Problems with the good leg

A 39-year-old male with type 1 diabetes of 27 years' duration and end-stage renal failure treated by continuous Fig. 7.2 Necrosis spreading to the leg after a major arterial occlusion. Fig. 7.2 Necrosis spreading to the leg after a major arterial occlusion. ambulatory peritoneal dialysis had a history of bilateral neuropathic ulceration and underwent amputation of left 3rd, 4th and 5th toes. The foot healed and he was issued with an orthotic walker. The foot remained intact for most of the...

Volume fluctuation

It is in the early stages that the greatest changes in the stump will occur, and the size and shape of the stump can be expected to change markedly for around 1 year. During the amputee's life, his body weight and the amount he walks are likely to fluctuate, and this results in alteration of the stump volume. Cardiac and renal disease can lead to stump oedema. Fluctuating stump volume is a particular problem in diabetic amputees, and patients with neuropathic stumps may have difficulty in...

What must I do to heal my foot quickly

You should ask for help (the same day) from your doctor, hospital or diabetic foot service Clean the ulcer with saline Cover the ulcer with a sterile dressing held in place with a light bandage Ask for help dressing the ulcer from your community nurse if you or your family have difficulty with this Keep right off the ulcer. Use crutches or a wheelchair and try not to put your foot to the ground Keep your foot up on a stool and cushion, sofa or bed Stay home from work or work from home if...

Choice of level of amputation

The level of amputation should be carefully considered to ensure that there is sufficient perfusion to achieve wound healing. When possible, a below-knee amputation should be carried out to conserve the knee joint and aid the fitting of a prosthesis. Preserving the knee joint lowers the energy expenditure necessary for walking. The cardiovascular cost for walking and foot plantar pressures in the opposite limb both increase in direct proportion as the amputation becomes more proximal. The aims...

Removal of sesamoids

A 69-year-old man with type 2 diabetes of 22 years' duration and peripheral neuropathy had a history of chronic full-thickness ulceration beneath his left 1st metatarsal head. The ulcer did not probe to bone (Fig. 8.11). Radiographs revealed a hypertrophic tibial sesamoid (Fig. 8.12). Conservative treatment was employed for 4 months with no improvement in his condition. The patient was offered the option of surgical treatment and he consented. In this case, the plantar ulcer was excised and...

Relapse of Charcots osteoarthropathy or infection

A 60-year-old type 1 diabetic of 42 years' duration who had bilateral Charcot's osteoarthropathy affecting both feet and 12 years' previous history of ulcers and infections, was referred to the foot clinic with a hot, swollen left ankle and erythema over the medial malleolus. Both her feet were intact. The left foot was very painful on weightbearing. A provisional diagnosis of infection was made although we could not be sure that this was not a relapse of Charcot's osteoarthropathy. She was...

Presentation And Diagnosis

The diabetic foot enters stage 2 when it has developed one or more of the following risk factors for ulceration neuropathy, ischaemia, deformity, swelling and callus. These risk factors may not cause symptoms. Patients do not, thus, report problems. It is therefore important to screen patients at the annual review, which is an important part of diabetic foot care. A recent evaluation of a diabetic foot screening programme showed that it could prevent major amputations. A large randomized...

Angiography

Initially, non-invasive angiography should be carried out. This is either duplex angiography or magnetic reson ance angiography (MRA), which should be carried out urgently to detect the presence of stenoses or occlusions which may be amenable to angioplasty or bypass. Duplex angiography is proficient at looking at the femoral and popliteal arteries but it is sometimes difficult to obtain good views of the infrapopliteal arteries and foot arteries because of the excessive calcification in the...

Outcomes of transmetatarsal and midfoot amputations

Of the three levels of amputation discussed in this chapter, the transmetatarsal amputation is the most successful with respect to functional outcomes, patient satisfaction and long-term results. Transmetatarsal amputation preserves foot function, is cosmetically acceptable, does not require a prosthesis and enables fitting with commercially available footwear. Amputations performed at the tarsometatarsal and mid-tarsal joint levels frequently result in deformity and difficulty fitting shoes....

Vascular control

If ulcers in the neuroischaemic foot fail to heal despite optimal treatment, the reason may be ischaemia. Atherosclerotic lesions commonly occur in the tibial arteries but also occur in the popliteal and femoral arteries, with the iliacs rarely involved. A careful vascular assessment is necessary, to determine the degree of ischaemia and to decide when to perform invasive investigations with a view to revascularization. Initially the ankle brachial pressure index should be measured,...

Percutaneous lengthening of Achilles tendon

A 55-year-old African-American male with poorly controlled type 2 diabetes HbA c 10.6 of 8 years' duration, and dense peripheral neuropathy was seen regularly in the diabetic foot clinic for treatment of a chronic nonhealing full-thickness ulcer located beneath the 2nd and 3rd metatarsal heads of his left foot. The ulcer did not probe to bone. Treatment consisted of surgical wound debridement, total-contact casting, walking brace and a variety of topical wound healing agents. Serial X-rays were...

Fall in an Aircast

A 40-year-old male with type 1 diabetes of 30 years' duration, proliferative retinopathy treated with laser photocoagulation, sensory neuropathy and autonomic neuropathy including postural hypotension, developed an acute right mid-foot Charcot's osteoarthropathy. Because of a previous episode of severe sepsis he was reluctant to wear a total-contact cast, but agreed to wear a removable Aircast. He suffered a fall in his home where the kitchen floor was covered with shiny linoleum and X-ray...

The Scope Of The Problem

Gangrene Diabetic Toe

Diabetic foot complications are a major global public health problem. Amputation rates vary throughout the world but are always increased in people with diabetes compared to those without diabetes. Amputations are increasing in diabetic patients. Throughout the world, health-care systems, both public and private, have been unsuccessful in managing the overwhelming problems of patients suffering with diabetic foot complications. The results of this failure are shown in the following case...

Transcutaneous oxygen tension TcPo

This measurement is a non-invasive method for monitoring arterial oxygen tension and reflects local arterial perfusion pressure. A heated oxygen sensitive probe is placed on the dorsum of the foot. Normal TcPo, is greater than 40 mmHg. A level below 30 mmHg indicates severe ischaemia and indicates the need for further vascular assessment such as non-invasive angiography. However, levels can be falsely lowered by oedema and cellulitis. Values in the foot can also be compared with those on the...

Management of the five presentations of infection

Treatment is discussed for the five presentations of infection, in neuropathic feet and in neuroischaemic feet, both as initial treatment and follow-up. Infection in the neuroischaemic foot is often more serious than in the neuropathic foot which has a good arterial blood supply. We regard a positive ulcer swab in a neu roischaemic foot as having serious implications, and this influences antibiotic policy. We give amoxicillin 500 mg tds, flucloxacillin 500 mg qds and metronidazole 400 mg tds...

Reasons for major amputation

Diabetic patients who present with extensive ulcers on their feet are sometimes offered early amputation as 'the one sure way of sorting out the problem permanently', on the basis that such an operation is likely to be inevitable at some time in the future. This approach may be useful for young, otherwise healthy, non-diabetic patients incapacitated by pain or a useless limb, whose other limb is normal. However, major amputation does not guarantee an ulcer-free existence for the diabetic...

Amputations Of The Foot

Amputations of the foot can be divided into nonemergency and emergency procedures. Non-emergency amputations allow some flexibility in the creation of skin flaps, selection of level and wound closure. These cases generally include neuropathic feet that are structurally or functionally impaired, with satisfactory circulation and controlled infection. They are characterized by moderate to severe forefoot deformities with associated chronic non-healing ulcers that are recalcitrant to conservative...

Case Study

Diabetic Cuts Foot

A 79-year-old patient with type 2 diabetes of 7 years' duration dropped the family bible on his left great hallux. The toe was exquisitely painful and rapidly developed discolouration beneath the nail plate. After 4 days he visited his general practitioner who diagnosed a subungual haematoma and referred him to the diabetic foot clinic and he was seen the same day Fig. 2.8a,b . The nail plate was cut back to reveal an area of necrosis involving the nail bed. Differential diagnosis was necrosis...

Management

Charcot Crutches

All neuropathic fractures should be treated promptly in conjunction with orthopaedic surgeons. Fractures that develop Charcot changes are associated with the greatest overall delay in diagnosis and management. Fractures should be treated with non-weightbearing and plaster Fig. 3.12 Fractured styloid process at base of 5th metatarsal. Fig. 3.12 Fractured styloid process at base of 5th metatarsal. immobilization, supported by crutches and or wheelchair. Fractures do not heal at the same rate as...

Neuropathic foot

Scotchcast Bnt

The most efficient way to redistribute plantar pressure is by the immediate application of some form of cast. If casting techniques are not available, temporary ready-made shoes with a cushioning insole can be supplied to off-load the site of ulceration. Alternatively, weight-relief shoes can be supplied, and felt padding can also be used. Additional off-loading measures are crutches, wheelchairs and Zimmer frames. Moulded insoles in bespoke shoes are sometimes used to treat ulcers. However,...

Feckless patient with endstage renal failure

Stub Toe Nail

A 44-year-old woman with type 1 diabetes of 26 years' duration, proliferative retinopathy, profound neuropathy and end-stage renal failure treated by renal transplant had her feet checked at monthly intervals at the renal unit as part of a research protocol. Her foot pulses were palpable. She was educated in foot care, foot inspections and early reporting of any problems. However, during a 3-year period she suffered nine separate episodes of foot trauma, none of which she reported early they...

Introduction

The discovery and commercial production of insulin in the early 1920s were seminal developments in the treatment of diabetes that allowed people affected by this disease to live an almost normal life. Although insulin commuted the death sentence attributed to diabetes, it was soon recognized that it was not a cure. As people affected by this disease lived longer, they began to experience serious complications including blindness, kidney failure, heart disease, stroke and amputations. In 1934,...

Extensive deep soft tissue infection secondary to interdigital tinea

A 43-year-old man with type 2 diabetes of 2 years' duration was admitted via casualty with an infected neuropathic left foot with cellulitis, oedema and a purple patch on the dorsum of the foot. He was apyrexial. The dorsum of his foot was fluctuant and he was taken to theatre and underwent incision and drainage of an abscess. The pus from the abscess grew Staphylococcus aureus and he was treated with flucloxacillin 500 mg qds. The wound was not sutured but left open to heal by secondary...

Conservative management of Charcots osteoarthropathy of the hindfoot

Amputation First Ray

A 46-year-old male with type 1 diabetes of 40 years' duration presented with bilateral Charcot's osteoarthropathy. He was referred from a clinic 80 miles away and had been advised to have a right below-knee amputation. The left foot had stable mid-foot Charcot's osteoarthropathy with rockerbottom deformity the right foot was hot with unstable hindfoot Charcot's osteoarthropathy with lateral talotibiofibular displacement. The Charcot's osteoarthropathy was diagnosed 3 years previously following...

Further Reading Presentation and diagnosis

Zondervan Publishing House. Grand Rapids, Michigan, USA, 1997. Jacobs AM, Appleman KK. Foot-ulcer prevention in the elderly diabetic patient. Clin GeriatrMed 1999 15 351-69. Lavery LA, Lavery DC, Quebedeax-Farnham TL. Increased foot pressures after great toe amputation in diabetes. Diabetes Care 1995 18 1460-2. Litzelman DK, Marriott DJ, Vinicor F. Independent physiological predictors of foot lesions in patients with NIDDM. Diabetes Care 1997 20 1273-8....

Choparts amputation

A 54-year-old man with type 2 diabetes of 17 years' duration and Charcot's arthropathy had chronic ulceration beneath the calcaneocuboid joint of his left foot. He also had nephropathy, peripheral vascular disease, retinopathy, neuropathy, congestive heart failure, hypertension and cardiovascular disease. He presented at accident and emergency with fever, rigors and a grossly infected left foot. Radiographs and clinical examination confirmed gas in the soft tissues on the dorsum of his foot,...

Principles of antibiotic treatment

The microbiology of the diabetic foot is unique. Infection can be caused by Gram-positive aerobic, and Gram-negative aerobic and anaerobic bacteria, singly or in combination Table 5.1 As there may be a poor immune response of the diabetic patient, even bacteria normally regarded as skin commensals may cause severe tissue damage. This includes Gram-negative organisms such as Citrobacter, Serratia, Pseudomonas and Acinetobacter. When Gram-negative Table 5.1 Bacteria isolated from the diabetic...

Technique

Diabetic Foot Care

The procedure is performed in the operating theatre under local anaesthesia, with a Penrose drain applied as a tendon and joint capsule are identified overlying the proximal interphalangeal joint, c Removal of the head of the proximal phalanx with a double action bone cutting forceps, d Immediate postoperative appearance. tendon and joint capsule are identified overlying the proximal interphalangeal joint, c Removal of the head of the proximal phalanx with a double action bone cutting forceps,...

Investigations

These should include neurological, vascular, laboratory and radiological investigations as described in Chapter 1. Fig. 4.4 This deep sinus has a slit-shaped aperture. Fig. 4.4 This deep sinus has a slit-shaped aperture. While it is not necessary to X-ray every stage 3 foot with a presenting ulcer, it may be advisable to do so in the following circumstances When the history suggests that the patient may have trodden on a foreign body When the ulcer probes to bone, clinically suggesting...

Ischaemia and cellulitis

In the neuroischaemic foot it may be difficult to differentiate between the erythema of cellulitis and the redness of ischaemia. It is helpful to elevate the leg. The redness of ischaemia is usually cold and is most marked on dependency it will disappear upon elevation of the limb, whereas cellulitis will remain. The erythema associated with inflammation is warm, although a very ischaemic foot may become deceptively warm when it is infected. Erythema also occurs secondary to traumas, including...

Hidden depthsunsuspected soft tissue infection complicating apparently superficial heel ulceration under callus

A 56-year-old man with type 2 diabetes of 12 years' duration and peripheral neuropathy trod on a nail while walking barefoot. The wound healed after 6 days, but the heel developed a callus which became painful after 2 weeks so he sought advice from the diabetic foot service. The callus was debrided and the underlying skin appeared to show superficial ulceration only Fig. 5.10a . However, when the heel was palpated the patient complained of pain, and careful inspection revealed a deep sinus from...

Mechanical control

Using Scotchcast Boot Pictures

During the peri- and postoperative period, bed rest is essential with elevation of the limb to relieve oedema and afford heel protection. Prophylaxis of deep vein thrombosis should be carried out using a low molecular weight heparin subcutaneously daily. Low molecular weight Fig. 6.28 a The wound has developed bluish discolouration, b The wound is breaking down, c The wound is sloughy and necrotic, d After 4 months the leg is fully healed and the bypass is still working. Fig. 6.28 a The wound...

Neuroischaemic ulcers

We prescribe antibiotics more readily for the neuroischaemic foot because untreated infections in neuroischaemic feet lead rapidly to extensive necrosis, destruction of the foot and major amputation. At the first visit, if the ulcer is superficial, we prescribe oral amoxicillin 500 mg tds and flucloxacillin 500 mg qds. If the patient is penicillin allergic, we prescribe erythromycin 500 mg qds or cefadroxil 1 g bd. If the ulcer is deep, extending to subcutaneous tissues, we add trimethoprim 200...

Indications for surgery

Antibiotics alone may be unable to control infection and it is necessary to decide whether adjunctive surgery is necessary. In severe episodes of cellulitis, the ulcer may be complicated by extensive infected subcutaneous soft tissue. At this point, the tissue is not frankly necrotic but has started to break down and liquefy. It is best for this tissue to be removed operatively. The definite indications for urgent surgical intervention are A large area of infected sloughy tissue Localized...

Early discharge without accepting treatment by a young diabetic patient addicted to crack cocaine

Crack Cocaine Necrose Feet

A 28-year-old man with type 1 diabetes mellitus for 18 years attended the casualty department complaining of a painful foot. He was well known to the hospital and was addicted to crack cocaine. He had severe infection of the left hallux, and deep, infected ulcers over both 1st metatarsal heads Fig. 5.27 . He was admitted to the ward for intravenous antibiotics and possible surgical debridement but walked off the ward 2 h later before treatment was started and was lost to follow-up. Three weeks...

Improper use of a rubber band

A 25-year-old man with type 1 diabetes of 15 years' duration presented with a painful nail sulcus and underwent removal of a spike of nail. The toe was dressed with Fig. 4.12 A ring of superficial necrosis around the toe following use of a tight rubber band to hold a dressing on the toe. Fig. 4.12 A ring of superficial necrosis around the toe following use of a tight rubber band to hold a dressing on the toe. Melolin and Tubegauz and he was advised to attend his practice nurse for dressings and...

Image Not Available

Plantar Ulcer

Fig. 8.33 Lisfranc amputation, a Initial presentation with a non-healing wound at the site of prior amputation of the 2nd toe, right foot, b Multiple draining plantar ulcers with sinus tracts, c Completed repair with a long dorsal flap and short plantar flap, d Healed Lisfranc amputation right foot, compared to transmetatarsal amputation of the left foot. Part d from Sanders 1997 with permission from Elsevier Science. underwent a Chopart's amputation of his left foot. In an effort to prevent...

Mobility aids

Amputation Stump

Before the definitive prosthesis is issued, some patients may be suitable for mobility aids. The amputee mobility aid AMA is suitable for below-knee and through-knee amputees only. The stump is supported and stabilized by an inflatable bag, which also assists in reducing oedema. It is a physical and psychological boost to get the patient on his feet early. It has a knee joint. The pneumatic postamputation mobility aid PPAM aid has an inflatable socket and is suitable for above-knee,...

Advances In Diabetic Foot Care

The diabetic foot has become a major area of interest, and insight has been gained into the reasons why diabetic feet go wrong and the ways in which patients can be helped. Of all the complications of diabetes, the diabetic foot is probably the easiest to prevent and treat. The groundswell of interest in the diabetic foot surged in the 1980s, and developments in foot care included the setting up of multidisciplinary diabetic foot clinics Fig. 6 and the pioneering educational work of Jean...

Wet necrosis

The microbiological principles of managing wet necrosis are similar to those for the management of infection of the foot with extensive soft tissue infection or the foot with blue discolouration as described in Chapter 5. When the patient initially presents, deep wound swabs and tissue specimens are sent off for microbiology. Deep tissue taken at operative debridement must also go for culture. Intravenous antibiotic therapy Both neuropathic and neuroischaemic patients need parenteral therapy....

Pressure index

Dopplerwaveform From Normal Foot

The pressure index is widely criticized because, when the arteries are calcified, it may be artificially raised. However, we feel that it is very relevant to the investigation of the diabetic foot as long as the potential difficulties of its interpretation are understood. If the pressure index is 0.5 then it is truly low, and indicates severe ischaemia whether the arteries are calcified or not. Indeed, if the artery is calcified the true pressure index may be even lower and even more urgent...

Prologue

Wet Gangrene

He's both their parent and he is their grave, And gives them what he will, not what they crave. Pericles, Prince of Tyre, II, iii, William Shakespeare Fig. 1 Foot from the UK. This 85-year-old man with type 2 diabetes of 8 years' duration received regular dressings of his ulcerated ischaemic foot for 9 months, but was not referred until extensive gangrene had developed. Fig. 2 Foot from Ukraine. This 48-year-old man with type 2 diabetes of 12 years' duration trod on a nail and developed severe...

Causes of necrosis

Necrosis can be due to infection, when it is usually wet, or to occlusive macrovascular disease of the arteries of the leg, when it is usually dry. Necrosis is not, as previously thought, due to a microangiopathic arteriolar occlusive disease, or so-called small vessel disease. Health-care professionals working with diabetic foot disease should avoid using this term, which is imprecise and may lead to therapeutic nihilism. Digital necrosis is common in patients with renal impairment,...

Historical Background

Plamen Kamenov

The last century made great inroads into improving the management of diabetes. The early work of pioneers such as Nicolas Paulesco in Rumania and Georg Zuelzer in Germany culminated in the work of Banting, Best, Collip and Macleod in Canada who produced a pancreatic extract which was used successfully in patients and ended the Fig. 6 International visitors at the King's Diabetic Foot Clinic left to right, Dr Kamenov Bulgaria , the Authors, Dr Harkless USA and Dr Plamen Bulgaria . Fig. 7 The...

Gas gangrene diagnosed from culture of tissue

Clostridium Perfringens Gangrene

A 65-year-old man with type 2 diabetes of 23 years' duration and chronic ischaemia developed four necrotic toes following an episode of infection which was treated in hospital with intravenous antibiotics. Vascular intervention was not feasible and the toes were treated conservatively, with treatment consisting of pain control with liberal analgesia, oedema control with diuretics, infection control with oral antibiotics, and wound control with Fig. 6.17 a The proximal portion of this necrotic...

Ulcer with local signs of infection

Diabetic Ulcer Bone Exposure Probe

Local signs that an ulcer has become infected include any or all of the following Base of the ulcer changes from healthy pink granulations to yellowish or grey tissue Increased friability of granulation tissue Fig. 5.4 Increased amount of exudate Fig. 5.5 Exudate changes from clear to purulent Fig. 5.6 A deep sinus has appeared in the base of this ulcer. Fig. 5.6 A deep sinus has appeared in the base of this ulcer. Sinuses develop in an ulcer Fig. 5.6 Edges may become undermined so that a probe...

Artefactual ulcers

Skin Disorders Diabetic Patients

Some patients cause ulcers by pulling skin off their feet Fig. 4.39 or applying noxious substances, or prevent ulcers from healing. The patients we have seen have been young and mostly female, and have suffered in the past from eating disorders or 'brittle' diabetes. Fig. 4.38 a This patient developed necrosis on the front of the ankle from a bandage which became too tight when her oedema increased, b A close-up view of the iatrogenic lesion shown in a . The conventional bandage was replaced...

Decubitus ulcers

Decubitus Ulcer Foot

Decubitus ulcers, which develop when the foot is exposed to unrelieved pressure, are common on the diabetic foot and especially on the heel. Patients who have been ill or immobilized are particularly vulnerable. Decubitus ulcers can develop in a short time. Contributing causes include Foreign bodies in the bed biscuit crumbs, etc. Patients attempting to move in the bed by putting excessive pressure on the heels Sliding down the bed so that feet are in contact with bed end.

Mallet toe correctiondistal interphalangeal joint arthroplasty

Hammer Toe Mallet Toe

Mallet toe correction is indicated for lesions that develop at the tip of the toe. In the presence of mallet toe deform Fig. 8.5 Surgical correction of hammer toe deformity, a Preoperative appearance of a rigid hammer toe, 2nd toe, right foot. Notice the very prominent deformity at the proximal interphalangeal joint, b The extensor digitorum longus Fig. 8.5 Surgical correction of hammer toe deformity, a Preoperative appearance of a rigid hammer toe, 2nd toe, right foot. Notice the very...

Case Study On Diabetic Foot Care

Subungual Ulcer Foot

A 78-year-old man with type 2 diabetes of 5 years' duration was referred with a discharging subungual ulcer on his right hallux which had been present for 8 years. Pedal pulses were palpable. The footwear was narrow and insufficiently roomy, and he was asked to purchase shoes with a deep toe box which would not cause pressure on the nails. The toe nail was cut back. The patient wore suitable shoes, and the ulcer improved, with less discharge, but Fig. 4.43 This subungual ulcer failed to heal...

Neuroischaemic foot

Necrosis Demarcation Line Photo

In the neuroischaemic foot, wet necrosis should also be removed when it is associated with severe spreading sepsis. This should be done whether pus is present or not. However, where necrosis is limited to one or two toes in the neuroischaemic foot we avoid surgery where possible until vascular intervention has been achieved. If angioplasty or arterial bypass is not possible, then a decision must be made either to amputate the toes in the presence of ischaemia or allow the toes, if infection is...

Acknowledgements

Ali Foster and Mike Edmonds offer special thanks first to their co-author, Lee Sanders, who contributed the chapter on surgical management of the diabetic foot and also cast a critical and helpful eye over the other chapters giving an American perspective. His advice was invaluable. For sections of the chapter on the management of diabetic major amputees we owe a great deal to Christian Pankhurst and Alan Tanner for details of prosthetic and orthotic management. We are also grateful to Rosalind...

Wet necrosis with rapid onset

A 73-year-old Afro-Caribbean woman with type 2 diabetes of 30 years' duration, peripheral vascular disease and a previous below-knee amputation attended the diabetic foot clinic with a 2-cm broken blister on her left heel. She was obese and confined to a wheelchair. She did not want to take antibiotics and said she would prefer not to have visits from the district nursing service as her daughter, with whom she lived, would look after the foot. Her daughter was carefully taught to clean and...

Th metatarsal head resection

An 80-year-old active man with peripheral neuropathy and loss of protective sensation presented to clinic with a prominent, painful tailor's bunion that could not be satisfactorily accommodated by footwear. The patient had a 5th metatarsal head resection performed 2 years earlier, for correction of a similar condition affecting his right foot. He was very satisfied with the results and returned for surgical correction of his left foot. The surgical procedure and postoperative course were...

Fear of gangrene

Some patients and their families find necrotic feet deeply upsetting. The use of the word 'gangrene' can distress and frighten some patients. It should be explained that just because a small area of the foot has developed necrosis it does not mean that the whole foot will be destroyed or that amputation is inevitable. The health-care practitioner should never express distaste or disgust. If he does not know the patient well, then before the foot is uncovered he should ask whether the patient...

Key points

Angioplasty is the first-line treatment for peripheral Fig. 4.18 The left foot is cold, red and ischaemic at presentation. Fig. 4.18 The left foot is cold, red and ischaemic at presentation. arterial disease in the diabetic limb, where the intention is to obtain straight line arterial flow to the foot Measuring the pressure index may be impossible in patients on haemodialysis with fistulas TcPo2 is a useful alternative method of quantitating ischaemia in these circumstances.

Local signs of infection not noted by patient

Dangers Infected Diabetic Toe

A 53-year-old lady with type 1 diabetes of 25 years' duration, proliferative retinopathy with reduced vision, peripheral neuropathy and hallux rigidus developed a neuropathic ulcer under callus on the plantar surface of her right hallux. She was warned of the usual danger signs of deterioration redness, warmth, swelling, pain, purulent discharge but did not return to clinic until her routine appointment. Callus had grown over the ulcer preventing drainage and the toe had become cellulitic Fig....

Open transmetatarsal amputation

Extensive forefoot infection or gangrene that extends on to the plantar skin may preclude a standard forefoot or mid-foot amputation. In these cases, an open or guillotine amputation performed at the mid-metatarsal level may be required. Guillotine amputations have a major disadvantage, in that they require extensive revision. A better alternative is to fashion flaps in the usual manner but to leave the wound open, with the intent to perform a delayed primary closure. The main disadvantage of...

Delayed presentation of infection masked by callus

Deep Extensive Cellulitis

A 72-year-old woman with type 2 diabetes of 20 years' duration and peripheral neuropathy developed 'a dark spot' on the apex of her right 3rd toe and applied sterile gauze which was replaced at weekly intervals. The toe did not improve and regular dressings were continued for several months until her daughter noticed that the toe had become pink, and brought her up to the diabetic foot clinic. Her pedal pulses were strong and bounding. A plaque of callus covered the entire apex of the pink toe...

I

Images Diabetic Foot Bleeding

Fig. 5.24 All necrotic tissue has been removed down to healthy pig. 5.25 Wrinkling of skin indicating resolution of oedema, bleeding tissue. Fig. 5.24 All necrotic tissue has been removed down to healthy pig. 5.25 Wrinkling of skin indicating resolution of oedema, bleeding tissue. some cases debridement may need to be accompanied by amputation of a toe or ray. Consent for these procedures should therefore be obtained prior to operation. The anaesthetist should understand that debridement of the...

Acute Charcots osteoarthropathy of the forefoot

Midfoot Breakdown

A 21-year-old woman with type 1 diabetes of 15 years' duration developed painless swelling of both forefeet Fig. 3.20a . There was no evidence of ulceration. X-ray revealed fragmentation and lucency of the 2nd, 3rd and 4th metatarsal heads of both feet Fig. 3.20b . The patient was supplied with a wheelchair and underwent strict non-weightbearing for 4 weeks. The oedema gradually resolved. Deformity did not develop and the radiological changes stabilized. The radiological changes of...

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Debride Toe Limitus

There is a callus with preulcerative changes on the plantar medial aspect of the great toe. Fig. 8.6 Hallux limitus. There is a callus with preulcerative changes on the plantar medial aspect of the great toe. requires regular debridement and footwear modification. The natural history for hallux interphalangeal joint lesions is for the preulcerative condition to progress to a full-thickness ulcer and eventually to amputation. Correlation between elevated plantar pressure...

Foreign body in foot

Diabetic Foot Ulcer Ray

A 68-year-old woman with insulin-treated type 2 diabetes of 20 years' duration complained of pain on the back of the left heel and a superficial ulcer surrounded by a halo of erythema Fig. 4.34a . She was unaware of the cause of the ulcer. An X-ray showed two dipped-off insulin needles in the soft tissues of her heel Fig. 4.34b . She had previously Fig. 4.34 a The superficial ulcer of unknown aetiology surrounded by a halo of erythema, b X-ray reveals two clipped-off insulin needles embedded in...

Iatrogenic lesions

Tape applied to atrophic skin and ripped off Tight bandages. We have seen a 53-year-old woman with type 2 diabetes mellitus of 13 years' duration and oedematous feet, who sustained a burn to the dorsum of the foot. She applied a sterile dressing held in place by a bandage which completely encircled the foot and ankle, and made an appointment to be seen at the diabetic foot clinic. When the bandage was removed she had developed superficial necrosis from an over-tight bandage and fluctuant...

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Tibiocalcaneal Fusion Cast

Fig. 8.41 a Lateral radiograph reveals extensive destruction of the left ankle joint with disintegration of the talus and fragmentation of bone, b Postoperative radiograph of the left ankle following tibiocalcaneal fusion with the intramedullary nail and interlocking screws in place, c Long-term follow-up. Clinical appearance of the left foot and ankle 5 years after surgery. over the course of several months, ankle deformity and instability progressed, with disintegration of the talus Fig....

Partial calcanectomy

Partial calcanectomy is indicated for the surgical management of large non-healing wounds located over the heel, with or without osteomyelitis. These wounds are typically chronic decubitus ulcers located on the posterior aspect of the heel, or neuropathic ulcers on the plantar surface of the heel. Regardless of the aetiology, heel ulcers are often unresponsive to conservative therapy and are frustrating to treat. Partial calcanectomy is a viable alternative to below-knee amputation for these...

Hallux amputation Fig ab

Amputation of the great toe invariably results in biomech-anical dysfunction of the foot. The degree to which this occurs depends upon whether or not a portion of the 1st metatarsal has also been removed. The loss of propulsive function is not detrimental to neuropathic patients who already have an apropulsive gait. Of greater concern, however, are the following postoperative sequelae Compensatory flexion contracture of the 2nd toe Ulceration at the tip of the 2nd toe Ulceration beneath the 1st...

Examination

Examination Ischaemic Foot

Foot examination should be carried out as described in the introduction. The ulcer should then be examined noting Fig. 4.1 An ischaemic ulcer on the margin of the foot with a halo of erythema. Fig. 4.1 An ischaemic ulcer on the margin of the foot with a halo of erythema. Appearance of the ulcer and surrounding tissues The implications of these are discussed below. Site Ulcers on the plantar surface are usually neuropathic and ulcers on the margins of the foot are usually neuroischaemic. However...

Metatarsal Disarticulations

Metatarsal Disarticulations

The 5th ray is amputated through a dorsolateral approach, with a racquet incision encircling the 5th toe. The toe is disarticulated at the metatarsophalangeal joint, and all necrotic tissues are excised. The incision is then extended proximally, in a curvilinear fashion over the 5th metatarsal shaft, to the level of the base. Dissection is kept close to the bone. The soft tissues are retracted using blunt Senn retractors. The exact amount of bone to be removed is determined, at the time of...

Practical Assessment

Gout And Tophi

This can be divided into three parts Every attempt should be made to encourage the patient to be open and non-defensive. The history can be divided into the following sections Be aware that some patients may be asymptomatic due to neuropathy. The presenting complaint is usually one or more of the following For skin breakdown, swelling and colour change or any other presenting complaints, the following questions may be helpful As regards pain, this maybe a specific complaint alone or it may...

Acute Charcots osteoarthropathy with rapid onset of bony destruction and deformity

A 46-year-old man with type 1 diabetes of 33 years' duration, end-stage renal failure treated by renal transplantation and severe neuropathy, received regular foot checks under a renal foot study protocol. Three days before he went on holiday to the Channel Islands his feet were routinely checked and nothing abnormal was discerned. Two weeks later he came to the clinic on his return from holiday to report that his foot was 'a little swollen'. He reported no trauma to the foot, but had been...

Tf

Fig. 5.15 a MRIT1 sequence shows normal uptake in soft tissues under extensor hallucis longus tendon, b Increased uptake on STIR sequence, c A small collection of fluid under E amp flMnBtiairgTCiinnnas gaBKETitaaisffi BfinESRsasM the extensor hallucis longus tendon post gadolinium , d Temperature chart showing resolution of fever. the extensor hallucis longus tendon post gadolinium , d Temperature chart showing resolution of fever. He underwent surgical debridement and 20 mL of pus was drained...

Angioplasty and delayed healing until removal of sequestrum in a neuroischaemic foot

A 91-year-old lady with type 2 diabetes of 20 years' duration who lived in a nursing home was referred as an emergency with a painful oedematous, ischaemic left foot complicated by severe cellulitis and lymphangitis and a malodorous ulcer on the apex of her 2nd toe. A swab grew mixed coliforms. The 5th toe had a bluish tinge. Her Doppler waveforms were severely damped and her pressure index was 0.3. She was admitted for wide-spectrum intravenous antibiotics and underwent angioplasty of the...

Preparations for transfemoral angiography and angioplasty

Patients taking metformin should stop this 2 days before the procedure and restart 2 days after, or when, renal function returns to normal. Insulin-dependent patients are placed first on the list in outpatient angiography and have their insulin after the procedure is finished. It is important to keep the patient well hydrated. Pre- and perioperative dopamine is no longer used. Further details of MRA are discussed in Chapters 5 and 6. Angioplasty is possible at several levels of the leg arterial...

Foot Callus And Fissures

Deep Fissure Feet Diabetic

Fig. 3.8 a Deep fissures before debridement, b The edges of the fissures have been cleared of callus, c The edges of the fissures are held together with Steri-strips. Fig. 3.8 a Deep fissures before debridement, b The edges of the fissures have been cleared of callus, c The edges of the fissures are held together with Steri-strips. Other common foot disorders and their management are described in Chapter 2. The majority of patients will be asymptomatic and ischaemia will be diagnosed on...

Dry necrosis

Arterial Embolism Foot

Dry necrosis is secondary to a severe reduction in arterial perfusion and occurs in three circumstances Peripheral arterial disease usually progresses slowly in the diabetic patient, but eventually a severe reduction in Fig. 6.4 a Neuropathic foot with infected plantar ulcer. The 4th toe has turned blue because septic arteritis has led to occlusion of both digital arteries. The 3rd toe is changing colour. Fig. 6.4 a Neuropathic foot with infected plantar ulcer. The 4th toe has turned blue...

Problems with totalcontact cast

A 63-year-old female with type 1 diabetes mellitus of 20 years' duration, developed an acute Charcot's osteoarthropathy which was treated in a total-contact cast. She was a very successful milliner who was currently making hats for Royal Ascot Races, and was working from a studio at home with a team of assistants. She failed to attend for her 1-week cast check. We telephoned her and she said that the cast was fine but she was frantically busy making hats and really did not want to come in. We...

Achilles tendon lengthening

5th Metatarsal Head Excision

Increased pressure on the plantar aspect of the forefoot has been shown to be associated with limited joint mobility and with equinus deformity of the ankle. In the Fig. 8.16 Technique for 5th metatarsal head resection. Before and after removal of the metatarsal head. Note that the osteotomy is angled in an oblique manner at the surgical neck of the metatarsal. Fig. 8.17 a Preoperative anteroposterior radiograph reveals deformity of the right 5th metatarsophalangeal joint with lateral bowing...

Percutaneous lengthening of Achilles tendon with ostectomy of cuboid

A 63-year-old man with type 2 diabetes of 12 years' duration presented to the diabetic foot clinic with a chief complaint of pain, redness and swelling of his left foot. This condition began 1 week earlier with sudden onset and with no history of injury. Physical examination revealed instability of the mid-foot, ankle equinus, bounding pedal pulses, absent deep tendon reflexes at the ankle and loss of protective sensation. He was unable to perceive the Semmes-Weinstein 6.10 90 g monofilament....

Overwhelming necrosis following arterial occlusion

Necrosis Foot

An 80-year-old woman with type 2 diabetes mellitus was admitted to hospital following a stroke and discharged home under the care of the general practitioner. The right foot became discoloured but she felt no pain and it was not until overwhelming necrosis of the right foot and Fig. 7.1 Overwhelming necrosis this foot was already destroyed at presentation. Fig. 7.1 Overwhelming necrosis this foot was already destroyed at presentation. lower limb had developed that she showed her leg to the...

Modified Lisfranc amputation

Modifications of the Lisfranc amputation include preservation of the 5th metatarsal base, and the 2nd metatarsal base, in its intercuneiform mortise. The patient is placed in a supine position with the foot and lower half of the leg prepared and draped in the usual manner. This procedure is performed in a manner similar to the transmetatarsal amputation, with the development of a longer plantar flap and short dorsal flap. The dorsal skin incision is made just distal to the 1st...

Case Study Of Wet Gangrene

Wet Gangrene

A 50-year-old man with type 1 diabetes of 30 years' duration underwent amputation of the second ray of his right foot for wet gangrene. At discharge from hospital he was reluctant to wear special shoes. After the foot healed he developed heavy callus over his 1st and 4th metatarsal heads. Speckles of blood within the callus indicated a preulcerative state Fig. 3.6 . He agreed to wear bespoke shoes after the significance of the blood within the callus was explained. The orthotists supplied...

Gangrenous heel

A 78-year-old man with type 2 diabetes of 9 years' duration and peripheral vascular disease treated with left distal bypass presented late with infection of the left foot which resulted in overwhelming necrosis. He was ill and toxic and underwent an above-knee amputation of his necrotic left leg. Four days later a blister was noted on his right heel which became infected and necrotic. He was given antibiotics to control infection. The necrosis dried out and became well demarcated from...

Anti Diabetic Patients

Callus Ischaemic Foot

In this early case from the mid-1980s an 80-year-old woman with type 2 diabetes of 20 years' duration developed a corn over her left 1st metatarsal head. She attended a podiatrist who debrided the corn, applied a felt pad to deflect pressure, and told the patient on no account to remove the pad for 3 weeks. After 1 week the foot became painful but the patient refused to allow the pad to be removed. Three days later she was taken to casualty by her daughter. Deep necrosis had developed under the...

Ulcers over the Achilles tendon

This is another notoriously difficult site to heal. It is an unusual site for ulceration and is usually triggered by unsuitable footwear or is a pressure lesion in an immobile patient. When tendon is exposed in the base of the ulcer the advice of a surgeon should be sought. Our colleague, E. Maelor Thomas, a founder member of our foot clinic and an orthopaedic surgeon, always said that dead tendon was the worst kind of sequestrum and should always be excised from ulcers. We have used Hyaff to...

Transmetatarsal amputation with excision of plantar ulcer

Chronic non-healing neuropathic plantar ulceration is often associated with the complications of soft tissue infection and osteomyelitis. Cases which are refractory to conservative care may benefit from a modified transmetatarsal amputation with excision of a triangular wedge of skin from the plantar flap. I have also employed this technique, in the absence of a plantar ulcer, to remodel excessively broad plantar flaps, thereby avoiding redundant skin and unsightly dog-ears. Following a...

Early signs of necrosis

The signs that part of a foot is becoming necrotic may be subtle in the early stages, and may mimic bruising or chilblains. A careful search should be made for early signs A toe which is developing a blue or purple tinge, having been previously pink because of infection or ischaemia Toes which have become very pale in comparison with their fellows An ulcer which has changed its colour from healthy shiny pink granulations to grey, purple or black or its texture from a smooth to a matt surface...

Classification

Classification and management of neuropathic and neuroischaemic ulcers. In Boulton AJM, Connor H, Cavanagh PR eds . The Foot in Diabetes. John Wiley amp Sons, Chichester, UK, 1994. Foster A, Edmonds M. Simple staging system a tool for diagnosis and management. Diabetic Foot 2000 2 56- 62. Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. Diabetic neuropathic foot ulcers the association of wound size, wound duration, and wound grade on healing. Diabetes Care 2002 25...

Large tissue deficit in a neuroischaemic foot secondary to infection needing distal arterial bypass

Femoral Popliteal Bypass Incision

A 43-year-old male with type 1 diabetes of 27 years' dura tion, with peripheral and autonomic neuropathy, was referred with indolent neuropathic ulceration complicated by local cellulitis over the left 5th metatarsal head His pedal pulses were palpable. He was treated with ora amoxicillin 500 mg tds and fludoxacillin 500 mg qds anc outpatient debridement. His deep wound swab hac grown Staphylococcus aureus and Streptococcus group G. The cellulitis resolved and he was given a total-contact cast....

Eczematous eruption within cast

Scotch Cast Boot Pictures

A 42-year-old neuropathic man with type 1 diabetes of 40 years' duration was given a total-contact cast for acute Charcot's osteoarthropathy. After 3 weeks he developed an eczematous eruption of the whole area covered by cast and some areas on the other leg and arms. He underwent patch testing by dermatologists, including testing to epoxy resins. These tests were all entirely negative, making a contact eczema rather unlikely, although it is possible that he was allergic to another component of...

Psychological problems

Concurrent psychological problems are also formidable barriers to care. Figure 5.28a,b shows the feet of a middle-aged depressed man who lived alone and neglected his feet. His right foot developed ulceration over the dorsum of the 2nd toe which was complicated by cellulitis. He had peripheral neuropathy with marked clawing of the toes. He wore no socks, the ulcer was not dressed and his shoes were too tight. It is important for all patients and their families to understand the dangers of...

Lesser metatarsal osteotomy

2nd Metatarsal Surgery

Dorsiflectory metatarsal osteotomies are performed for the treatment of lesser metatarsalgia, most often for Fig. 8.14 Chronic intractable plantar keratosis beneath the 2nd metatarsal head. The callus has been debrided, revealing preulcerative haemorrhage within the skin. This is an indication for lesser metatarsal osteotomy. Fig. 8.13 Sesamoidectomy. a Intraoperative photograph, the ulcer has been excised, b The hypertrophic tibial medial sesamoid has been grasped with a bone clamp and is...

Lisfranc amputation

A 50-year-old man with a history of IV drug abuse and type 2 diabetes underwent amputation of his right 2nd toe and was referred to us for surgical management of his infected right foot. Examination revealed several draining ulcers and sinus tracts, extending from the site of his amputated 2nd toe, to beneath the 2nd and 3rd metatarsal heads and into the central plantar space Fig. 8.33a . Radiographs revealed osteolytic changes in the 2nd and 3rd metatarsals consistent with osteomyelitis. The...

Further Reading

Adler AI, Ahroni JH, Boyko EJ, Smith DG. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy and foot ulcers. Diabetes Care 1999 22 1029-35. Anderson SP. Dysvascular amputees what can we expect J ProsthetOrthot 1995 7 43-50. Bowker JH, Michael JW eds . Atlas of Limb Prosthetics Surgical, Prosthetic and Rehabilitation Principles, 2nd Edn. American Academy of Orthopaedic Surgeons, USA, 1992,429-78. Cochrane H, Orsi K, Reilly P. Lower...

Bony destructiondeformity

Foot Xray Views Subluxation Metatarsl

If treatment is given early in acute Charcot's osteoarthropathy, it should help to prevent the second phase, that of bony destruction and deformity. Once the foot becomes deformed or shows X-ray changes, it has entered the bony destructive phase. Clinical signs are swelling, warmth, a temperature 2 C greater than the contralateral foot and deformities which can Fig. 3.18 There is a Lisfranc's tarsometatarsal joint dislocation red arrow with metatarsal bases shifted laterally. Yellow arrow shows...

Extensive debridement of severe sepsis in a neuroischaemic foot

Debridement Toes

A 66-year-old man with type 2 diabetes of 10 years' duration went to casualty complaining of a swollen foot with a small purple area on the medial border. His foot pulses were impalpable and his pressure index was 0.7. He was unwell with pyrexia of 39 C and had rigors. He was taken to operating theatre for debridement. Although the area of non-viable tissue appeared to be not more than 3 cm in diameter Fig. 6.23a , surgical debridement revealed very extensive tissue destruction involving...

Acute onset

Mdp Diabetic Foot

There is unilateral erythema and oedema Fig. 3.15 . The foot is at least 2 C hotter than the contralateral foot and the difference may be as great as 10 C. This may be measured with an infrared skin thermometer. There may be a history of minor trauma such as tripping, twisting the ankle or walking over rough surfaces such as cobbles. Charcot's osteoarthropathy may follow injudicious mobilization after surgery, a period of bed rest or casting. About 30 of patients complain of pain or discomfort....

Hallux limitus

Peak Plantar Pressures

A 46-year-old man with type 2 diabetes of 12 years' duration, documented peripheral neuropathy with loss of protective sensation and history of a chronic non-healing ulcer on the plantar medial aspect of his right hallux inter-phalangeal joint, had limited joint mobility in the 1st metatarsophalangeal joint, with approximately 10 of hallux dorsiflexion Fig. 8.9 . Quantitative plantar pressure measurements revealed markedly elevated peak plantar pressure, 95 N cm2, beneath the great toe Fig....

Open reduction and rigid internal fixation of midfoot fracturedislocations

Open Reduction Internal Fixation Foot

A 53-year-old Caucasian, male, janitorial worker, with type 2 diabetes of 6 years' duration presented to the diabetic foot clinic with the chief complaint of sudden and unexpected swelling of his left foot. There was no history of injury, ankle sprain, tripping or falling. Physical examination revealed moderate to severe redness, swelling and elevated skin temperature, approximately 4 C, of the left foot and ankle. Swelling extended up the leg to the knee. The medial column of the foot was...

Amputations through the midfoot

Chopart Level Amputation

Lisfranc and Chopart amputations are frequendy Fig. 8.30 Transmetatarsal amputation, a Preoperative appearance of the right foot with a large necrotic wound at the site of a failed hallux amputation, b The plantar flap has been rotated medially to achieve closure of the surgical wound. c Lateral radiograph reveals the level of amputation. Notice the angled cuts of the metatarsals. Stainless steel staples were used to close the wound, d Healed transmetatarsal amputation right foot. Fig. 8.30...