Over the years, many people have asked for the generalized flowchart for the assessment of diabetic foot ulcers that we have emphasized with the Southwestern Academic Limb Salvage Alliance (SALSA). See the attached flowchart at the right. As always, these are living documents that change over time. Feel free to improve upon it and pay it forward!
This is probably the first flowsheet that follows the Wound, Ischemia, Foot Infection (WIfI) system closely.1 The bottom line when evaluating a patient is that one needs to ask: “What is dominant? Infection? Ischemia? Tissue loss (wound)?” Often, it is a mixture of these but looking for this systematically helps to crystallize a framework and consistent approach.
Utilizing such a framework recognizes the importance of close consultation with vascular colleagues, the unique challenges of plantar wounds and the role of surgical reconstruction as a method of offloading when necessary.
In regard to section “H,” Wound Hospice/Amputation, this is a concept that reflects the unique needs of a subset of our patient population. For these patients, treating their wounds with the primary intention of healing them may actually be less beneficial than primarily aiming to keep them comfortable and uninfected. We call these patients “podiatric hospice” or “wound hospice” patients.
In previous work that I have contributed to, we advocated for categories of patients who may benefit from “wound simplification” or a reorientation to a more patient-oriented outcome.2 These patients can still benefit from intervention commensurate with their individual circumstances.3
Dr. Armstrong is Professor of Surgery at the Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA).
Editor’s note: This blog originally appeared at: https://diabeticfootonline.com/2020/10/01/salsas-diabetic-foot-ulcer-flowchart-to-help-actagainstamputation/ . It is adapted with permission from the author.
- Mills JL, Conte MS, Armstrong DG, et al. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia and foot infection (WIfI). J Vasc Surg. 2014;59(1):220-234.
- Mills JL, Armstrong DG. The concept and proposed definition of “wound simplification.” Wound Med. 2013;2-3:9-10.
- Armstrong DG, Salas P, Short B, et al. Maggot therapy in “lower-extremity hospice” wound care. Fewer amputations and more antibiotic-free days. J Am Podiatr Med Assoc. 2005;95(3):254-257.