Juggling risk to reduce amputations: The three-ring circus of infection, ischemia and tissue loss-dominant conditions

Wound classification systems have evolved from linear systems describing only one factor to more matrix-oriented, allowing wider clinical applicability. We suggest that, in a similar fashion to wound classification, a flexible long-term management philosophy should be dynamic and conceptually inclusive. We visualize amputation prevention as the management of three partially intersecting rings whose complex interplay competes for dominance at any given time during the life of the patient and his or her limb. These rings of dominance involve tissue loss, ischemia, and infection and are constantly in motion. Once a patient has a wound or has healed a wound, one might consider this flexible approach to management and assessment. A question that might be asked would be: "At this moment, which ring does this patient's biggest problem lie? Infection? Ischemia? Tissue Loss? Combinations?" This approach may help the interdisciplinary team understand who is primarily responsible for care at any given time while understanding the dynamic nature of management of the high-risk patient.