Frykberg's Case From the High Risk Foot Clinic: Part 1

 

Robert Frykberg, DPM, MPH PRESENT RI Editor Diabetic Limb Salvage

This month I’ll present another case from our High Risk Foot Clinic that presented a potentially difficult situation for us if we hadn’t seen this problem numerous times before. Our patient, Mr L., was a 70 year old diabetic man of 14 years duration with a history of peripheral neuropathy and mild renal insufficiency. He had had several prior ulcerations in the preceding two years, all of which had healed uneventfully with standard wound care and appropriate offloading. Luckily, he had palpable pedal pulses and there was no evidence for underlying ischemia.

Six months prior to the current visit, he developed a gangrenous left great toe that started from a blister after wearing tight cowboy boots (Mr L has horses and likes to ride them).  The blister became infected, turned to wet gangrene, and when he presented to our clinic he was admitted for intravenous antibiotics, diabetes control, and amputation of the great toe.  Unfortunately, the level of infection and tissue loss extended proximally to the first metatarsophalangeal joint and metatarsal head.  Of course, we changed our operative plans and performed a left first ray amputation with primary closure.  Fortunately, this healed uneventfully and his incision was completely healed by four weeks postoperatively.  He was gradually allowed to progress from partial to full weight bearing in a fixed ankle walking boot.  Eight weeks postoperatively he was able to wear his therapeutic diabetic shoes with custom pressure relieving orthoses.

He resumed his usual activities, occasionally wearing riding boots, and noticed the rather insidious development of swelling in his left foot almost 6 months after his ray amputation.  His surgical incision remained closed, however, he did notice that his foot was also warm and slightly reddened. What most disturbed him was the onset of aching pain in the foot where he previously had not had any feeling for several years.  On examination at presentation, his foot revealed the findings consistent with his own observations: an edematous, warm foot with modest erythema to the ankle. There were no open lesions nor drainage from his healed first ray amputation incision.  He did have some discomfort on palpation of the foot, however.  Suspecting a possible recurrence of infection as one of our differential diagnoses, we took the X-rays in Figures 1 and 2.

Figure 1. AP view of left foot

 

Figure 2. Lateral view

 

With the information at hand, you should be able to develop a diagnostic and treatment plan. Since the diabetic foot is often not straightforward to deal with, you must use your clinical acumen to arrive at the diagnosis. Please note, however, this is really a fairly common presentation for this condition.

What do you think is happening to Mr L’s foot ?  What further diagnostic tests should be ordered at this point? How would you make the diagnosis ?  Go to eTalk to see what your colleagues are saying about this case.  Part 2 of this case will be published in the coming weeks, showing the diagnosis and treatment.

Until next time,

Robert Frykberg, DPM, MPH
PRESENT Editor, 
Diabetic Limb Salvage

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References:

1. Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg. 2006;45(5 Suppl):S1-66.
2. Aragon-Sanchez J. Seminar review: A review of the basis of surgical treatment of diabetic foot infections. Int J Low Extrem Wounds. 2011;10(1):33-65.
3. Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ, et al. Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment. Diabetes Metab Res Rev. 2008;24 Suppl 1:S145-61.
4. Boulton AJ, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al.Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Diabetes Care. 2008;31(8):1679-85.
5. Dalla Paola L, Faglia E, Caminiti M, Clerici G, Ninkovic S, Deanesi V. Ulcer recurrence following first ray amputation in diabetic patients: a cohort prospective study. Diabetes Care. 2003;26(6):1874-8.
6. Frykberg RG, Wittmayer B, Zgonis T. Surgical management of diabetic foot infections and osteomyelitis. Clin Podiatr Med Surg. 2007;24(3):469-82, viii-ix.
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