A 56-year-old man with type 1 diabetes and schizophrenia, was referred to the diabetic foot clinic for dry gangrene of his hallux, 2nd and 3rd toes (Fig. 8.28). The patient was new to our clinic, having been transferred from another hospital. The patient's medical history was quite remarkable: he had recently been very ill, in ketoacidosis, with a blood sugar level > 1200 mg/dL (66.7 mmol/L). The gangrenous changes in his toes developed during this episode, and appear to be related to a shower of emboli to his toes. Pedal pulses were present and Doppler studies were otherwise normal. He underwent a successful transmetatarsal amputation with an unremarkable postoperative course (Fig. 8.29a). A custom-made orthosis with a stump filler was provided for the patient for use in extra-depth therapeutic shoes (Fig. 8.29b). The patient is very satisfied with the results of his amputation and ambulates normally without a limp. This transmetatarsal amputation has been durable with no further complications for more than 15 years.
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