Ray amputation in a neuropathic foot and its postoperative care

A 58-year-old man with type 2 diabetes of 10 years' duration, presented at casualty with a cellulitic right foot and blue 5th toe (Fig. 6.19). Pedal pulses were bounding and he did not complain of pain. He was admitted for intravenous antibiotics and a ray amputation was performed to remove all necrotic and sloughy tissue. When the dressing was 'taken down' after 48 h the wound bed was grey

Fig. 6.19 This neuropathic patient developed a blue toe 'out of the blue', as the patient said. There was no history of trauma but a small tissue defect which was painless, and which was the portal of entry for infection.

and sloughy. The wound was irrigated with 2% Milton for 4 days until a wound bed of pink, healthy granulations was present, after which it was cleansed with saline and dressed with a foam dressing. He was discharged after 3 weeks. The foot healed in 6 weeks with minimal scarring; he received follow-up care in the diabetic foot clinic, and ulceration did not recur.

Key points

• Digital necrosis in the neuropathic limb is best treated by toe or ray amputation

• At surgery all necrotic tissue should be removed but sometimes it is difficult to be sure about the viability of all tissue at the operation site

• Thus at the first postoperative dressing, the wound may still contain necrotic and sloughy tissue

• Patients are sometimes taken back to operating theatre for the first change in dressings when further operative debridement can be carried out if necessary

• When postoperative wounds in neuropathic feet are sloughy, Milton irrigation can be used until the wound bed shows healthy granulations

• Milton irrigation does not appear to impair healing of sloughy wounds.

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