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.

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 time, but broke down if he had to run for a bus or walked more than usual. He was desperate to wear 'normal' footwear. He was placed on the waiting list for a joint renal/pancreas transplant but had been told that if he had ulceration the transplant could not be carried out. He had two young children and deeply resented being unable to run and walk freely and participate in sports. His orthotist referred him to the rehabilitation team who advised him to consider a below-knee amputation since he was a comparatively young man and would do well with a modern prosthesis.

When the patient discussed this proposal with the multidisciplinary diabetic foot team they perceived major amputation far less positively. They pointed out to the patient that with a prosthetic limb his remaining foot, with a previous history of ulceration would be overloaded and that a major amputation could not guarantee that he would remain free from ulceration. Nonetheless he made the decision to ask for a major amputation and was put on the waiting list for an elective below-knee amputation.

One month later he attended at the diabetic foot clinic as an emergency, complaining of pain and numbness in the right foot (the 'good' foot) which had been present for several days. The foot pulses were impalpable, and the leg and foot were mottled and grey and cold from mid-calf downwards. He developed necrosis of his medial longitudinal arch and hallux which slowly extended to involve three of the lesser toes and the heel. The angiogram showed occlusion of the mid and distal popliteal artery with faint filling of the anterior tibial artery and no plantar arch was seen. The popliteal artery was angioplastied, which allowed increased flow through the popliteal artery, anterior tibial artery and some flow into the plantar vessels. He has subsequently had repeat angioplasty of the popliteal and superficial femoral arteries at 3 and 4 months after presentation, and also underwent surgical debridement of necrotic tissues. He has cancelled amputation of the left leg.

Key points

• Every foot is a precious commodity which should be preserved if at all possible because of future risks to the other foot

• Angioplasty can be a successful treatment even for occlusion of the popliteal artery

• Angioplasty can be repeated to maintain the patency of the artery.

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