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12 Debridement oftheDiabetic Foot andLeg
Fig. 12.9 Surgical debridement instrumentation is appreciated. The time-honored instruments utilized for surgical
debridement include, but are not limited to, rounguers, curettes, scissors, and scalpel blades
165
Fig. 12.10 The micro water jet device is a useful adjunctive instrument utilized for meticulous debridement of tissues of the foot and leg. Despite its obvious benets, its
use should be judiciously implemented as a supplement to
the normal manual instrumentation for traditional surgical
debridement
Technique
Atraumatic Technique
Regardless of the precise location, topography,
or etiology of a wound, proper tissue handling is
paramount and may quite literally “make or
break” an attempted wound closure, especially
in the comorbid population. Sterling Bunnell,
M.D. (1882–1957) (Fig.12.11), rst coined the
term “atraumatic technique” to describe how tissues ought to be handled during surgery [9].
Although written a century ago, his tenets of tissue handling have remarkably withstood the test
of time and are quite pertinent to all surgical specialties today. In the debridement of foot and leg
wounds an atraumatic technique should be
implemented at all times in order to preserve
vascularity to the existing and surrounding tissues and maximize the potential for healing.
This is perhaps no more pertinent than in the diabetic and comorbid population, where the risk
for complication is exponentially increased. One
should minimize excessive traction and manipulation of the tissues. This is best accomplished
with strictly intent motions and manipulations
and blunt retraction only when necessary for
appropriate visualization. Proper instrumentation selection is key to preserving an atraumatic
technique. A thorough understanding and knowledge of the available instrumentation and more
importantly how well a particular surgical task
can be performed in one’s own hands is crucial.
For example, the authors often prefer to forgo
the use of forceps for tissue handling unless
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Fig. 12.11 Dr. Sterling Bunnell (1882–1957) rst coined
the term “atraumatic technique” to describe how tissues
ought to be handled during surgery. His tenets remain pertinent to all surgical specialties today, especially in the
debridement of the foot and leg
absolutely necessary, especially during suturing
as this will cause repeated trauma to the microvasculature of the remaining tissue periphery.
Rather, the use of strategically positioned and
oriented sutures are best utilized for transposition, rotation, and overall manipulation of tissues during a denitive wound closure attempt.
Ideally, when utilizing suture material one
should use a nonabsorbable monolament. The
authors prefer a vertical mattress technique when
reapproximating most skin layer closures
directly for its superior mechanical hold of tensioned stresses. Absorbable monolament
sutures are used when afxing split thickness
skin grafts or skin substitute grafts with staple
supplementation where warranted; however, this
is largely driven by surgeon preference.
Debridement ofSkin
Debriding skin consists of removing nonviable
and/or nonbleeding skin. Anecdotally, if the
injured skin does not blanch, is insensate, and has
C. E. Attinger and J. N. Atves
blistered, it is unlikely that it will survive. This is
the equivalent of a third-degree burn. No advantage can be gained by waiting in the hopes that
this skin suddenly revitalizes. At the edges and
under the dead skin, there is a high concentration
of harmful proteases with or without bacteria to
inhibit subsequent healing. The protracted course
necessary for the dead skin to separate itself from
the underlying tissue may lead to functional loss,
poor scarring, deeper tissue damage, and disseminated infection. Therefore, the approach to nonviable skin should be to remove it as soon as
possible. If the border between live and dead tissue is demarcated clearly, then the skin should be
excised along that border. If the border demarcation is unclear, then one should start at the center
and remove concentric circles of skin until the
level of viable tissue is appreciated. When excising skin, one should seek bleeding at the normal
skin edge. Thrombosed venules at the skin edge
reect a complete interruption in the local microcirculation and are an excellent indicator that further skin excision is needed. Only when there is
normal arterial bleeding at the edge of the wound
can one be satised that the cutaneous debridement has been adequate.
When removing the skin, it is important to
examine the subcutaneous tissue. If the tissue
appears viable but is infected, then a topical antibiotic should be placed on the wound [10–12].
For Pseudomonas infections, 0.25% acetic acid
or gentamicin ointment may be more appropriate.
For MRSA infections, mupirocin (Bactroban) is
an appropriate initial topical antibiotic; however,
one should keep in mind that resistance can
develop quickly [13].
Debridement ofSubcutaneous Tissue
Subcutaneous tissue consists of subcutaneous
adipose tissue, cutaneous vessels, and cutaneous
nerves. However, due to the decreased concentration of blood vessels in the subcutaneous fat,
bleeding at the tissue’s edge is not always a reliable indicator of tissue viability. Healthy fat has a
shiny yellow color and is soft and resilient. Dead
fat has a grey pallor to it, is hard, and is nonpliable. Fat should be debrided until soft yellow
normal-appearing fat is attained. Undermining
12 Debridement oftheDiabetic Foot andLeg
167
should be avoided as it threatens the viability of
the overlying skin. To prevent desiccation, it is
important to keep the fat in a moist environment
after debridement. Small blood vessels should be
coagulated with bipolar cautery to minimize
damage to the surrounding tissues. If the vessels
are larger than 2–3 mm, then they should be
ligated. Liga-clips are the least reactive foreign
body material to accomplish this task. If a suture
is to be used, then a small diameter monolament
suture should be used to minimize the risk of
facilitating further infection. For example, silk
acts like a foreign body and stimulates a vigorous
foreign-body reaction, and bacteriostatic,
polyglycolic- woven suture has multiple recesses
within which bacteria can survive in a semiprotected state.
Nerves, when viable, have a shiny, white, glistening appearance to them. In the subcutaneous
tissue, the cutaneous nerves are sensory in function. Intact exposed sensory nerves in a sensate
patient can be painful. The decision must be
made whether to remove or preserve them. If the
nerve is to be preserved, then it has to be kept
moist until it can be covered with adequate tissue.
A skin graft alone does not provide an adequate
tissue interface to prevent pain on contact to the
nerve and thus consideration should be given to
burying the nerve underneath other tissue or a
ap. If the nerve is to be sacriced, then longitudinal traction should be utilized to allow the
nerve to retract within normal tissue when it is
cut at the edge of the wound. Taking the epineurium and sewing it over the nerve fascicles with
8-0 or 9-0 suture can minimize the possibility of
stump neuroma formation.
Debridement ofDeep Tissues
Healthy fascia has a distinct white, glistening,
and hard appearance and should be preserved if it
appears viable. When devitalized or dead, the
appearance is dull, soft, and stringy and is in the
process of liquefactive necrosis. All necrotic fasciae should be debrided until solid normalappearing fascia is reached. Since neurovascular
bundles can be close to the overlying fascia,
debridement should proceed with caution. The
viable fascia must be kept moist in the post-
debridement period to avoid desiccation and ultimately necrosis. The underlying muscle must be
examined as well. Healthy muscle has a bright
red, shiny, and resilient appearance to it and contracts when grasped with forceps or touched with
electrocautery. In neuropathic patients, the muscle may have a pale, perhaps yellowish, color and
may appear nonviable. It will, however, have
some tone and bleed when cut. Frankly dead
muscle will be swollen, dull, and grainy when
palpated and falls apart when pinched. If viability
of the muscle is questionable, it is best to err on
the side of caution and remove only what is not
bleeding and appears nonviable. Subsequently,
the wound should be serially debrided until only
viable muscle remains. There is always a question of whether to remove the entire muscle when
part of it is dead. Generally, one should remove
only what is dead because removing the viable
portion of the muscle involves further dissection
that may very well compromise blood ow to the
surrounding tissues. Tendon debridement is
always complex because sacrice of most tendons may lead to a signicant loss of function.
All attempts should be made to preserve viable
paratenon surrounding the tendon. The tendon
must be kept moist after debridement, and this
requirement becomes all the more important
when the paratenon is removed. The tendon
should be covered with viable tissue as soon as
the wound is stabilized. Otherwise, the tendon
will desiccate, necrose, or become infected.
Infected tendon looks dull, soft, and grainy with
parts fraying, liquefying, or both. The treatment
is to shave the tendon to viable, hard, and shiny
texture and appearance and then ensure that it
stays moist until it granulates sufciently to be
skin grafted or is clean enough to be covered with
other tissue. If the tendon is small or infected, all
of the exposed portions should be removed. It is
important to make a proximal and distal incision
above and below the exposed tendon to ensure
that any hidden necrotic tendon is removed also.
When the extensor tendons on the dorsum of the
foot become exposed, it is hard to preserve them
unless they quickly are covered with healthy tissue. If the tendons remain in place while the
wound progresses to the point at which it is ready
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C. E. Attinger and J. N. Atves
to be closed, they usually become infected and
impede further wound healing until they are
removed. When the tendon is larger (i.e., Achilles
tendon, anterior tibial tendon, etc.), only that portion of the tendon that is necrotic or infected
should be debrided. The hard, shiny tendon
underneath should be left intact. Great care
should be taken to keep the remaining tendon
moist. The Achilles tendon deserves special mention since it is the largest tendon in the body and
receives excellent blood supply from the posterior tibial and the peroneal arteries. If exposed
and healthy, it should be covered with a local,
pedicled or free ap as soon as the wound is stable. If part of the tendon is necrotic, it should be
debrided to a hard, shiny tendon. It should be
kept moist with an occlusive dressing while granulation tissue forms. Once surrounded by granular tissue the tendon can be skin grafted atop.
Granulation tissue formation can be accelerated
with the vacuum assisted closure (V.A.C.) device
(rst covering the tendon with a Vaseline mesh
gauze) or with the combined usage of hyperbaric
oxygen treatments and a topical growth factor
product or skin substitute “graft” [14].
Debridement ofBone
Debridement of necrotic or dead osseous tissue is
relatively straightforward. Any soft, nonbleeding
bone should be removed. Useful manual instruments include rongeurs, curettes, and rasps.
Power instrumentation such as the sagittal saw
and the rotary cutting burr is also quite useful, if
not necessary. The key in debriding bone is to
remove only what is dead and infected, leaving
bleeding bone behind. Care should be taken not
to signicantly disrupt viable bone. In this regard,
power instruments are safer to use than rongeurs,
chisels, or osteotomes. The best way to debride
the osteomyelitic smaller long bones (phalanx,
metacarpals, or metatarsals) is to cut slices of
bone serially until healthy bone is reached. For
larger bones (tibia, bula, calcaneus, talus, etc.) a
rotary cutting burr should be used to remove
layer-by-layer of the osteomyelitic bone until
healthy bleeding bone is encountered. Copious
irrigation should be used to ensure that the heat
generated by the burr does not damage the healthy
bone. When burring the cortical bone, the process
is continued until punctate bleeding is visualized
emanating from the cortical bone (Paprika sign).
This signies that healthy bone has been reached.
When debriding cancellous bone, bleeding and a
normal-appearing marrow is ideal. Biomechanical
considerations should not deter the surgeon from
debriding enough bone to ensure that all osteomyelitis has been eradicated. Correction of the
resultant biomechanical aberration can be made
once the wound has been stabilized or healed.
Current orthopedic techniques, including bone
grafting, antibiotic spacers, and the use of external xators allow repair of many bone defects
with a preservation of alignment and stability. It
is important to obtain cultures of what is considered a normal bone margin proximal to the area
of debridement and of the debrided osteomyelitic
bone. Once the infected bone has been removed
and only bleeding healthy bone is left behind,
then the wound is “primed” to close, assuming
the surrounding soft tissue is also healthy. When
healthy uninfected bone remains, only 2–5 days
of appropriate antibiotics may be necessary after
wound closure [15]. The exception to a 1-week
course of antibiotics post closure is when the surgeon suspects that the bone left behind may still
harbor osteomyelitis. In this instance, a longer
course of antibiotics may be indicated.
Staged Approach
Much has been recognized on the use of a staged
approach to lower extremity pathology especially
in instances of large soft tissue loss or bony decit. In truth, surgical wound management is perhaps the prototypical procedure type for a staged
approach due to the precarious and potentially
catastrophic stakes associated with improper
wound management, especially in the diabetic
and comorbid population. The successful eradication of infection with minimization of bacterial
bioburden should be considered the primary goal
of surgical debridement. In this light, it is imperative to accurately and condently determine the
successful acquisition of an infection-free wound
bed. This goal may seem simple to the untrained
or inexperienced clinician. However, a staged
approach is the only manner in which to guaran-
12 Debridement oftheDiabetic Foot andLeg
169
tee the appropriate preparation of a wound bed.
Especially in the comorbid population, the eradication of infection and bacterial burden can prove
to be a burdensome and exhaustive struggle
necessitating numerous returns to the operative
theater for continued surgical debridement [16].
Ideally, prior to denitive closure the wound will
yield negative microbiology cultures and a
healthy progressive character which has not stagnated nor digressed in character with continued
infection, bacterial harborization, or tissue necrosis. Rather, tissues will display a progressive
improvement in overall character with perhaps
improvement in overall wound size. Only once a
wound has successfully completed the primary
goal of eradication of infection and minimization
of bacterial bioburden has it reached candidacy
for soft tissue closure. For these reasons we advocate for a staged approach to surgical wound
management in order to maximize the potential
for a condent closure while minimizing the likelihood for recurrence.
Additionally, we routinely utilize and lobby
for the universal use of a two-table or “dual”
operative setup for each surgical debridement
(Fig. 12.12). In this operative setup the rst
“dirty” table is utilized for the bulk of surgical
debridement and infective source control.
Following sufcient debridement and copious
lavage of the wound site the second or “clean”
table setup is utilized. Between chronological use
of the dual tables both outer gloves, draping, and
light handles are changed to a new sterile setup.
This tact alone provides for signicant control of
possible cross-contamination of the predebridement wound tissues and ora with the
post-debridement wound state [17].
Save asMuch Tissue asPossible Prior
toClosure
An indispensable tact for permitting the greatest
potential for soft tissue envelope closure options,
regardless of the exact location or topography of
the wound, is to save as much of the healthy and
viable tissues prior to the denitive closure as
possible. This discretion provides several distinct
advantages when it comes to the potential closure
of a wound site. Namely, by saving as much tissue as is possible during earlier surgical debridements, one does not commit to a specic surgical
plan which may very well evolve or change as the
wound and the patient react to staged surgical
Fig. 12.12 The two-table setup during surgical debridement is a mainstay in our institutions “dirty” operative
cases. The judicious prevention of cross-contamination
between the “dirty” (1) and “clean” (2) tables is of the
utmost importance in order to prevent the spread of bacteria and to avoid the falsication of tissue cultures
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C. E. Attinger and J. N. Atves
debridements. All too often, a surgeon will amputate all toes or rays as part of a drainage amputation to a localized area of infection of the forefoot.
While this often ensures the zone of infection has
been eradicated, it needlessly disposes of healthy
and viable portions of tissue of the toes and forefoot which may have otherwise been utilized during an attempted closure and allows a general
contracture of the remaining soft tissues, which
can severely limit or even ruin the possibility of a
future closure attempt. Saving healthy and viable
tissues permits the maintenance of length of
tissues, as in the case of a partial foot amputation,
which can provide for the much-needed tissues
used during a closure attempt.
Methylene Blue
A method employed by the authors to ensure a
more accurate evaluation and thus more efcacious debridement, especially those pending soft
tissue closure, is to topically “paint” the wound
with methylthioninium chloride (methylene blue)
immediately prior to surgical debridement
(Fig. 12.13). Sharp debridement, sufcient to
remove all of the blue-stained tissue, provides a
clear delineation between more supercial
Fig. 12.13 The sequential use of methylthioninium chloride (methylene blue) is a novel method employed at our
institution. Sharp debridement, sufcient to remove all of
the blue-stained tissue, provides a clear delineation
between tissues that harbor bacteria and underlying
healthy tissues
12 Debridement oftheDiabetic Foot andLeg
171
exposed tissues that harbor bacterial burden and
the healthy tissues below with no deleterious
effects to the viable tissues themselves [18].
Assessing Tissue Viability
A vital consideration for the processes of debridement, especially for surgical debridement, is the
assessment and ultimately the determination of
tissue viability. Those tissues which are foreign,
dead, dying, or infected must be removed from
the wound bed and failure to do so will mean
assured failure of healing. While those tissues
that are overtly infected or dead are quite easy to
delineate from the frankly healthy and uninjured
tissues, it becomes increasingly difcult to make
an accurate declaration of tissue viability for
those tissues which are merely injured or altered
from the wound progression or surgical interventions and lie somewhere between the two ends of
the spectrum of tissue health. Additionally, tissues of all varieties and depths may endorse an
altered character depending on the overall health
of the patient. For these reasons the determination of tissue viability becomes a matter of subjective or qualitative judgement rather than
objective or quantitative calculation. Fortunately,
through the meticulous process of tissue evaluation one can reliably predict the viability of most
tissues based on a thorough clinical and microbiological assessment.
Clinical Determination
A meticulous clinical evaluation of the tissue
character is paramount in determining tissue viability. The character of the tissues encountered
during surgical debridement may be quite varied
and a sufcient evaluation for their viability can
be difcult. One should aim to determine the
viability of tissues as they relate to the tissue’s
inherent character. Tissues which deviate more
widely from normal quality may be considered
nonviable and should be excised. Again, this
determination may be easier said than done.
However, in this light, we suggest the utilization
of several clinical determinants in order to gauge
tissue viability. Namely, the color and consis-
tency of tissues are incredibly helpful determinants of tissue viability, or nonviability.
The “color ag” of tissue viability is a useful
diagnostic determinate of tissue quality based
merely on the color of tissues upon their observation (Fig.12.14). Healthy and viable tissues will
appear red, white, and/or yellow in color. Care
should be taken to preserve these tissues during
the debridement process. Unhealthy and nonviable tissues will have a black, blue (except for
veins), purple, green, brown, and/or orange color
to them. These tissues should be clearly and
denitively excised in order to properly eradicate
their burden within a wound.
Additionally, the consistency of tissues upon
palpation and manipulation is a useful determinant of overall viability. Those tissues, especially
when seen on the periphery of a wound, which
are severely indurated, hardened, and immobile
are to be considered nonviable tissues which
should be excised. Truthfully, the excision of
pathologically altered tissue consistency often
permits the mobilization of the remaining tissues
for use in primary or delayed primary closure.
Alternatively, the removal of indurated and effectively nonviable tissues will account for the
removal of stalled tissues which would otherwise
impede the healing process of a wound.
Microbiological Determination
Routinely, we perform operative tissue cultures
both prior to and immediately following the performance of surgical debridement. These
“pre- debridement” and “post-debridement” cultures are an important and guiding diagnostic
aspect of wound management. In truth, the culture data can determine the presence of latent
infection or chronic bacterial harborization of a
wound and are especially useful when the clinical
determinants of tissue viability are misleading, as
when the wound appears clinically viable and
healthy but is actually not yet sufciently
“primed” for closure techniques due to subclinical bacterial harborization. Additionally, culture
data are an indispensable adjunct for catering
antibiotic choice and duration and when combined with clinical and medical determinants of
tissue infection and health can signicantly aid in
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Fig. 12.14 Viable tissues will appear red, white, and/or yellow in color (“Color Flag” of Tissue Viability). Nonviable
tissues will appear black, blue (except for veins), purple, green, brown, and/or orange color to them
C. E. Attinger and J. N. Atves
the clearance of infection and progression of
healing. It is important to obtain aerobic and
anaerobic cultures of the wound as soon as possible by obtaining a piece of deep, initially unexposed tissue. A swab culture of supercial tissue
is of limited utility as it merely reects the presence of supercial skin ora as opposed to the
actual underlying bacteria responsible for the
infection. If there is access to a quantitative bacterial culture laboratory, then a minimum of
0.3 cm3 of tissue specimen is necessary for the
culture to be processed. A concentration of
greater than 105 bacteria per gram of tissue
reects a signicant infection that will inhibit
healing [19, 20].
Conclusion
With the myriad of local and systemic complications seen in the diabetic and comorbid patient
population, treating the complex foot and leg
wound environment can be a monumental undertaking for both the patient and physician alike. In
chronic wounds, healing is more protracted due
to the etiology of the wound being more difcult
to determine, and the measures to reverse the
medical abnormalities are often much more complex. Even when the wound etiology has been
identied and addressed, debridement still plays
the prominent role. Debridement converts the
chronic wound into an acute state so that it may
progress through the normal sequential stages of
healing. The key is for clinicians to be aggressive
and not allow reservations about the residual tissue defect to limit an appropriate tissue
debridement.
Multiple factors and considerations are at
play in the diabetic and comorbid populations
and must be given attention, respect, and careful
consideration in both their assessment and management. A fundamental understanding and
working knowledge of the complex interactions
between the numerous and varying physiologic
components involved in wound healing is paramount. Advances and innovations in research
and technology will likely continue to evolve
our understanding and ability to efcaciously
treat this pathology. To this day, debridement
remains the primary means of wound treatment
12 Debridement oftheDiabetic Foot andLeg
173
and is necessary in order to anticipate a successful outcome. However, the surgeon must adapt
to the wound as it presents and evolves and cater
their treatment modalities to the patient and the
environment in which they are treated.
Regardless of the exact setting, the multidisciplinary approach should be pursued and utilized. This consortium of disciplines and
patient-specic treatment modalities is paramount in order to prevent, heal, and suppress
nonhealing wounds in order to ultimately provide patients with the most expedient and functional outcome possible.
Acknowledgments No acknowledgements are made.
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An Evidence-Based Approach
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toTreating Osteomyelitis
BenjaminA.Lipsky andSuzanneA.V.van Asten
13
Introduction
Infections of the foot are a common, complex,
and costly complication of diabetes mellitus [1].
They are associated with considerable morbidity,
cause substantial discomfort, require extensive
medical care (in both outpatient and hospital settings), and frequently lead to serious complications [2, 3]. Among persons with diabetes, about
a quarter will develop a foot wound, just over half
of which will be infected; the rate of osteomyelitis in these diabetic foot infections (DFIs) ranges
from <20% in mild infections to up to 80% in
severe infections (Fig. 13.1). Perhaps the most
frequent major complication of diabetic DFI is
lower extremity amputation. This outcome is
associated with 5-year mortality rates of about
50% [4], which exceeds that those of most cancers. Most of the DFIs that lead to hospitalization
or amputation are those that progress to involve
underlying bone. Thus, diabetic foot osteomyelitis (DFO) has become one of the leading, and
fastest growing, causes of bone infection. One
study from the USA found that while the rate of
B. A. Lipsky (*)
Department of Medicine, University of Washington,
Seattle, WA, USA
e-mail: balipsky@uw.edu
S. A. V. van Asten
Department of Medical Microbiology, Leiden
University, Leiden, The Netherlands
e-mail: s.a.v.van_asten@lumc.nl
osteomyelitis in children and young adults were
steady between the years 2000 and 2009, the rate
almost tripled among individuals older than 60
years, partly driven by a signicant increase in
DFO [5]. Furthermore, in this study, despite
treatment in a renowned referral medical center
(the Mayo Clinic), 68% of those with DFO
underwent an amputation.
It is clear that DFIs that involve underlying
bone, compared to just skin and soft tissue, are
more difcult to successfully treat and are associated with worse clinical outcomes. A study from
Pittsburgh found that among patients hospitalized for a DFI, those with bone involvement,
compared to those with just soft tissue infection,
had a signicantly higher: number of operative
procedures (an extra 0.5); mean hospital length
of stay (by 1 day); and rate of lower extremity
amputation (OR 5.6) [6]. Studies from Dallas [7]
and Istanbul [8] have shown similar ndings, and
also signicantly longer durations of both antibiotic therapy and time to wound healing for the
DFO cases. Similarly, a meta-analysis of 12 studies of DFO found that the likelihood of isolating
a multidrug-resistant pathogen was threefold
higher than in soft tissue DFI [9]. Thus, optimizing management of DFO is crucial in limiting a
variety of associated complications, but especially lower extremity amputations.
© Springer Nature Switzerland AG 2023
C. E. Attinger, J. S. Steinberg (eds.), Functional Limb Salvage,
https://doi.org/10.1007/978-3-031-27725-2_13
175
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