The intent of this report was to juxtapose the rationale used to determine which treatment strategy best suited two similar patients with severe diabetic foot infections, and outline the subtle differences in each patient's clinical presentation, disease history, socioeconomic status, and life needs and expectations that helped guide the decision-making process. Although such decisions impact the patient not only physically, but also economically, socially, and emotionally, they are all too often made on the basis of what is easiest for the surgeon. As with many decisions in medicine, sufficient doctor-patient communication must take place concerning how particular treatment options will influence the patient's life in both the short-term and the long.
This report describes two patients who at first glance might seem quite similar. Their ages, cultural and ethnic backgrounds were nearly identical. They each had a diabetic foot ulcer complicated by severe infection. From a technical and purely surgical standpoint, limb salvage was quite possible in each patient. On more careful inspection, distinct differences pertaining to the underlying cause, disease duration, bony involvement and architecture, workplace needs, and socioeconomic realities resulted in the divergent decision pathways to move forward with a limb salvage approach in one patient and a below the knee amputation in the other.
In patient 1, the clinical history was that of an active tile layer and roofer who developed ulceration secondary to a puncture wound while on the job. There was neither an underlying bony abnormality nor ulceration due to repetitive stress. Prior to this insult one could have classified this patient's foot using American Diabetes Association standards as a grade 1, relatively low risk foot for amputation. (12
). When determining a treatment approach for this patient we decided to follow the recommendations of surgery in the diabetic foot based on the risk-based classification for diabetic foot surgery developed by Armstrong et al. (13
). This was considered a class 4 surgical emergency, which involves rapid surgical intervention to decrease complications regardless of perfusion to the limb. Even though there was an extensive amount of debridement and repeat operations in order to remove all infection from the foot, the patients overall skeletal structure was uncompromised. This meant that bone resection was avoided and if the patient were to heal this wound he would be able to return to a functional type diabetic work boot and be highly likely to maintain employment as a roofer for a construction company. This patient was very emotionally optimistic about being able to heal and return to his lifestyle given this was a first ‘foot event’ for him. He had sufficient sick leave to be able to afford the time necessary for wound stabilization, granulation and eventual STSG.
The overall treatment regimen and clinical outcome correlate closely with that of a recent study by Kim et al. who sought to determine the efficacy of a management algorithm that includes NPWT in diabetic limb-threatening infections (14
). There are similarities in the number of surgical debridement's (3 vs. 2.4±1.3 days) of NPWT application (26 vs. 26.2±14.3 days), and complete wound healing (90 vs. 104 days). The conclusion of the retrospective case series was that a management algorithm including NPWT application following debridement and early vascular intervention (if applicable) was beneficial in treating severe diabetic foot infections. The successful attempt to salvage our patient's limb using a similar algorithm also demonstrates the effectiveness of postoperative NPWT along with an early and aggressive surgical approach.
In patient 2, the initial surgical approach to limit the progression of life and limb threatening infection was nearly identical to that used for patient 1. Thereafter, subtle issues led to the divergent recommendation of primary limb amputation, an option that many limb salvage centers such as our own often hesitate to even seriously consider. Patient 2 had a 10-year history of Charcot arthropathy that yielded a rocker-bottom foot even after a remote attempt at surgical reconstruction 10 years ago. This residual deformity predisposed him to recurrent ulcerations (secondary to repetitive stress rather than isolated external trauma from a nail) and infections that resulted in multiple hospital admissions and nearly constant wound management for repeat ulcerations. This burden of constant morbidity ultimately cost him his job and further limited his ability to receive the care needed to prevent ulceration and infection. He had, however, recently acquired a position with the local Sheriff's department, but was in probationary status. Any prolonged time away from the job would have resulted in further unemployment. He admitted to being physically and emotionally exhausted dealing with this chronic problem limb, and had a much more positive outlook about the idea of amputation being likely to rid him of a source of infection and allow him to start rehabilitation promptly so that he could return to work and resume his clerical responsibilities.
As a team with a significant predisposition to a locally aggressive approach to debridement, reconstruction, and healing, we strongly contemplated the aggressive approach of salvaging the limb in this relatively young man and proceeding in a similar direction to that pursued in the first patient. Because of wound chronicity and the severe underlying bony deformity, however, it became apparent that even if we attempted to pursue limb salvage in this case, the outcome would likely not be favorable. Sohn et al. reported that the amputation risk in diabetic patients with an ulcer and Charcot arthropathy is 12 times higher than in patients with Charcot arthropathy without ulceration (15
). Outcomes are worse in such patients in the presence of bone infection and a deep wound. Yesil et al. found that osteomyelitis and ulcer depth increased the risk for major amputation in a retrospective observational study that included 574 foot ulcer episodes (16
In patient 2, had a limb salvage approach including removal of infected bone and Charcot foot reconstruction were been attempted, final wound healing and a complete return to weight bearing status would most likely have been 6–12 months. This approach likely would have led to the patient's loss of current employment and subsequent inability to financially cover costly procedures, devices, shoe gear, and ancillary services such as home health care. Ultimately the decision to perform below-the-knee amputation was made jointly by the patient with the surgical team. The patient recovered uneventfully from the amputation. He was able to return to work within 4 weeks. At a recent visit with patient, he stated his gratitude for the procedure and stated how much more emotionally positive he has been not having to ‘deal’ with the overwhelming burden of a complicated limb. A below the knee amputation in our first patient would have been devastating to his current job, as he would have had significant difficulty kneeling or repeatedly climbing stairs throughout the day.