Early outcomes and complications of surgically treated diabetic hallucal infection.

OBJECTIVE: Severely infected diabetic ulcers of the big toe often necessitate surgical treatment. Depending on the wound stage and presence of osteomyelitis, conservative surgery and amputation are the main surgical treatments. Few articles reported the outcomes and complications of such procedures. This study is a preliminary comparative report on the early outcomes and complications of hallucal DFI treated with either conservative surgery or amputation.

SETTING AND DESIGN: This is a retrospective comparative study comprising a continuous series of patients admitted at our hospital. Initially, all DFU were infected and at advanced stage (Wagner Grade 3 or 4). All clinically suspected cases of osteomyelitis were confirmed by bone pathology and microbiology culture.

METHODS: The study included 37 patients diagnosed with DFI. Infection profile was as follows: 23 DFU with osteomyelitis (Wagner Grade 3 or 4) and 14 infected DFU (Wagner Grade 2). Twenty-four conservative procedures and 13 amputation surgeries were performed initially. The primary outcome was defined as the frequency of subsequent surgery (deep infection recurrence treated with surgery). Statistical analysis was used to look for significant difference between both groups.

RESULTS: Ten patients (27%) required additional surgeries because of deep infection recurrence. Four recurrences (16.7%) were observed in the conservative group and 6 (46%) in the amputation group (p = 0.054). Amputation rate as a subsequent procedure was 8.3% for the conservative group and the re-amputation rate for the amputation group was 23.1% (p = 0.2).

CONCLUSION: The study findings would indicate that the more severe is the initial hallucal infection severity (higher Wagner grade), the higher is the frequency of early surgical complications mainly after an index amputation procedure. Our assessment tools of initial infection extent seems to be underperforming. A more aggressive treatment in the form of a more proximal cut with regard to MRI bone infection signal could be considered to minimize the risk of subsequent surgeries and re-amputations.