From Foot to Fatality: The #DiabeticFootAttack Is Real, and It’s Worse Than You Think @alpslimb #ActAgainstAmputation

Our colleagues at St Antonius Hospital in Nieuwegein, the Netherlands, led by Olaf Bakker, have just published a sobering paper in the Journal of Plastic, Reconstructive & Aesthetic Surgery that quantifies what many of us have felt in our bones for years: the diabetic foot attack (DFA) is a devastating clinical event with outcomes that rival some cancers.

The term “diabetic foot attack” was introduced to draw a direct parallel to cardiac and cerebrovascular emergencies — to signal that a rapidly spreading deep foot infection in a person with diabetes demands the same immediate, coordinated, aggressive response. We’ve been writing about the foot attack concept on this site since 2013, when the UK launched its “Fast Track” campaign to reduce amputations, and Diabetes UK released a public booklet on how to spot a foot attack. And yet, despite the severity of the entity, we’ve had almost no hard data on what actually happens to these patients once the dust settles.

Ghijsen, Bakker and colleagues changed that. They retrospectively reviewed 104 DFAs in 97 patients treated between 2017 and 2023 at their regional referral center — a high-volume center seeing roughly 1,000 diabetic foot patients per year. Critically, they used a rigorous definition requiring intraoperatively confirmed spread of infection into deeper foot compartments. This isn’t the “everything infected is a DFA” approach — this is the real thing.

Here’s what they found:

Wound closure was achieved in only 48.5% of cases, with a median time to healing of 153 days — over five months — among those who did heal. More than half never healed their wounds at all.

Major amputation during the index admission was 31.7%. By 12 months, the overall major amputation rate climbed to 46.2%. Among neuroischaemic DFAs, it was 55.4%.

In-hospital mortality was 6.7%. One-year mortality was 26%. For neuroischaemic DFAs, the 12-month mortality rate reached a staggering 39.3%. To put that in perspective, we’ve noted before that the diabetic foot fills our hospitals more than heart attacks — and now we see that its most acute presentation carries mortality that should make anyone pay attention.

Amputation-free survival at 12 months was 39.7% overall, and only 23.2% for neuroischaemic DFAs. Meaning: more than three-quarters of patients with a neuroischaemic DFA lost either their limb or their life within a year.

38% of surviving patients were readmitted within 90 days, and roughly 40% required additional surgery within 12 months after discharge.

These numbers are substantially worse than the Vainieri et al. DFA outcomes we covered in 2020, which reported 5.6% major amputation and 71% AFS at 12 months. Ulusoy et al. reported 12.5%. The difference is almost certainly because Bakker’s group used a stricter, surgically confirmed definition. This isn’t a limitation — it’s a strength. They captured the true severity of the entity.

The paper raises several important points worth reflecting on.

First, “Time is Tissue” remains the mantra. The authors cite earlier work showing ~90% major amputation when surgical intervention was delayed beyond 72 hours, versus ~20% with early surgery. In their series, median time from presentation to first surgery was just 1 day — reflecting the urgency baked into their protocol. This is exactly why we’ve long advocated for systems like the “Hot Foot Line” — rapid-response pathways for emergency department referrals that get these patients to the OR before the infection gets to them.

Second, the 25% of DFAs that originated from surgical wounds — not primary DFUs — is notable. Over a third of neuroischaemic DFAs arose from a prior surgical site. We should keep this in our heads every time we operate on these feet.

Third, the authors make a case for earlier plastic surgery involvement. Once infection is controlled, the resulting soft tissue defects expose bone and joint, creating complex reconstruction challenges. Free flap success rates of up to 80% have been reported in this setting. The intersection of vascular surgery and plastic surgery in the diabetic foot is fertile ground that remains underexplored in many systems.

Finally, and perhaps most importantly: this paper reminds us that we still lack a consensus definition for the DFA. The IWGDF infection grading tells us moderate versus severe, but it doesn’t tell us when a severe infection becomes a DFA. Until we can name it consistently, we can’t measure it, we can’t compare interventions, and we can’t improve outcomes. This is a definitional gap the field needs to close. We’ve been teaching Foot CPR and handing out risk communication cards for over a decade now. It’s time for a formal, internationally agreed-upon definition to match that effort.

Ghijsen SC, Lenssen HH, Coert JH, Hamers FPT, Zonnevylle EDH, van den Heuvel DAF, Rakhorst HA, Bakker OJ. From Foot to Fatality: The Alarming Outcomes Following Acute Diabetic Foot Infections (“Diabetic Foot Attacks”). J Plast Reconstr Aesthet Surg. 2026. doi:10.1016/j.bjps.2026.03.041

#DiabeticFoot #DiabeticFootAttack #DFU #LimbSalvage #Amputation #AmputationPrevention #TimeIsTissue #WIfI #PAD #DFUMortality #WoundHealing #FreeFlap #Netherlands #JPRAS