Overwhelming necrosis after patient lost to followup

A 73-year-old man with type 2 diabetes of 25 years' duration, peripheral neuropathy, peripheral vascular disease and previous amputation of his 2nd toe for osteomyelitis, failed to attend follow-up appointments in the diabetic foot clinic. He lived alone and turned away ambulance transport, despite frequent reminders and notification of his general practitioner, who arranged weekly visits by the district nurses. His forefoot changed colour: it was initially blue and then became black but because the patient did not complain of pain no help was sought. After 5 weeks the discolouration spread up the foot. He was admitted to hospital with wet gangrene. The foot was already destroyed at presentation (Fig. 7.1). He underwent a below-knee amputation.

Key points

• Necrosis is often painless in the diabetic foot

• If dry necrosis becomes infected, wet necrosis can supervene and destroy the foot in a short time

• Regular follow-up is crucially important for high-risk diabetic patients with foot problems

• We become alarmed if high-risk patients fail to keep appointments and try to arrange for regular inspections of the feet.

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