From the Guidelines
For a diabetic patient with forefoot gangrene, a transmetatarsal amputation (TMA) is typically the most appropriate initial surgical intervention, as it provides a good balance between removing all infected and necrotic tissue while preserving maximum foot function and weight-bearing capability. This approach is supported by the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1. The guideline emphasizes the importance of surgical intervention in patients with severe foot infections, including those with forefoot gangrene.
When considering amputation, it is essential to evaluate the patient's overall condition, including vascular status and the extent of the infection. The guideline recommends seeking urgent surgical consultation for patients presenting with clinical evidence of a life- or limb-threatening infection, or if the involved limb is critically ischemic 1. In addition, the surgeon should consider vascular, reconstructive, and rehabilitation issues in selecting the level of amputation 1.
Key considerations in the management of diabetic patients with forefoot gangrene include:
- Vascular assessment, including ankle-brachial index and possibly angiography, to ensure adequate blood flow for healing
- Broad-spectrum antibiotics, such as piperacillin-tazobactam or ertapenem, started preoperatively and continued for 1-2 weeks postoperatively, adjusted based on culture results
- Regular wound checks and offloading the surgical site with specialized footwear
- Strict glucose control with target HbA1c below 7%
- Physical therapy to maintain mobility
It is crucial to note that TMA is preferred over more distal amputations because forefoot gangrene often has more extensive deep tissue involvement than is visible superficially, making limited toe or ray amputations prone to failure 1. However, if the infection has spread proximally or if vascular supply is severely compromised, a below-knee amputation may become necessary. The goal of treatment is to preserve as much of the limb as possible while ensuring the patient's safety and promoting optimal functional outcomes 1.
From the Research
Amputation Type for Diabetic Patient with Forefoot Gangrene
- Transmetatarsal amputation (TMA) is an effective surgical approach to treat forefoot infection and gangrene in diabetic patients 2.
- TMA associated with revascularization can provide an effective limb salvage and functional results in diabetic patients with forefoot tissue loss and infection 2.
- The success rate of TMA and factors predictive of TMA healing, such as arterial foot anatomy, have been studied, but no angiographic factors were found to be predictive of limb salvage 3.
- Revascularization is crucial in the management of gangrene in diabetic extremities, and it can help limit the amputation to the gangrenous tissue 4.
- TMA is a valuable option for diabetic foot gangrene that can prevent major limb loss and minimize loss of function, thus improving the quality of life for diabetic patients 5.
- The STAGE principle, which guides surgical intervention during the wound treatment of diabetic foot ulcers, has been proposed as a treatment approach for diabetic foot gangrene 6.
- The choice of amputation type and treatment approach should be individualized based on the patient's specific condition, including the extent of gangrene, blood supply, and overall health status 2, 3, 5.
- Factors such as ankle brachial indices, toe pressures, laser Doppler skin perfusion pressures, angiography, and Doppler assessment of foot vasculature may help physicians in deciding the best course of treatment 5.