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Treatment of diabetic foot for limb salvage

Ahmed M. Abdel Modaber

General Surgery Department, Faculty of Medicine, Mansoura University Hospitals; Egypt

E-mail : aa

Ahmed Hammad

General Surgery Department, Faculty of Medicine, Mansoura University Hospitals; Egypt

Vusal Aliyev

General Surgery Department, Emsey Hospital, Istanbul, Turkey

DOI:10.15761/DSJ.1000118

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Abstract

Diabetic foot infection is a common health problem, presenting most commonly with ulcer, abscess or gangrene therefore the most common surgical treatment is debridement, incision and drainage, minor or major amputation. Care of diabetic foot includes Preventive measures like patient education of proper foot care, avoidance of localized trauma, and daily foot inspections. Wound care and aggressive debridement, good glycemic control either by insulin or oral hypoglycemic drugs, proper antibiotic according to culture and sensitivity, those measures could lead to dramatic reduction in amputations rate.

Keywords

diabetic foot, limb amputation

Introduction

Diabetic foot and related problems are important causes of morbidity in diabetic patients especially if they end up with amputation. They not only cause major financial burden on medical health but also cause extensive human suffering, prolong functionl disability and associated mortality [1].

Uncontrolled diabetes affects infection, and infection adversely affects diabetes. The basic rules in treating any foot infection are: Absolute bed rest, regulation of diabetes, adequate culturing of wound, administration of appropriate antibiotics, adequate drainage of all infection, and appropriate wound care [1].

Only by careful examination of all parts of both feet and legs can any foot disease be fully appraised. Afoot problem may be ablister, a moist fungal infection between the toes, a callus with an underlying abscess, a painful fissure on the heel, or a frankly gangrenous toe once discovered, any infected site must be opened to provide drainage of the pus and to obtain an adequate culture of any secretions [1].

In this study we are trying to evaluate and treat patients with diabetic foot.

Patients and methods

This study was carried out on 50 patients with diabetic foot, they were 28 females and 22 males, their ages ranged from 30 years to 80 years , they were subjected to:

1- History taking which include:

- History of present illness (Diabetic foot) duration and initial cause of lesion.

- Duration of diabetes and mode of treatment oral or insulin injection.

- History of peripheral vascular disease was defined as the presence of ischemic symptoms and signs such as intermittent claudication, rest pain and / or colour changes, coldness.

- History of peripheral neuropathy is considered to be present if there is numbness in the feet, hypothesia.

- Past history of similar condition as diabetic foot lesion, pervious ulcer or amputation.

2- General examination:

To detect the presence of other associated diseases

3- Local Examination:

In the form vascular examination such as loss of pulse, colour changes and coldness either in toes, foot or leg. Neurological assessement such as absence of pain in the foot or altered fine touch sensation and proprioception, presence of deformity (claw toe, hallux valgus or charcot joint), gangrene.

4- Clinical evaluation of diabetic foot

- infection depth classification according to:

Grade 0" At risk foot with previous, ulcer or neuropathy with deformity that may cause new ulceration

Grade 1” Superficial ulceration not infected

Grade 2" Deep ulceration exposing a tendon or joint with or without superficial infection

Grade 3" Extensive ulceration with exposed bone and /or deep infection (osteomyelitis)or abscess

- Ischemia classification according to:

Grade A" Not ischemic

Grade B" Ischemia without gangrene

Grade C" Partial gangrene of the foot

Grade D" Complete foot gangrene

5- Laboratory investigations:

In the form of fasting and postprandial blood sugar, renal and liver function tests, serum cholesterol and blood picture.

6- Bacteriologic examination:

This includes identification of the pathogenic organisms in wound discharge and detection of appropriate antibiotics suitable for eradication of such organisms through culture and sensitivity tests.

7- Duplex ultrasound: for evaluation of the arteries of lower limb.

8- Radiological examination:

All affected feet had x ray to exclude osteomyelitis and detection of deep infection in the foot which appear as subcutaneous collection of air and signs of osteomyelitis such as bony destruction and cortical erosion.

9- Angiography: is performed in diabetic patients for disabling claudication, ischemic rest pain, ischemic ulceration, and gangrene.

10- Management of diabetic foot:

1- without vascular impairment:

A) minor diabetic foot infection.

Grades 0,1 conservative treatment will be started with wound care, antibiotics therapy.

B) major diabetic foot infection.

- Infection without gangrene. grades 2,3 which treated by, surgical debridement, incision and drainage for abscess and collection, toe amputation, Trans metatarsal or forefoot amputation for exposed bone and tendon.

- Infection with gangrene. grades 2,3 below knee or above knee amputation will be done for massive infection and osteomyelitis

2- diabetic foot with vascular impairment

- with gangrene. Grades C, D partial foot amputation for partial foot gangrene and above or below knee amputation for complete foot gangrene.

- without foot gangrene. Grades A, B vascular reconstruction in the form of Bypass procedure or balloon angioplasty.

11- Follow up: For all lines of treatment to observe the result of treatment as:

- Complete healing.

- Needs skin grafts.

-Deterioration of the lesion with the need of other line of treatment.

-Reconstructive(bypass) surgery in patients with failure of healing of the foot lesion after long period due to ischemia.

Results

In table (1), most diabetic foot cases were in age group between (51- 60 y) 21 cases (42%), and the sacond age group between (41-50 y)13 cases (26%).

Table 1. Age distribution of diabetic foot patients

Age

Number of patients

%

30- 40 y

5

10

41 – 50 y

13

26

51 – 60 y

21

42

> 60 y

11

22

Table 2 show diabetic foot lesions more common in females 28 cases (56 %) than in males 22 cases (44%).

Table 2. Sex distribution of diabetic foot cases

Sex

Number of patients

%

Female

28

56

male

22

44

The most cases of diabetic foot had onset of diabetes between (10 – 24 y) 28 cases (56 %), and more than 20 years of diabetes in 12 patients 24% (Table 3).

Table 3. Duration of diabetes in related to diabetic foot

Duration of diabetes

Number of patients

%

< 10 years

10

20

10 – 20 years

28

56

> 20 years

12

24

The neuropathy was the most important cause of diabetic foot lesions, the most common symptoms of neuropathy was hypothesia and tingling 23 cases (46 %) (Table 4).

Table 4. Symptoms of neuropathy in diabetic foot infection

Symptoms of neuropathy

Number of patients

%

Hypothesia

7

14

Hypothesia and tingling

23

46

The number of cases associated with ischemic symptoms, claudication and rest pain was in 12 cases (24 %) (Table 5).

Table 5. Ischemic pain in diabetic foot

Ischemic symptoms

Number of patients

%

claudication

12

Rest pain

6

12

In table (6), signs of ischemia were colour changes, black colour in 10 patient (20%) presented with gangrene of different parts of the foot, coldness in toes 6 patients (12%), coldness foot 4 patients (8%) coldness leg 1 patients (2%) and loss of pulse were popliteal artery 3 patients (6%), posterior tibial artery 6 patients (12%), dorsalis pedis artery 15 patients (30%).

The most common organisms identified in diabetic wound discharge as shown in table 6, were staphylococci 7 cases (14%), streptococci 7 cases (14 %), and proteus 5cases (10%), then pseudomonas 4 cases (8 %), and klebsiella 3 case (6%). Other organisms were present E-coli 5 cases (10%)and corynebacterium 3ceses (6%), anaerobes were present in 13Cases (26%) in our study diabetic foot infections are polymicrobial in nature and showed mixed infection in most cases, staphylococci and pseudomonas in many cases and streptococci and E - coli in the other cases (Table 7).

Table 6. Signs of ischemia in relation to diabetic foot infection

Ischemic signs

Number of patients

%

Colour changes

black

purple

blue

10

2

2

20

4

4

Coldness in

toe

foot

leg

6

4

1

12

8

2

Loss of pulse

popliteal artery

posterior tibial artery

Dorsalis pedis artery

3

6

15

6

12

30

Table 7. Culture and sensitivity of wound discharge In diabetic foot infection

Organisms

Number of patients

%

Staphylococci

7

14

streptococci

7

14

 proteus

5  

10

Pseudomonas

4

8

Klebsiella

3

6

E- coli

5  

10

Neisseria

6

Anaerobes

13  

26

corynebacterium

6

Table 8 showed that increased number of cases of osteomyelitis of different parts of foot bones, were toes phalanges in 7 cases (14%), phalanges and metatarsal bones in 7 cases (14%) due to delayed treatment with proper antibiotics and extension of infection from soft tissue to bone (Table 9).

Table 8. Osteomyelitis in diabetic foot by plain x ray

Bone affection

Number of patients

%

Toes phalanges

7        

14

Metatarsal bones

4    

8

Calcaneus bone

2    

4

Phalanges and metatarsal  bones

7    

14

Table 9. Doppler ultrasound examination of diabetic foot

Duppler U.S Exam

Number of patients N=24

%

Popliteal artery

Obstructed flow

Weak flow

-

3

-

12.5

Posterior tibial artery

Obstructed flow

3

12.5

Dorsalis Pedis artery

Obstructed flow

12

50

Both posterior tibial and dorsalis pedis arteries

Obstructed flow

 

6

25

The number of cases examined by Doppler U.S. was 24 patients from 50 patients. We examined blood vessels of lower limb from external iliac to dorsalis pedis artery, the flow in the popliteal artery was within normal in all cases except in 3ceses (12.5%) showing weak flow the posterior tibial artery show obstructed flow in 3 cases (12.5%) The dorsalis pedis artery was obstructed in 12 cases (50%) both Posterior tibial and the dorsalis pedis arteries were obstructed in 6 cases (25%) (Table 10).

Table 10. Lines Of treatment in diabetic foot patients

Treatment

Number of patients

%

1- Antibiotics only

5

10

2-Incision and drainage

6

12

3- Debridement

16

32

4- Minor amputation

Toe amputation

Trans metatarsal

Forefoot

6

2

1

12

4

2

5- major amputation

below knee

Above knee

   

3

7

  

6

    14

6- Reconstruction  Surgery ( bypass)

4

8

In Table (11), the most common line of treatment was debridment, 16 patients (32%), then second common line was incision and drainage 6patients (12%) then above Knee amputation 7 patients (14%), Below knee amputation was done in3cases (6%), then toe amputation 6 patients (12%)Trans metatarsal amputation in 2 patients (4%) and forefoot amputation in one patient (2%). Reconstruction surgery in form of femoro - popliteal to distal (bypass)was done in 4cases (8%) There are number of patients treated by more than one line of treatment, either incision and drainge with debridement or debridement with amputation.

Table 11. Clinical outcome of conservative treatment for diabetic foot infection without vascular impairment

 Results of treatment

Number of patients

%

Complete healing

22

44

Needs skin grafting

5

10

Needs Conservative amputation  

9

18

In table 12, clinical outcome of conservative treatment was complete healing occur in24 cases (44%) and in 5cases (10%)are needs skin grafts, were conservative amputation needed in 9cases (18%).

Table 12. Clinical outcome of major diabetic foot gangrene without vascular impairment

Results of treatment

Number of patients

%

Needs Major amputation

Below knee

2

4

Above knee

5

10

In table 13, needs major amputation in 7 cases were in 2 cases (4%) below knee amputation was done and above knee amputation in 5 cases (10%).

Table 13. Clinical outcome of diabetic foot gangrene with vascular impairment

Results of treatment

Number of patients

%

Major amputation

Below knee

1

2

Above knee

2

4

In table 14, needs major amputation in 3 cases were below knee amputation in 1 cases (2%) and above knee amputation in 2 cases (4%).

Table 14. Clinical outcome of vascular impairment of diabetic foot without gangrene

Level of vascular Impairment

(occlusion)

Number of patients

N= 4

Reconstructive surgery

Superficial femoral artery

2

Femoro - popliteal
by pass

Anterior and posterior tibial arteries and peroneal artery

1

Femoro- distal by pass

Superficial femoral, anterior and posterior tibial arteries and peroneal artery

1

Femoro- distal by pass

Table 15 shows that reconstructive surgery in 4 patients (8%) in from of femoro - popliteal and femoro - distal by pass.

Discussion

Diabetic foot and related problems are important causes of morbidity in diabetic patients especially if they end up with amputation. Uncontrolled diabetes affects infection, and infection adversely affects diabetes. Only by careful examination of all parts of both feet and legs can any foot disease be fully appraised [1].

50 patients with diabetic foot were evaluated and treated. We found that the age of the patient ranged from 30- 80 years, this age was associated with increase incidence of peripheral neuropathy as well as higher incidence of ischemia, poor controlled diabetes and more exposed to trauma. In our study of 50 patients with diabetic foot we found that 28cases (56%) were females and22cases were males (44%).

Seabrook et al. [1] reported that the diabetic gangrene occurred 53 times as frequently in diabetic men and 71 times as frequently in diabetic women as in their nondiabetic. The incidence of atherosclerotic gangrene was also increased in diabetic women.

In our study loss of pulse were as follow the popliteal artery 3 patient (6%) posterior tibial artery 6 patient (12%), dorsalis pedis artery 15 patients (30%).

Miller et al. [2] reported that neuropathy and peripheral vascular disease are the most common predisposing factors for foot ulcers in patients with diabetes. between 60% and 70% of diabetic patients with ulcers have peripheral neuropathy, 15-20% have peripheral vascular disease, and 15 -20% have both.

In our study peripheral neuropathy was present in 30 patients (60%), ischemia is present in 12 patients (24%) and combination of ischemia and neuropathy in 8 patients (16%) this result more or less similar to the result reported by Miler [2] and Gavin [3].

In our study of distribution of initial causes of diabetic foot we found that the most common initial cause of diabetic foot was pinprick in neuropathic foot 9 patients (18%), trauma and cut wound in 9 patients (18%) ,and second common initial cause was abscess in 8 patients (16%), fungal infection in 7 patients (14%), cellulites in 7patients (14%),and another causes as removal of callus in 4 patients (8%), trimming nails in 4 patients(8%) and bulla in 2 patients (4 %).

Fry et al. [4] stated that in the study of 20 patients with diabetic foot infection that most common organisms isolated (enterococcus faecalis (7 cases), streptococci (7 cases) and aerobic gram negative cocci were proteus species (11cases) , E. coli (6 cases), Klebsialla species (4 cases) , pseudomonas ( 4 cases), Enterobacter (3 cases) and gram positive anaerobes were Streptococcus in (16 cases), clostridium(7cases) and gram negative anaerobes the most frequently isolated organisms were bacteroides fragilis (9 cases).

In our study, we found that the bactriological examination of diabetic foot cases, the most frequently isolated organisms were staph, streptococci in 14patients, (28%), proteus, pseudomona, E coli, were isolated in 14 patients, (28%), in 3 patients (6%) ware isolated klebsiella and in 3 patients (6%) isolated neisseria, corynebacterium were isolated in 3patients (6%), mixed infection are seen in most cases and anaerobes will be isolated in the 13 cases (26%). Thus, culture and sensitivity tests were important for proper treatment of diabetic foot associated with wound discharge, and select the proper antibiotic, better prognosis was obtained in patients treated according to culture and sensitivity than the patients use abuse antibiotics.

In our study we found the number of patients with bone affection by plain x ray 20 patient (40%) were7 patients (14%) with toes phalanges affection, 7 cases (14%) with phalanges, and metatersal bones affection, 4 cases (8%) with metatarsal bones affection and 2 cases (4%) with calcaneus affection, bone affection due to delayed treatment with proper antibiotic and incomplete debridement of soft tissue infection.

In our study we examined 24 patients by doppler ultrasound. We found that weak flow through the popliteal artery in3 patients (12.5%), obstructed posterior tibial artery in 3 patients (12.5%), obstructed dorsalis pedis artery in 12 patients (50%), and obstructed flow of the posterior tibial and dorsalis pedis arteries in 6 patients (25%), in our study the ischemia is the main cause of diabetic foot infection.

In our study patients on oral hypoglycemic drugs exposed to diabetic foot infection 32 patients (64%)and patients treated with insulin from the start were18 patients (36%), which have more controlled diabetes and less exposed to diabetic foot infection and its complications.

In our study the most cases of diabetic foot have onset of diabetes between 10-20 years 28 cases (56%), the long period of diabetes increase neuropathy and atherosclerotic changes and increase diabetic foot lesion.

Stokes [5] stated that the degree of atherosclerotic occlusive disease is related to the duration of diabetes (15%) have involvement at 10 years after initial diagnosis and (45 %) at 20 years.

In our study the lines of treatment for 50 patients with diabetic foot were antibiotic only in 5 patients (cellulites and superficial infection), incision and drainage in 6 patient (12%), debridement in 16 patients(32%)alone or with other lines of treatment, toe amputation in 6 patients and trans metatarsal amputation in 2patients(4%) and forefoot amputation in one patient, below knee amputation in 3 patients(6%) and above knee amputation in 7 patients(14%) and reconstructive surgery (bypass) in 4 patients(8%),and Balloon angioplasty in 2 patients (4%), the most patients treated by more than one line of treatment as incision drainage and debridement, debridement and amputation.

Cook et al. [5] reported that in the study of 22 patients with diabetic foot, were debridement alone in 6 patients (24%) debridement with amputation of toes in 8 patients (32%) toe amputation only in one patient (4%) metatarsal amputation in one patient (4%), while below knee amputation in3 cases (12%).

Our study, showed that the healing time was increased with increasing severity of diabetic foot infection according to the graded classification, healing time ranged from 2 weeks to 10 weeks or more.

In our study the clinical outcome of conservative treatment were complete healing occur in 22 cases (44%) with debridement and minor amputation, and 5cases (10%)are needs skin grafts, were conservative amputation needed in 9cases (18%), in 3 cases (6%) below knee amputation and above knee amputation in7cases (14%), reconstructive surgery in 4 patient 8% in from of femoro- popliteal and femoro -distal By pass.

Conclusion

Diabetic foot infection is a common health problem, presenting most commonly with ulcer, abscess or gangrene therefore the most common surgical treatment is debridement, incision and drainage, minor or major amputation.

Care of diabetic foot includes. Preventive measures like patient education of proper foot care, avoidance of localized trauma, and daily foot inspections. Wound care and aggressive debridement, good glycemic control either by insulin or oral hypoglycemic drugs, proper antibiotic according to culture and sensitivity, those measures could lead to dramatic reduction in amputations rate. The patient should be informed by the following instructions:

  1. Inspect your feet twice daily. Look all over the feet for cracks, blisters, reddened spots, cuts, and ulcers or for excessively moist skin between the toes.
  2. Bath your feet daily with warm water and mild soap. Dry gently and carefully between the toes. Blot do not rub.
  3. Never use heating pads, hot water bottles, or any other heat source to warm your feet, irreparable damage can be done in a minute. Wear socks in bed if your feet are cold at night.
  4. Skin calluses and corns. Do not use chemical agents or medicated pads, these can cause burns, do not perform bathroom surgery with a razor blade, use a pumice stone or foot file to reduce calluses gently at bath time, keep the skin moist regularly to prevent cracking and infection by using a gentle skin lotion, a very thin layer of petroleum jelly can also be used to seal in moisture after the bath and do not put creams, lotions, or ointments between the toes.
  5. Trimming nails straight, do not attempt to dig out the corners.
  6. Make sure shoes are long and wide enough and have enough room for the toes, especially if they are clawed. Avoid synthetic material that do not breathe. Leather is still generally the best material because it shapes and stretches. Avoid shoes made of hard materials eg. Plastic or patent leather.
  7. Avoid stockings elastic topes or garters. Wash and change stocking daily. Stockings made of absorbent, natural materials such as cotton and wool are best.
  8. Be sure that your physician examines your feet periodically.

Better results of treatment can be obtained if the following instruction are carried out:

  • Aggressive debridement of infected and necrotic wounds is essential to achieving the quickest and the most dependable healing.
  • Adequate control of blood sugar.
  • Evaluation of the vascularity of the foot and early management.
  • Hospitalization and bed rest during the period of treatment and administration of appropriate antibiotics. Treatment of all patients according to depth – ischemic classification of diabetic foot, helps in proper management and give a good prognosis.
  • Strict medical control of the diabetic process, with prompt wound care management along with preventive measures, lowers morbidity associated with lower extremity diabetic ulcers.

The assessment of the patient’s vascular state with clinical evaluation and duplex ultrasound as well as angiography if needed plus proper control of diabetes, good antibiotic therapy, wound care, can avoid unnecessary amputation or at least to do lower or conservation amputation instead of higher above knee amputations.

References

  1. Seabrook GR, Edmiston CR, Schmitt DD, Krepel C, Bandyk DF, et al. (1991) Comparison of Serum and tissue antibiotic levels in Diabetes related foot infection. Surgery 110: 671-676. [Crossref]
  2. Miller OF (1993) Essentials of Pressure Ulcer Treatment. The diabetic experience. J Dermatol Surg Onc 19: 759-763. [Crossref]
  3. Gavin L (1993) A comprehensive approach to side step diabetic foot problems. Endocrinologist 3: 191-203.
  4. Fry DE, Marek JM, Langsfeld M (1998) Infection in the ischemic lower Extremity. Surg Clin North Am 78: 471-479. [Crossref]
  5. Cook,et al, (1996) Two novel targets of the MAP kinase Kss1 are negative regulators of invasive growth in the yeast Saccharomyces cerevisiae. 10: 2831-48.

Editorial Information

Editor-in-Chief

Mitsuhiro Kida
Kitasato University & Hospital

Article Type

Research Article

Publication history

Received: March 06 2018
Accepted: March 16 2018
Published: March 19 2018

2018Copyright

©2018 Modaber AMA, Hammad A, Aliyev V. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Modaber AMA (2018) Treatment of diabetic foot for limb salvage. Dig Sys 2: DOI: 10.15761/DSJ.1000118

Corresponding author

Ahmed Hammad

General Surgery Department, Faculty of Medicine, Mansoura University Hospitals; Egypt

Table 1. Age distribution of diabetic foot patients

Age

Number of patients

%

30- 40 y

5

10

41 – 50 y

13

26

51 – 60 y

21

42

> 60 y

11

22

Table 2. Sex distribution of diabetic foot cases

Sex

Number of patients

%

Female

28

56

male

22

44

Table 3. Duration of diabetes in related to diabetic foot

Duration of diabetes

Number of patients

%

< 10 years

10

20

10 – 20 years

28

56

> 20 years

12

24

Table 4. Symptoms of neuropathy in diabetic foot infection

Symptoms of neuropathy

Number of patients

%

Hypothesia

7

14

Hypothesia and tingling

23

46

Table 5. Ischemic pain in diabetic foot

Ischemic symptoms

Number of patients

%

claudication

12

Rest pain

6

12

Table 6. Signs of ischemia in relation to diabetic foot infection

Ischemic signs

Number of patients

%

Colour changes

black

purple

blue

10

2

2

20

4

4

Coldness in

toe

foot

leg

6

4

1

12

8

2

Loss of pulse

popliteal artery

posterior tibial artery

Dorsalis pedis artery

3

6

15

6

12

30

Table 7. Culture and sensitivity of wound discharge In diabetic foot infection

Organisms

Number of patients

%

Staphylococci

7

14

streptococci

7

14

 proteus

5  

10

Pseudomonas

4

8

Klebsiella

3

6

E- coli

5  

10

Neisseria

6

Anaerobes

13  

26

corynebacterium

6

Table 8. Osteomyelitis in diabetic foot by plain x ray

Bone affection

Number of patients

%

Toes phalanges

7        

14

Metatarsal bones

4    

8

Calcaneus bone

2    

4

Phalanges and metatarsal  bones

7    

14

Table 9. Doppler ultrasound examination of diabetic foot

Duppler U.S Exam

Number of patients N=24

%

Popliteal artery

Obstructed flow

Weak flow

-

3

-

12.5

Posterior tibial artery

Obstructed flow

3

12.5

Dorsalis Pedis artery

Obstructed flow

12

50

Both posterior tibial and dorsalis pedis arteries

Obstructed flow

 

6

25

Table 10. Lines Of treatment in diabetic foot patients

Treatment

Number of patients

%

1- Antibiotics only

5

10

2-Incision and drainage

6

12

3- Debridement

16

32

4- Minor amputation

Toe amputation

Trans metatarsal

Forefoot

6

2

1

12

4

2

5- major amputation

below knee

Above knee

   

3

7

  

6

  14

6- Reconstruction  Surgery ( bypass)

4

8

Table 11. Clinical outcome of conservative treatment for diabetic foot infection without vascular impairment

 Results of treatment

Number of patients

%

Complete healing

22

44

Needs skin grafting

5

10

Needs Conservative amputation  

9

18

Table 12. Clinical outcome of major diabetic foot gangrene without vascular impairment

Results of treatment

Number of patients

%

Needs Major amputation

Below knee

2

4

Above knee

5

10

Table 13. Clinical outcome of diabetic foot gangrene with vascular impairment

Results of treatment

Number of patients

%

Major amputation

Below knee

1

2

Above knee

2

4

Table 14. Clinical outcome of vascular impairment of diabetic foot without gangrene

Level of vascular Impairment

(occlusion)

Number of patients

N= 4

Reconstructive surgery

Superficial femoral artery

2

Femoro - popliteal
by pass

Anterior and posterior tibial arteries and peroneal artery

1

Femoro- distal by pass

Superficial femoral, anterior and posterior tibial arteries and peroneal artery

1

Femoro- distal by pass