SLR - September 2019 - Kristen N. Treleven
Reference: Al Wahbi A. Operative Versus Non-Operative Treatment in Diabetic Dry Toe Gangrene Diabetes Metab Syndr. 2019 Mar - Apr;13(2):959-963. doi: 10.1016/j.dsx.2018.12.021.Scientific Literature Review
Reviewed By: Kristen N. Treleven, DPM
Residency Program: North Colorado Medical Center – Greeley, CO
Podiatric Relevance: This article is of podiatric relevance because due to diabetes mellitus being a major comorbidity amongst the patient population within many podiatric practices. A dry gangrenous complicated by peripheral arterial disease as part of diabetic foot ulcerations is seen to often This article cautions the podiatric surgeon awaiting autoamputation of dry gangrenous toes to consider surgical amputation as this could lead to better clinical outcomes.
Methods: This is retrospective case series of 12 patients with diabetic toe gangrene, including seven males and five females. Inclusion criteria consisted of the diagnosis of type 2 diabetes mellitus, patients followed by an endocrinologist, the presence of osteomyelitis, patients with peripheral arterial disease, absent pedal pulses, ABI <0.5, and those that either failed or declined revascularization. The initial treatment plan with all patients was to wait for autoamputation. Dressings consisted of betadine gauze changed daily. Follow up appointments were included once weekly with vascular surgery, and every four weeks with endocrinology and infectious disease.
Results: One patient, who was compliant with the designated treatment course, had a successful autoamputation after 11 months. One patient had no changes in 12 months. Eight patients went on to surgical amputation, including two above knee amputations (AKA), four below knee amputations (BKA), and two midtarsal amputations after any time point ranging from one month to eight months of treatment. Two patients died during the course of the study. One death was due to a mycocardial infarction after two months, and another patient developed sepsis and passed away after three months. Five patients were non-compliant with treatment protocol, and the outcomes for these patients included death, sepsis, AKA, and/or BKA.
Conclusions: The study concluded that there was no correlation seen between the autoamputation rate and the compliance with the treatment regimen. The most severe outcomes, including death and AKA, only occurred in the noncompliant patients. There did seem to be a correlation with location of the gangrenous digit and prognosis of the severity of amputation that may later occur. For example, if the first or second digit was gangrenous, it was associated with a higher level of amputation, including BKA and AKA. The author cautions that utilizing autoamputation as a treatment strategy should be used on an individual and selective basis; particularly, in regards to patients with limited resources and a lower level of education. It is also implied that early, definitive surgical intervention may improve quality of life for those who choose not to wait or are not appropriate candidates for autoamputation. Prevention of complications associated with dry gangrene of the digits in the diabetic population can occur with a multidisciplinary team approach to the management of complex patients, awareness amongst health care professionals, and early thoughtful treatment of the patient.