Case Presentation

We present a case of a 58 years old patient, male, who was accepted among our first aid department with a severe condition of wet gangrene and necrosis of fifth left toe (Figure 1).

Patient presented poor hygienic conditions and he was not controlled about diabetic exams patterns and he did not show any documents about positive medical history for diabetes. Patient medical history showed a therapy for hypertension, gastroesophageal reflux and hypercholesterolemia and outcomes of myocardial infarction. The patient came to our attention because he referred he had been in pain for a month at level of his forefoot. He was taking care of this lesion without any medical help but just with some autonomous dressing and some generic medical ointment.

We decided to perform a urgent amputation of the fifth ray of the left foot. We did not close the wound and we left a draining surgical sites so to be able to have a better follow up of the lesion and allowing a slow demarcation of necrosis area (Figure 2).

As protocol, we made several microbiologic samples which were luckily negative. The first day after surgery we requested specific exams which evidenced a not controlled pattern of diabetic exams (glucose 217 mg/dL). Therefore our diabetes consultant evaluated the patient and made a proper diagnosis of it and he introduced a correct therapy of diabetic disease (Repaglinide 1 mg 1cp h 12 and h 20 pm), with good correction of diabetic indices, and specific dietary principles. Finally we did a second surgery to regularize necrosis edges and we sent the patient to a specific center for foot reconstruction. Patient underwent a prophylaxis with amoxicillin and clavulanic acid for 5 days after surgical procedure.

Discussion

The peculiarity of this case is to show and to demonstrate how many patients still come to medical attentions for lesions or signs of diabetes, but without a proper diagnosis or therapy for this terrible disease. After this kind of patients suffer for metabolic or dyslipidemia diseases with associated multiple signs of cardiovascular pathologies. The surgery procedure was performed in urgency because it is to prevent further consequences of necrosis over foot area. Moreover it is primary to design a clinical diagnostic framework to be able to start a successful pharmacological therapy.

Conclusion

It is very important to have suspect of diabetic disease when we discover necrotic or gangrene areas among foot, especially in patients with low hygienic conditions. Diabetic foot gangrene is always an urgency and it is basic to avoid further spreading of infections or ulcerative lesions. The alliance between surgeons and Diabetologist is the key strategy to achieve a full and complete treatment of diabetic foot and diabetic disease in general. Therefore it is more and more common the development of specialist centers for diabetic foot care. It is mandatory to remember diabetes is a pathology including several orthopedic complications so the orthopedic surgeon should be always ready to face them in the proper way and with the proper knowledge. In the end it is important to perform diabetic foot surgery in order to foresee a future limb reconstruction or a dedicated application of orthosis.

Statement of Ethics: All procedures were in accordance with ethical standards of the responsible committee on human experimentation (institutional and national) and with the Declaration of Helsinki of 1964 and its later amendments. Informed consent was obtained from the patient for being included in this case report.

Disclosures Statement: The authors have no conflict of interest to declare.

References

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