A developing world experience with distal foot amputations for diabetic limb salvage

Abstract

Objectives: To evaluate the functional outcome, morbidity, and viability of foot salvage in diabetic patients.

Materials and methods: This prospective case series was conducted from March 2007 to December 2012 at the department of surgery Pakistan Ordnance Factories Hospital, Wah Cantt, Pakistan. 123 males and 26 female patients were included in the study. All the patients were treated after getting admitted in the hospital and wounds were managed with daily dressings, nursing care and debridement of necrotic tissue with adequate antibiotic coverage.

Results: In total, 149 patients (mean age: 56±7.52 years) with 171 amputations were included in the study. The mean duration of diabetes mellitus (DM) was 9±4.43 years. Ninety-seven percent of the patients were diagnosed with type 2 DM. Wound debridement was performed under general anesthesia in 48 (33.2%) patients, whereas local anesthesia was used for the rest of the patients after having good glycemic control and improvement in general health. The most common pathogen isolated from the infected wounds was Staphylococcus aureus in approximately 46% cases. Regarding the types of amputation, partial toe amputation was performed in 21 (12.2%) cases, second-toe amputation in 60 (35%) cases, hallux amputation in 41 (24%) cases, multiple toe amputations in 29 (17%) cases, bilateral feet involvement was observed in 16 (9.3%) cases, and transmetatarsal amputation was performed in 4 (2.3%) cases. The wounds healed well except in 19 cases where amputation had to be revised to a more proximal level. Thirty-nine patients died during the study period: 3 died of wound-related complications and 36 died of systemic complications.

Conclusion: With the ever-increasing epidemic of DM, the number of patients with diabetic foot ulcers has also significantly risen. Early surgical management with good glycemic control and foot care with close monitoring can decrease amputations and thus foot salvage can be successfully achieved.

Keywords: amputations; diabetic foot; glycemic control; infections; limb salvage.

Fig. 1

Age distribution of patients.

Fig. 2

Frequency of Wagner grades of diabetic foot ulcers.

Fig. 3

Types of diabetic foot amputations.

Fig. 4

Pre-operative clinical (A) and radiographic (B) views of a big toe (hallux) gangrene in a 58-year-old type 2 diabetic female, with a healed wound 6 months after surgical debridement and partial hallux amputation (C, D).

Fig. 5

Extensive necrosis and toe gangrene in a 49-year-old male (A), with a healed wound after surgical debridement, negative-pressure wound therapy, and split thickness skin graft at 5 months post-operatively (B).