A 70-year-old male patient who had type 2 diabetes since the age of 58 years was referred to the outpatient diabetic foot clinic because of wet gangrene of his left foot. He was treated with insulin but his diabetes control was poor. He had hypertension, background diabetic retinopathy and he was a current smoker. The patient noticed black areas on the toes of his foot 7 days previously, but he continued his daily activities since he felt only mild pain.
On examination, he was feverless and his cardiac rhythm was normal. Wet gangrene on his left midfoot and forefoot and an infected necrotic ulcer on the outer aspect of the dorsum were noted (Figure 7.24). An infected ulcer was found under the base of his fifth toe (Figure 7.25), probably the portal of pathogens. Peripheral pulses were absent. He had findings of diabetic neuropathy: loss of sensation of pain, light touch and vibration.
The patient was admitted to the hospital and was treated with i.v. administration of clindamycin plus piperacillin-clavulanic acid. Extensive surgical debridement of the necrotic areas was carried out. An angiogram revealed diffuse peripheral
vascular disease with involvement of the pedal arteries. Seven days after admission the patient sustained a mid-tarsal (at Lisfranc's joint) disarticulation.
Wet gangrene is the most common cause of foot amputations in persons with diabetes. It often occurs in patients with severe peripheral vascular disease following infection. Dry gangrene may become infected and progress to wet gangrene. Patients with dry gangrene, awaiting a surgical procedure, should be educated in meticulous foot care. They must be taught to inspect their feet daily, including the interdigital spaces, and wash them twice daily with mild soap and lukewarm water; their feet should be dried thoroughly, particular the web spaces. It is extremely important for patients to avoid wet dressings and debriding agents, as the use of these may convert localized dry gangrene to limb-threatening wet gangrene. The correct footwear is crucial to avoid further injury to the ischemic tissue.
Keywords: Wet gangrene; mid-tarsal disarticulation
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