One of the most foundational principles in foot and ankle surgery is that wounds heal in the presence of an adequate blood supply, and they don’t in its absence. The question this 2019 consensus paper examined is the operational extension of that principle: in patients with peripheral vascular disease, should we revascularize the limb — restore the blood supply through angioplasty or bypass — before doing the foot/ankle operation, in order to reduce post-operative infection?

Why the question matters

Patients with peripheral vascular disease have a documented, very substantial increased risk of surgical site infection after foot/ankle surgery. A wound trying to heal with marginal blood supply is a wound at risk of breaking down, getting colonised, and progressing to deep infection. So the question of pre-operative revascularization isn’t academic. For the right patient, it could be the difference between a routine recovery and a limb-threatening complication.

What we did

The international Foot & Ankle community held a consensus session in 2019 to address several questions in foot and ankle infection. I led the workgroup on this specific question: does pre-operative revascularization reduce surgical site infection? We reviewed the published evidence and reached consensus.

What we concluded

The general evidence linking poor blood supply to wound complications is overwhelming. The specific evidence that pre-operative revascularization reduces post-operative SSI in foot/ankle surgery is, surprisingly, sparse. There’s a strong biological case — better inflow, better wound healing, lower infection — and observational data align with that case. But there is no randomised controlled trial that proves the benefit of revascularization specifically in foot/ankle pre-op. The consensus, which I supported, is to recommend it where peripheral vascular disease is significant, while acknowledging the formal trial evidence is incomplete.

What this means for patients

If you have peripheral vascular disease and you’re facing foot/ankle surgery, your work-up should explicitly include vascular assessment. If significant disease is found, ask the team whether revascularization should come first. The intuitive answer in most cases is yes — even where the formal evidence base has not yet caught up to the biology.