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 surrounding tissue. He underwent angiography and distal bypass to the right leg. A pressure-relieving ankle-foot orthosis (PRAFO) was issued. The foot healed in 6 months.

Key points

• Heel protection is essential for diabetic patients during the perioperative and postoperative period

• Dry necrosis of the heel can be treated by gentle debridement and does not necessarily need operative surgical debridement

■ There should be close liaison between the diabetic foot service and the rehabilitation team

• The remaining foot will be at risk of overloading, and should be carefully protected during the perioperative and postoperative period. The remaining foot also needs careful attention.

Diabetic amputees should:

• Not attempt to cut their own toe nails

• Check the foot and stump every day

• Report problems immediately

• See a podiatrist regularly.

Rehabilitation physiotherapists, prosthetists, orthotists and ward staff must understand the need to avoid trauma to the remaining foot at all costs. Major amputees are among the most high risk of all diabetic foot patients. Even with optimal foot care, foot problems occur in many major amputees, and unless they are detected early and aggressively treated by a multidisciplinary team, the outlook will be very poor.

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