Treatment of Severe Diabetic Foot Ulcers and Progressive Gangrene

By Cailing He, Hong Yin, Shoubao Wang

Affiliations

1. Department of Endocrinology, The First People’s Hospital of Lanzhou, Gansu, China

doi: 10.29271/jcpsp.2025.07.937

Sir,

Diabetic foot ulcers are one of the common complications of diabetes mellitus, and globally, about 18.6 million people with diabetes mellitus suffer from foot ulcers every year.¹ About 20% of people with diabetic foot ulcers undergo amputation of varying extent.² Infection and progressive gangrene are two of the main reasons for lower limb amputation.³ Infection occurs in about 50% of people with diabetic foot ulcers of varying degrees of severity.⁴ The above data suggests that diabetic foot ulcers and gangrene should not be ignored. It is therefore important to choose the right treatment.

A 65-year old man with a 10-year history of diabetes mellitus was admitted to the hospital with pain and discomfort in the right foot, skin ulceration, soft tissue infection, and gangrene of the foot. The patient was diagnosed with Type II Diabetes mellitus 10 years ago. He took medications regularly, and the blood sugar levels tended to be normal during this period.

Figure 1: (A, B) Physical examination of the diabetic foot (C) X-ray showing loss of third, fourth, and fifth phalanges and corresponding bones (D) Suturing of the incision (E) Picture of the incision at 1 week of treatment (F) Picture  of  the  incision  at  2  weeks  of  treatment.

Physical examination revealed darkening of the skin of the right foot, with part of the skin turning black, swelling of the right lower extremity, ulceration of the skin of the sole of the right foot with pus formation, and necrotic detachment of the 3^rd, 4^th, and 5^th phalanges and part of the metatarsal bones of the right pedal region (Figure 1A,B). X-ray examination showed that the 3^rd, 4^th, and 5^th phalanges of the right foot as well as part of the 3^rd, 4^th, and 5^th metatarsal bones, were missing. There were osteomyelitis-related manifestations with insect-like bone destruction (Figure 1C). The patient's fasting and postprandial blood glucose, glycosylated haemoglobin, C-reactive protein, white blood cell count, and neutrophil count were all well above normal.

In the first stage, some ulcerated tissues and pus were taken for bacterial culture. Then, the right foot was debrided to remove necrotic tissues, and it was rinsed with saline, iodophor solution, and hydrogen peroxide alternately. Finally, the wound was covered with dressing, and dressing change was carried out once a day. In the second stage, according to the patient's blood glucose level, metformin, acarbose, and short-acting insulin, were given to lower blood glucose, and the patient was instructed to have a reasonable diet. According to the results of bacterial culture, antibiotics were administered to control the infection. An intravenous infusion of mannitol was given to reduce oedema. In stage three, after the control of blood glucose, the infection, and the oedema, partial limb amputation was performed. Under general anaesthesia, the Lisfranc amputation technique was used to remove the first and second phalanges and metatarsals, as well as the residual material of the third, fourth, and fifth metatarsals, skin, and soft tissue. After adequate haemostasis and irrigation of the incision, a drain was placed to drain exudate or to inject medications, and the stump was sutured (Figure 1D). During this stage, the clinician needs to be mindful of preserving the limb as much as possible while adequately removing the necrotic tissue to prepare the limb for prosthesis fitting. In the final stage, a daily dressing change was performed for at least 1 week, and growth factors were applied to the incision site to promote incision healing  (Figure  1E,F).

At present, a total of 30 similar cases have been treated, with a satisfaction rate of more than 95%. However, we admit that our treatment methods as well as the number of cases are still insufficient. Further research is required on this important public health problem.

FUNDING:
Lanzhou City Health Science and Technology Development Project (2021014); Lanzhou City Science and Technology Development Guiding Programme Project (2020-zd-115);

COMPETING   INTEREST:
The  authors  declared  no  conflict  of  interest.

AUTHORS’   CONTRIBUTION:
CH: Drafted, revised, and edited the manuscript.
HY: Conducted data collection, analysis, and interpretation.
SW: Performed data collection.
All authors approved the final version of the manuscript to be published.

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