center, Framingham, MA
Podiatric Relevance: 6.5 percent of the world population is burdened by diabetes mellitus. Associated complications of diabetes mellitus include microangiopathic and macroangiopathic complications. Patients with arterial obstructive disease have increased risk of amputation. Up to 10 percent of patients living with diabetes will develop a foot ulcer; this is a commonly encountered pathology in our field. Patients with diabetic foot infections often need to be treated through a multispecialty approach involving podiatry, vascular and infectious disease. Because of the high occurrence of vascular complications associated with diabetes, these patients often require vascular intervention along with surgical debridement and antibiotic therapy. The purpose of this study was to review the results of patients with infected diabetic foot ulcers who underwent surgical debridement with delayed revascularization versus surgical debridement with early revascularization through a multidisciplinary approach.
Methods: From January 2007 to December 2011, 375 patients with diabetic foot infections and critical limb ischemia were admitted to the hospital for treatment. From 2007 to 2009, 192 patients (group A) underwent surgical debridement of the foot followed by delayed revascularization. From 2010 to 2011, 183 patients (group B) underwent treatment through a four-step protocol: early diagnosis within 24 hours, aggressive surgical debridement, early revascularization, long-term care involving wound healing, reconstructive surgery and orthosis. Patients underwent clinical examination, ABI measurements and ultrasound examination. Endovascular intervention was performed in 84.7 percent of patients, and intraoperative surgical conversion was performed if this failed. The Kaplan Meier method was used to compare survival rates, amputation rates and wound healing rates between the two groups at six month follow-up.
Results: Patients in group A underwent revascularization approximately three days following the debridement with a range of one to seven days. Patients in group B underwent revascularization within 24 hours following debridement. All patients underwent revascularization. Endovascular revascularization was successful in 84.7 percent, and those that failed were converted to intraoperative open revascularization. All patients were placed on a culture-specific antibiotic regimen. At six months, there was a statistically significant difference in mortality between the groups with 11 percent deaths in group A and 4.4 percent deaths in group B. Major amputation rates were 39.6 percent in group A and 24.6 percent in Group B. Wound healing was achieved in 17.8 percent of group A and 20.8 percent in group B.
Conclusions: In patients with diabetic foot infections, the immediate goal of therapy is infection control; however, adequate blood flow restoration is crucial to help provide pain relief, promote wound healing and avoid amputation. This four-step protocol can help decrease mortality and amputation rates and increase wound healing potential. It is important to remember that optimal treatment of diabetic foot infections involves a multidisciplinary team involving early diagnosis, debridement and revascularization.