𝗖𝗔𝗦𝗘 07
𝗦𝗮𝗹𝘃𝗮𝗴𝗶𝗻𝗴 𝗮 𝗖𝗼𝗺𝗽𝗹𝗲𝘅 𝗗𝗶𝗮𝗯𝗲𝘁𝗶𝗰 𝗠𝗶𝗱𝗳𝗼𝗼𝘁 𝗔𝗺𝗽𝘂𝘁𝗮𝘁𝗶𝗼𝗻 𝗦𝘁𝘂𝗺𝗽 𝗔𝗳𝘁𝗲𝗿 𝗣𝗲𝗿𝘀𝗶𝘀𝘁𝗲𝗻𝘁 𝗜𝗻𝗳𝗲𝗰𝘁𝗶𝗼𝗻
A 65-year-old gentleman with poorly controlled diabetes mellitus presented with a severe diabetic foot infection involving the right forefoot.
Clinical assessment revealed wet gangrene affecting the first, second, and third toes with associated soft tissue infection extending into the midfoot.
The patient was septic on presentation and required urgent intervention.
Initial management focused on aggressive source control and stabilization.
The gangrenous toes were amputated, abscess cavities were drained, broad-spectrum intravenous antibiotics were commenced, and intensive diabetic control was initiated.
Despite aggressive treatment, the infection continued to progress through the forefoot.
Repeated clinical assessments demonstrated ongoing tissue loss and extension of infection, making limb preservation at the forefoot level no longer feasible.
Following multidisciplinary discussion, a midfoot amputation was performed to achieve definitive source control and preserve maximum functional limb length.
Although the infection was controlled surgically, the postoperative course was complicated by persistent stump infection.
Wound cultures subsequently demonstrated Pseudomonas infection.
At this stage, the challenge was no longer performing another amputation but preserving the remaining foot and creating a durable functional stump.
The patient underwent:
• Prolonged targeted antibiotic therapy
• Serial wound assessments
• Multiple wound debridements
• Meticulous dressing care
• Optimization of glycemic control
• Close surveillance for recurrent infection
Over several weeks, progressive improvement was achieved.
The wound gradually developed a healthy granulating bed, repeat cultures became negative, and there was no further evidence of active infection.
Once infection control had been confirmed and a satisfactory wound bed established, definitive reconstruction was undertaken using split-thickness skin grafting.
The graft healed successfully and produced durable soft tissue coverage of the stump.
The patient subsequently progressed to rehabilitation and is now mobilizing with customized protective footwear and ongoing diabetic foot care surveillance.
𝗞𝗲𝘆 𝗟𝗲𝗮𝗿𝗻𝗶𝗻𝗴 𝗣𝗼𝗶𝗻𝘁𝘀
Successful diabetic foot management begins with rapid control of sepsis.
Early aggressive debridement and drainage remain fundamental principles of treatment.
Determining the correct amputation level is critical to balancing infection control and functional preservation.
Persistent stump infection does not automatically mandate a higher amputation.
Pseudomonas infections often require prolonged targeted antimicrobial therapy and meticulous wound management.
Repeated debridement is frequently necessary before definitive reconstruction can be considered.
Skin grafting should only be performed once infection has been eradicated and a healthy granulation bed established.
Glycemic control is as important as surgical treatment in achieving wound healing.
Limb salvage extends beyond the operating theatre and requires coordinated multidisciplinary care.
Rehabilitation and customized footwear are essential components of long-term success.
𝗞𝗘𝗬 𝗠𝗘𝗦𝗦𝗔𝗚𝗘
The success of diabetic foot surgery is not determined by the first operation. It is determined by the ability to control infection, preserve function, achieve wound healing, and return the patient to independent mobility.
This case demonstrates that even when a diabetic foot infection progresses despite initial treatment, persistence with meticulous wound care, repeated debridement, targeted antibiotic therapy, and staged reconstruction can achieve a durable functional outcome while avoiding major limb amputation.
Patient identity protected. Images shared for educational purposes with appropriate consent.
