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, and over the 1st metatarsal to the level of the medial cuneiform. On admission his glucose was 398mg/dL (22.1 mmol/L), white blood cell count was 18 300/|_lL, with 96% granulocytes. The patient was diagnosed with gas gangrene, a limb-threatening infection, and was immediately taken to the operating room for a guillotine amputation of his forefoot, under general anaesthesia. The surgical wound was left open. Intraoperative wound cultures revealed anaerobic Gram-positive cocci, Peptostreptococcus magnus and Peptostreptococcus asaccharolyticus. Blood cultures also grew Peptostreptococcus magnus. In consultation with the infectious disease specialist, he was placed on intravenous piperacillin sodium/tazobactam sodium and clindamycin. Daily dressing changes were performed, until the wound was clean and free from infection. The patient was given the options of a Chopart's amputation, to salvage a portion of his foot, or a below-knee amputation. He was opposed to losing his leg and chose the first option.
The patient returned to the operating theatre where under spinal anaesthesia, and a thigh tourniquet, he
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