- See:
-
diabetic foot menu:
-
amputation menu;
-
osteomyelitis in the diabetic patient;;
- Discussion:
- amputation should be considered for any diabetic patient w/ advanced changes (
Charcot joints, multiple ulcers,
vascular pathology) who has who has undergone a surgical debridement which could not logically leave the patient w/ a functional foot;
-
vascular considerations:
-
exam:
- it is essential to distinguish between proximal and distal vascular lesions, since distal vascular
lesions may be less amenable to arterial bypass (this statement is restricted to the diabetic
patient w/ ischemic ulcerations or osteomyelitis);
- if there is an iliac pulse but no popliteal pulse (proximal lesion) then the patient should under go a formal vascular work
up (since vascular bypass may be possible);
- if there is a popliteal pulse but no DP or PT pulse (distal lesion), then it is less likely that a vascular bypass will be successful);
- these patients should still have a vascular workup;
-
doppler ABI:
- in most cases, serves no useful role in the management of diabetic feet;
- the loss of compliance of the diabetic vessels will falsely elevate ABI readings, (which may falsely indicate that the diabetic foot is well perfused);
- references:
-
Arterial systolic pressures in critical ischemia.
-
Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer.
- Transcutaneous Doppler ultrasound in predictions of healing and selection of surgical levels.
Wagner FW:
Clin Orthop Rel Res 1977;162:110-121.
-
Transcutaneous Doppler ultrasound in the prediction of healing and the selection of surgical level for dysvascular lesions of the toes and forefoot.
-
Doppler-determined segmental pressures and wound-healing in amputations for vascular disease.
-
An index of healing in below-knee amputation: leg blood pressure by Doppler ultrasound.
-
transcutaneous O2:
- references:
-
Transcutaneous oxygen as a predictor of wound healing in amputations of the foot and ankle.
-
Segmental transcutaneous measurements of PO2 in patients requiring below the-knee amputation for peripheral vascular insufficiency.
-
Transcutaneous oxygen tension measurement in peripheral vascular disease.
-
Transcutaneous oxygen and carbon dioxide pressure monitoring to determine severity of limb ischemia and to predict surgical outcome.
- Surgical Considerations:
- often diabetic patients do not do well w/
transmetatarsal amputations, but this procedure
may be indicated for wet gangrene involving the great toe and multiple lesser toes;
- if there is any debate as to whether a distal foot amputation will heal, then the surgeon can start
out w/ the distal amputation and can assess the adequacy of bleeding at that time;
- needle test:
- this can be used to help determine the level of amputation once the patient is under anesthesia;
- prick the patient's thigh w/ a 20 gauge needle and assess the rate of bleeding;
- then sequentially prick the patient's foot, ankle, and calf and compare the bleeding to the control;
- patients with wet gangrene of the foot should be treated w/ open amputation just above or thru the ankle;
- once the sepsis has cleared, a definative
BKA can be performed;
- it is generally a mistake to perform an open amputation at the same level as is planed for the definative amputation;
-
references:
Simplified two-stage below-knee amputation for unsalvageable diabetic foot infections.
Syme amputation in patients with severe diabetes mellitus.
The diabetic foot: evolving technologies.
Management of the diabetic foot.
Harrelson J: Orthop Clin North Am 1989;20:605.
Eikenella corrodens as a cause of osteomyelitis in the feet of diabetic patients. Report of three cases.
Konugres GS.
Linda L.
Goldstein EJ.
Wallace SL. Journal of Bone & Joint Surgery - American Volume.
69(6):940-1, 1987 Jul.
One-stage versus two-stage amputation for wet gangrene of the lower extremity: a randomized study.
Diabetic foot infections. Bacteriologic analysis.
Simplified two-stage below-knee amputation for unsalvageable diabetic foot infections.
Long term prognosis after healed amputation in patients with diabetes.
J Larsson MD.
CORR. No 350. p 149-158. p 149.
