A 54-year-old smoker with type 2 diabetes of 7 years duration had a minor abrasion to the lateral aspect of the left fifth toe. The patient was known to have hypertension, nephropathy and retinopathy, and he was overweight. His glycaemic control was good following recent addition of insulin to his oral medication. The superficial ulcer did not bother the patient, and it was initially followed up in his local healthcare centre. Two months later, the patient was referred to a community hospital because of infection and suspicion of osteomyelitis. He now had an infected ulcer lateral to the head of the fifth metatarsal,withadischarge.PlainX-rayfilmsshowedsuspectedosteomyelitis.Dorsalis pedis and posterior tibial pulses were reported to be present. The C-reactive protein (CRP) level was 31 mg/L, leucocytes 14.8 × 109/L, and blood glucose 12 mmol/L.

Question 1

What condition(s) are likely to be responsible for the foot problem?

A.  Infection

B.  Atherosclerotic macroangiopathy

C.  Diabetic microangiopathy

D.  Neuropathy

Question 2

What is the simplest tool available in the surgery or outpatient clinic to detect osteomyelitis?

A.  Plain X-ray films.

B.  Clinical examination with blunt nasal probe. C.  Magnetic resonance imaging.

D.  Computer tomography.

M.J.A. Lepäntalo ( )

Department of Vascular Surgery, Helsinki University Central Hospital, Helsinki, Finland

Question 3

What simple tools are available in the surgical outpatient clinic to assess angiopathy?

A.  Palpation of foot arterial pulses.

B.  Examination of audible signal with hand-held continuous wave Doppler. C.  Ankle pressure measurement.

D.  Duplex scanning of lower extremity arteries.

Question 4

What simple tools are available in the surgery or outpatient clinic to assess neuropathy?

A.  Monofilament sensation testing. B.  Achilles tendon reflex.

C.  Tuning fork testing.

D.  Electroneuromyography (ENMG).

The patient was admitted to the medical ward for treatment of his infected foot. Despite the administration of intravenous antibiotic treatment, later modified according to the results of bacterial cultures, the infection progressed. One week after admission, lateral and superficial plantar compartments were drained operatively on the lateral side of the fifth metatarsal head and between the fourth and fifth metatarsal heads. Abundant pus was obtained, and the fifth metatarsal head was observed to be soft. The operative wound was left open. The infection seemed to subside, and the patient was discharged after a 16-day admission with oral clindamycin treatment and local wound care.

Question 5

What major problems were neglected at this point?

A.  Presence of osteomyelitis. B.  Presence of ischaemia.

C.  The wound was left without coverage with split thickness skin grafting.

D.  The weight-bearing wound area of the foot was not protected with a cast.

Despite continuous antibiotic treatment and local treatment of the open lesion on the lateral aspect of the foot, the situation worsened over the next 2 months and the patient was readmitted to the hospital. The patient had fever and his CRP level was 123 mg/l. The serum creatinine was 1.6 mg/dL. An immediate wound debridement and amputation of the fourth toe was performed, after which the patient was admitted to a vascular surgical unit (Fig. 26.1). There was a faint popliteal pulse with no other pulses palpated distally. Ankle brachial indices (ABIs) were 1.35 and 1.21. The patient could not feel the

Fig. 26.1  Foot at the time of admission to the vascular unit

touch of the monofilament on the plantar surface of the great toe or the first and fifth metatarsal heads.

Question 6

How would you further examine the circulation non-invasively or invasively?

A.  Toe pressure measurement.

B.  Ankle pressure measurements and pulse wave recordings. C.  Treadmill test with pressure measurements.

D.  Duplex scanning of distal arteries. E.  Magnetic resonance angiography.

F.  Digital subtraction angiography.

The toe pressures were 73 mm Hg on the right side and 29 mm Hg on the left side. A selective angiography was obtained the next day (Fig. 26.2).

Question 7

What angiographic findings typical of diabetes can you see?

A.  Normal aortoiliac segments.

B.  Haemodynamically non-significant occlusive disease of crural vessels. C.  Significant occlusive disease of crural vessels.

D.  Severe occlusive disease of all foot vessels.

E.  Patent foot vessel.

Fig. 26.2  Angiography of the left lower limb