66-year-old infected ischaemic foot at WIfI 3 — infection-first sequencing, quartile counselling, and level selection

Examiner notes

Probe four domains: (1) SINBAD description in words with the IWGDF no-individual-prediction rule^[14]; (2) infection control before revascularisation with the 59.54% minor-amputation-first figure and the duration ladder^[13][36]; (3) WIfI benefit-quartile counselling with Q4 25.7% honesty plus BASIL-2/BEST-CLI numbers^[12][44][45]; (4) level selection counselled-not-dictated with transmetatarsal and partial-foot pricing^[50][54]. Award marks for exact numbers with named papers; deduct for quoting classification totals as prognoses, promising salvage in Q4, defaulting to 12-week antibiotics, or calling transmetatarsal definitive.

Model dialogue

Describe this ulcer so another clinician sees it. SINBAD in words — site, ischaemia, neuropathy, bacterial infection, area, depth — because the IWGDF makes SINBAD the first communication option with variables described rather than totalled, and recommends no system for predicting this specific ulcer's outcome.^[14][7]

What comes first — vessels or infection? Infection control: nearly 60% of admitted infected feet need minor amputation to control infection before revascularisation, and PAD with WIfI benefit-stage-3 (RR 4.56) or high Wagner scores (RR 9.46) multiplies amputation risk — so debride and drain first, revascularise second.^[13] Confirm bone first by probe-plus-X-ray (0.97/0.92 sequential, LR 12.8/0.02) with biopsy as gold, since MRI goes unconfirmed in 29.3%.^[32][28][35]

What does WIfI 3 mean for his leg? Stage 3 concentrates with stage 4 for amputations, falling amputation-free survival and slower healing — yet stage-3 revascularisation accelerates healing, and benefit quartiles separate Q1 7.2% from Q4 25.7% one-year amputation at hazard 4.26 with over half amputated despite patent wires — so quote the quartile, and note the multidisciplinary 5.7% stage-4 figure as what a team can achieve.^[9][12][10]

Which revascularisation, and what do the trials say for diabetes? PLAN first — patient risk, limb severity, anatomic complexity with GLASS and vein availability — then BASIL-2 infrapopliteal numbers favouring endovascular-first (HR 1.35 against vein-first, £1690 saved) and BEST-CLI-diabetes pricing late presentation (WIfI 3–4 in 73.7 vs 45.9%) with amputation 1.75-fold and death 1.63-fold independent — plus the 5-year split of death lower after bypass regardless of diabetes with amputation modality-blind but doubled by diabetes itself.^{[43][44][45][47]}

How long are antibiotics, and does he need bone surgery? The tested floors as study regimens: 6 weeks where non-surgical treatment is chosen (65% remission, fewer gut events), 3 weeks after debridement (84 vs 73%, noninferior), 10 days for soft tissue (77 vs 71%) — with the 23-versus-16% new-osteomyelitis tail disclosed.^[36][37][38] Operate for life-threat, limb-threat or failure (23% in the non-surgical series) with foot-sparing priority — conservative surgery succeeds in 49.1%, S. aureus leads at 51.3% — and complete resection shortens antibiotics without changing 12-month outcomes.^[39][40][41]

If amputation is needed, what do you promise? Nothing dictated: deep infection with pulses favours below-ankle healing yet nothing alone excludes it; minor amputations heal below-ankle in 64% overall and 79% of survivors; transmetatarsal carries 30.16% pooled major-amputation risk and the all-partial-foot meta-analysis 23% with re-ulceration to 69% — so consent the ladder, the 26-week median healing, and lifelong surveillance for the 22.1%-per-year recurrence.^{[53][52][50][54][4]}