Factors influencingthe management of diabetic foot gangrene

Triki Wissem |

La tunisie chirurgicale - 2019 ; Vol 2019


Diabetic foot is a common presenting complaint for diabetic patients who consult general surgery clinics. In order to analyze the epidemiological, clinical, and evolutionary aspects of  the disease and the factors affecting its management, we have lead a retrospective study on cases that were managed at the Medical Center Habib Bougatfa, Bizerte in the time frame expanding from January 1st 2014 to December 31st 2017.

Most of the patients in this study were males. Their median age was 62 years old.The underlying disease was essentially non insulin dependent diabetes mellitus (type 2).The average time limit for consulting the clinics was 13 days. The patients presented with severe injuries; a grade 4 on the Wagner Ulcer Classification System in 63% of cases. It was clinically certain that infection had an important role in the development of the disease. All our patients were amputated; 75% underwent a minor amputation (toe, forefoot) and 25% had a major amputation at above ankle-level. After the surgery, they were prescribed insulin treatment. The average hospital stay was 7 days. There were no deaths in our patient series.The factors influencing the management of diabetic foot gangrene were patients’ sex and age, the progression of diabetes, smoking, high blood pressure, the type of management and the lack of efficient strategies for disease prevention.

Complications could be prevented effectively when a comprehensive strategy for managing diabetic patients is developed.

Mots Clés

Diabetic - Gangrene - Foot - Epidemiology - Clinical - Surgery.

Introduction :

The diabetic foot is an umbrella term that covers infections, ulcers and deep tissue necrosis in the feet of diabetic patients. It is linked to peripheral neuropathy and lower limb arteriopathy. Infection is the most dreaded complication as it can precipitate death or lead to long term functional sequelae. It initially involves soft tissues then expands to the bone if the wound persists. The positive diagnosis is made by clinical assessment and not by laboratory tests.Two types of infection have been described; ischemic foot necrosis and necrotizing infectious cellulitis. The latter could be associated to osteitis.These injuries are ranked by severity following the Wagner Ulcer Classification System and the more recent IWGDF and IDSA guidelines[1]. They are at the bottom of more more than 50% of amputations [2,3]. The cost of management is still high and varies across the world. Therefore, primary and secondary prevention remains the best method to reduce the costs.

The goal of our study is to present our experience in managing diabetic foot gangrene and to extricate the factors that influence treatment.


Patients et Methods:

This is a retrospective study held at the General Surgery Department of the Medical Center of Bizerte. It spans through a period of three years from January 1st, 2014 to December 31st, 2017. It includes the files of diabetic patients presenting with foot injuries. Some cases had their diabetes diagnosed following this complication.

Data was collected from admissions records, clinical observation charts and surgical reports.

It includes:

- General information (age, sex, profession, address, date of entry),

- clinical information  (if the patient has already been diagnosed with diabetes mellitus, a history of foot injury, vascular risk factors, how did the injury occur and for how long has it been present).

The described lesions were ranked according to the Wagner Ulcer Classification System. Inferior limb paresthesias and absent deep tendon reflexes were the diagnostic elements for peripheral neuropathy. We evaluated our patients arterial function by palpating peripheral pulses.

- paraclinical information (glycemia, plain X Ray of the foot, blood cholesterol, triglycerides, uric acid and creatinine, 24h urine protein, optic fundus, electrocardiogram),

- Therapeutic information (medical treatment, local care, amputation),

- Progression after the surgery (complications, exit mode, whether or not a prosthesis was used).

The collected data was then uploaded on a computer using the SPSS software.

To compare the proportions, we used the Fisher Exact test.

The significance threshold for all comparisons was 5%.


We have recorded cases of 48 men and 12 women, meaning 80% of our patients were male and 20% were female (sex ratio= 4). The average age was 62 years old with extreme values at 30 years old and 83 years old. Upon distributing the cases according to age, the 50-60 years old and above 70 years old age categories predominated.Our patients had type 2 diabetes 85% of the time and type 1 diabetes 15% of the time. Among them, 65% had a regular follow up for diabetes, the rest were unobservant.Smoking was found in 23 cases and high blood pressure in 20 cases.A history of toe amputation was found in 7 cases.The average length of diabetes evolution was 12 years. Our patients had been treated for their diabetes for 15 years on average with extreme values at 2 and 30 years.

In most cases, the origin of the injury was unknown. 16,7% reported a traumatic injury and 5% reported wearing ill-fitting shoes.The average time for consulting a doctor in our study was after 13 days of progression with a range from 3 days to 60 days.The most common injury was gangrene, seen in 68% of cases, against 8% of osteitis cases.The gangrene was located in one of the toes 63% of the time (n=38), in the forefoot 18% of the time (n=11), involved the whole foot 8% of the time (n=5), and on the heel and on the leg in 1.7% of the time each (n=1).A WAGNER grade 4 was the most common injury, seen in 63% of the cases, grade 1 was seen 13% of the cases, and grade 3 in 12% of cases. On the etiopathogenic side, infection was the most common etiology found in 25% of the cases. Diabetic neuropathy and arteriopathy were found respectively in 12% and 8% of the cases. The average blood glucose level was 19.4 mmol/l, the extreme values being 4.7 and 33.3 mmol/l.Plain X Ray of the affected foot was systematically ordered for all of our patients and showed signs of osteitis in seven cases.35 patients -58%- declared they were taking insulin shots while 18 patients -30%- were under oral anti diabetics.The rest were either taking both insulin and OAD or just following a diabetic diet.All patients were given insulin after the surgery.The most used antibiotics were Penicillin, Fusidic Acid and Quinolones.The surgical treatment, which consisted in an amputation, was undertaken in 56 patients.In descending order, the most common amputation level was: toe 57%, forefoot 19%, leg 22% ankle 2%.Fifty patients had a favorable evolution and six patients presented with complications; four cases of stump infection and two cases of of stump necrosis.Four patients were lost to follow up. We did not record any death in our study.

The average length of hospital stay was 7 days, with a minimum of 1 day and a maximum of 23 days. Only two patients could get limb prosthesis.


Diabetes is a major public health concern in every country around the world. Nevertheless, an adequate management of diabetic patients in developed countries has considerably decreased the rate of complications and the rate of diabetic foot amputations. Many factors seem to influence the frequency of amputations and therefore affect mortality. Among them, we mention the prevalence of diabetes, population age, the conditions of management without forgetting the therapeutic attitude of the medico-surgical team.In fact, as it differs from one team to another, the therapeutic attitude can affect not only the level of amputation but also its frequency [4, 5]. The sex ratio M/W in our study was 4. The male predominance is a finding that has been described by many authors. The frequency of severe injuries and the risk of amputation was higher in men than in in women [6-9].  According to Benotmane et al, foot injuries and their severity reported more frequently in men can be explained by smoking which is more prevalent in men than in women. The male sex is a risk factor for amputation with a relative risk of 2 [10, 11]. The average age in our study was 62 years old which is closer to the average reported in Occidental countries (60-67 years old) [6, 12, 13] than to the one found in African studies (52-57 years old) [7, 14, 15]. This could be explained by the fact that our lifestyle in Tunisia is more Occidental than African.The advanced age of the diabetic patient is a risk factor for amputation because it increases the risk of neuropathic and arteriopathic complications related to diabetes and thus rendering the management of the foot gangrene more difficult [10, 16]. Socioeconomic position, insecurity as well as life expectancy seem to be elements which affect this average age creating the gap between Occidental and African countries. The average time of the progression of diabetes in our series was 12 years.It is comparable to the one reported in Occidental studies [6, 17] but higher than the one found in African countries [7, 8]. This difference can be due to the quality of management.A better management for the diabetes decreases the risk of injuries.In their study, Ravinthar and al [9]have proven that the longer the duration of diabetes, the higher the risk of infection and amputation. Certain authors consider that smoking and high blood pressure essential risk factors as they aggravate the diabetic angiopathy and delay the scarring, thus increasing the risk of major amputation [9]. However, according to other authors, the significance of these factors’ role is still debated [18, 19].

The average time for seeing a doctor in our study was 13 days. Most of our patients confess underestimating their injuries.Practically all of our patients were admitted in advanced stages of the disease and could not get a limb-saving procedure.Infection was the most common etiopathogenic component in our study.In the literature, it was at the root of 30 to 60% of diabetic foot amputations [2, 3]. The risk of amputation increases with the severity of diabetic foot infection [20]. The patients presented with fever, edema, local inflammation, and sometime with a putrid smell and crepitus. Unfortunately, the microbiological aspect is not specified because we did not systematically collect samples (only 2 samples were taken). In the lack of a systematic microbiological study, patients were prescribed broad spectre antibiotics.  Benotmane and al [4] underline the importance of an adequate and prolonged antibiotic therapy in the management of foot gangrene which is essentially caused by aerobic and anaerobic germs.In our study, amputation was performed on all the patients because of the advanced stages of the injuries.The amputation was done above knee level in 15% of cases (major amputation).This rate is much lower than the one found in the African studies which ranges from 66% to 73% [7, 14]. In developed countries, there is a current tendency to attempt limb revascularization before any amputation.The unavailability of a technical platform in our hospitals impedes revascularization attempts resulting in a high rate of amputations.We should also mention the aggressive and sometimes abusive attitude of certain surgical teams which increases the rate of major amputations and therefore the rate of morbidity and mortality.Otherwise, some authors opt for conservative treatment even for grade 4 injuries avoiding amputation as much as they can. [21].


Although our study might be restrospective and involving a small sample, we find the same factors influencing the management of diabetic foot gangrene the were described in literature. These factors are: male sex, age , length of diabetic history, smoking, high blood pressure, the therapeutic attitude, as well as the lack of structured prevention strategies. In fact, all of these are responsible for the increase of amputation rate and therefore the increase of morbidity, of mortality and of management costs.The delay in diagnosis, the difficulties of treatment and monitoring, the lack of educational facilities, the low socioeconomic position of our populations, are the main hurdles to a good prevention of diabetes complications. This is why the establishment of educational programs for patients is essential. We must also set up specialized care units to detect and treat diabetes. Furthermore, we should prioritize the development and invest in vascular reconstruction services.

Conflict of interests:

The authors declare no conflict of interest.


1.   Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, Armstrong DG, et al. 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections a. J Am Podiatr Med Assoc. 2013 Jan;103(1):2–7.

2.   Pecoraro RE, Reiber GE, Burgess EM. Pathways to Diabetic Limb Amputation: Basis for Prevention. Diabetes Care. 1990 May 1;13(5):513–21.

3.   Hennis AJM, Fraser HS, Jonnalagadda R, Fuller J, Chaturvedi N. Explanations for the High Risk of Diabetes-Related Amputation in a Caribbean Population of Black African Descent and Potential for Prevention. Diabetes Care. 2004 Nov 1;27(11):2636–41.


5.   LindegåRd P, Jonsson B, Lithner F. Amputations in Diabetic Patients in Gotland and Umeå Counties 1971-1980. Acta Med Scand. 2009 Apr 24;216(S687):89–93.

6.   Huang Y-Y, Lin C-W, Yang H-M, Hung S-Y, Chen I-W. Survival and associated risk factors in patients with diabetes and amputations caused by infectious foot gangrene. J Foot Ankle Res [Internet]. 2018 Dec [cited 2018 Jul 30];11(1). Available from: https://jfootankleres.biomedcentral.com/articles/10.1186/s13047-017-0243-0


8.   Monabeka HG, Nsakala-Kibangou N. Aspects épidémiologiques et cliniques du pied diabétique au CHU de Brazzaville. :3.

9.   Enathur, K. A Study of Prognostic Factors of Diabetic Foot in Relation to Plan of Management.

10. Dangelser G, Besson S, Gatina J, Blicklé J. Amputations among diabetics in Reunion Island. Diabetes Metab. 2003 Dec;29(6):628–34.

11. Resnick HE, Carter EA, Sosenko JM, Henly SJ, Fabsitz RR, Ness FK, et al. Incidence of Lower-Extremity Amputation in American Indians: The Strong Heart Study. Diabetes Care. 2004 Aug 1;27(8):1885–91.

12. MCNEELY MJ, BOYKO EJ, AHRONI JH, STENSEL VL, REIBER GE, SMITH DG, et al. The Independent Contributions of Diabetic Neuropathy and Vasculopatny in Foot Ulceration. DIABETES CARE. 1995;18(2):4.

13. Girod I, Valensi P, Laforêt C, Moreau-Defarges T, Guillon P, Baron F. An economic evaluation of the cost of diabetic foot ulcers: results of a retrospective study on 239 patients. Diabetes Metab. 2003 Jun;29(3):269–77.

14. Factors Influencing the Outcome of Treatment of Foot Lesions in Nigerian Patients with Diabetes Mellitus. QJM Int J Med [Internet]. 1989 Nov [cited 2018 Jul 30]; Available from: https://academic.oup.com/qjmed/article/73/2/1005/1567408/Factors-Influencing-the-Outcome-of-Treatment-of

15. Nyamu PN, Otieno CF, Amayo EO, Mcligeyo SO. Risk factors and prevalence of diabetic foot ulcers at Kenyatta National Hospital, Nairobi. East Afr Med J [Internet]. 2004 Jan 13 [cited 2018 Jul 30];80(1). Available from: http://www.ajol.info/index.php/eamj/article/view/8664

16. Abbott CA, Garrow AP, Carrington AL, Morris J, Van Ross ER, Boulton AJ. Foot Ulcer Risk Is Lower in South-Asian and African-Caribbean Compared With European Diabetic Patients in the U.K.: The North-West Diabetes Foot Care Study. Diabetes Care. 2005 Aug 1;28(8):1869–75.

17. A Study of Prognostic Factors of Diabetic Foot in Relation to Plan.pdf.

18. Mayfield JA, Reiber GE, Nelson RG, Greene T. A Foot Risk Classification System to Predict Diabetic Amputation in Pima Indians. Diabetes Care. 1996 Jul 1;19(7):704–9.

19. Lehto S, Ronnemaa T, Pyorala K, Laakso M. Risk Factors Predicting Lower Extremity Amputations in Patients With NIDDM. Diabetes Care. 1996 Jun 1;19(6):607–12.

20. Lavery LA, Armstrong DG, Murdoch DP, Peters EJG, Lipsky BA. Validation of the Infectious Diseases Society of America’s Diabetic Foot Infection Classification System. Clin Infect Dis. 2007 Feb 15;44(4):562–5.

21. Krone W, Müller-Wieland D. Special Problems of the Diabetic Patient. In: Dormandy JA, Stock G, editors. Critical Leg Ischaemia [Internet]. Berlin, Heidelberg: Springer Berlin Heidelberg; 1990 [cited 2018 Jul 30]. p. 145–57. Available from: http://www.springerlink.com/index/10.1007/978-3-642-75625-2_19