A 56-year-old diabetic man with type 1 diabetes of 31 years' duration and peripheral neuropathy stubbed his left hallux when walking barefoot. He was aware that the nail was damaged but felt no pain and assumed the injury was trivial. He denied ever receiving foot care education and had not attended the diabetic foot clinic. One week later he attended casualty with a necrotic hallux and cellulitis spreading up the foot (Fig. 6.13). Pedal pulses were bounding. Intravenous antibiotics were administered and he went to theatre within 24 h and underwent amputation of the first ray. There was no collection of pus, but extensive sloughy tissue. The foot healed in 10 weeks.
• In the neuropathic foot, there is good arterial circulation and the treatment of choice of wet necrosis is surgical removal
• The postoperative wound in the neuropathic foot heals as long as infection is controlled
• Diabetic neuropathic patients who are ignorant of foot care are extremely vulnerable
• We give them education and frequent follow-up appointments.
Fig. 6.13 Wet necrosis of the hallux with cellulitis spreading up the foot. There was no collection of pus but extensive sloughy tissue was present and he underwent amputation of the 1st ray.
Very occasionally, patients with neuropathic feet may not be suitable for or refuse operation, and the aim would then be to convert wet gangrene into dry by conservative treatment and intravenous antibiotics and allow autoamputation, where after a number of weeks or months the toe 'drops off leaving a healed stump. Many debridements of necrotic tissue can be performed in the outpatient clinic by podiatrists. Diabetic patients do not require local anaesthetic by virtue of their neuropathy and the fact that the tissue being removed is not living and therefore insensitive.
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