In the neuroischaemic foot, wet necrosis should also be removed when it is associated with severe spreading sepsis. This should be done whether pus is present or not. However, where necrosis is limited to one or two toes in the neuroischaemic foot we avoid surgery where possible until vascular intervention has been achieved. If angioplasty or arterial bypass is not possible, then a decision must be made either to amputate the toes in the presence of ischaemia or allow the toes, if infection is controlled, to
Fig. 6.15 This 4th toe is dry and well demarcated and has been debrided at 2-weekly intervals by the podiatrist—note the beautifully clean demarcation line between necrosis and viable tissue.
convert to dry necrosis and autoamputate. Sometimes this decision can be a difficult one. Surgical amputation leaves a large tissue defect which, in the neuroischaemic foot, may never heal. However, a transcutaneous oxygen tension of greater than 30 mmHg on the dorsum of the foot indicates a reasonable chance of healing. Autoamputation is a process which takes many months and there is always a danger that the foot may become infected if the necrotic toe is left to autoamputate.
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