The diabetic foot: consequences of delayed treatment and referral

The pathophysiology of foot problems in diabetic patients is poorly understood by many physicians. Two major factors that frequently lead to a delay in appropriate treatment with subsequent limb loss are failure to appreciate the presence and severity of underlying infection and attribution of gangrene of the toe and forefoot to microvascular disease. To evaluate the consequences of delayed recognition and treatment, we reviewed the records of 55 diabetic patients with localized gangrene or infection of the forefoot in 62 limbs, treated consecutively on a single vascular surgical service over a 2-year period using a standard protocol. All appropriately treated neuropathic ulcers and forefoot infections healed in patients with palpable pedal pulses. If foot pulses were absent and arteriography confirmed large-vessel occlusive disease, foot lesions and infections likewise healed if concomitant revascularization was done. In our series, 33 bypasses were required because of severe atherosclerotic occlusive disease. Only one patient had "unreconstructable" arterial disease. Limb salvage was 86% at a mean follow-up of 12.4 months. In 16 of the patients (29%), there was a prolonged delay between initial treatment and referral for definitive care. The specific causes of delay were underestimation of the severity of foot infection in 10 patients, and lack of recognition of ischemia due to large-vessel occlusive disease in six. These delays led to more proximal levels of amputation in six patients, including three below-knee amputations in patients with limbs that were initially salvageable.