Ischaemic foot complicated by extensive deep soft tissue infection needing a wide excision

A 73-year-old Afro-Caribbean patient with type 2 diabetes of 7 years' duration, attended the diabetic foot clinic at 2-monthly intervals for nail care. He had no excessive callus formation requiring debridement. His daughter brought him to the clinic as an emergency: he was unable to put his shoe on because his foot was swollen. He felt no pain in the foot and was apyrexial. We found an ischaemic ulcer on his 5th toe which had not been present at his previous visit to the diabetic foot clinic, and brawny oedema of the dorsum of the foot (Fig. 5.23a). He was admitted to hospital for intravenous antibiotics (amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 500 mg tds and ceftazidime 1 g tds) and underwent amputation of the 4th and 5th toes and extensive debridement (Fig. 5.23b) followed by split-skin grafting and a distal bypass. The weightbearing area of the foot was greatly reduced. After the successful distal bypass had improved perfusion of the foot he began to develop plantar callus over his metatarsal heads and his wounds also developed callus and took on the appearance of neuropathic ulceration.

The foot failed to heal initially despite provision of regular debridement and bespoke footwear. The foot finally healed after the orthotist manufactured a patellar-tendon bearing weight-relieving orthosis (Fig. 5.23c).

Key points

• Extensive tissue destruction was associated with 5th toe ulcer and cellulitis needing a wide excision

• Heavy pigmentation can prevent detection of cellulitis

• The clue to infection was the swelling of the foot

• When blood flow is restricted, the ischaemic foot does not produce heavy callus in response to mechanical forces of friction and shear. However, reconstructed neuroischaemic patients may have blood flow sufficient to grow callus and hence be prone to plantar neuropathic ulceration

• If footwear does not off-load a foot effectively a patellar-tendon bearing orthosis maybe helpful

• Patients who have undergone a successful bypass are observed carefully for plantar callus regrowth

• They receive regular podiatry and orthotic assessment for plantar off-loading where necessary.

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