Essential Questions For Surgical Intervention Of Diabetic Foot Infections

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An Overview Of Plantar Musculature By Compartment And Layer

Medial Compartment
Abductor hallucis (first layer)
Flexor hallucis longus tendon (second layer)
Flexor hallucis brevis (third layer)

Central Compartment
Flexor digitorum brevis (first layer)
Flexor digitorum longus tendon (second layer)
Lumbrical muscles (second layer)
Quadratus plantae (second layer)
Adductor hallucis (third layer)
Interosseous muscles (fourth layer)

Lateral Compartment
Abductor digiti minimi (first layer)
Flexor digiti minimi (third layer)

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By Andy Meyr, DPM

     Surgeons need to take it a step further in order to garner specific information about which vessels are actually carrying blood into the foot and the collateral circulation. This is information that is readily available with a thorough physical examination using angiosome principles.

     The term angiosome describes all tissue contained within the surgical layers of dissection supplied by a single source artery. There are five angiosomes in the foot and ankle, and they are supplied by the posterior tibial, anterior tibial and peroneal arteries. One can determine angiosome patency in the presence of macrovascular occlusive disease in the area of infection via a complete physical examination with a handheld Doppler. This information is vital in terms of incision placement, systemic antibiotic tissue penetration and the overall healing potential of infected sites.17-19 Thorough knowledge of angiosome principles is strongly encouraged for any surgeon undertaking diabetic limb salvage.

In Conclusion

     Diabetic foot surgeons do not cure infection. Our ultimate goal is facilitating healing through our surgical intervention, treatment and education. This is a challenging field that is only going to get more difficult in the future. With so many variables against us, we need to take advantage of those factors that we have some control over.

     Expert knowledge of lower extremity anatomy is one of those factors that can have a true positive impact on patient outcomes if one applies this knowledge appropriately during the preoperative planning. Ask yourself the three questions of “Where?” the next time you encounter a diabetic foot infection.

Dr. Meyr is affiliated with the INOVA Fairfax Hospital Podiatric Surgical Residency Program in Falls Church, Va.

Dr. Steinberg is an Assistant Professor in the Department of Plastic Surgery at the Georgetown University School of Medicine in Washington, D.C. He is a Fellow of the American College of Foot and Ankle Surgeons.


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