Successful Right 3rd & 4th Toe Ray Amputation for Diabetic Foot Gangrene

Chief Complaints

A 61-year-old female patient with a body mass index (BMI) of 20 presented to the Plastic and Reconstructive Surgery Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of discoloration of the right 3rd and 4th toes for 5 days, associated with discharge from the wounds. She also complained of weakness and fever during the same period. The patient additionally reported episodes of hypoglycaemia (low blood sugar). 

The patient was a known case of type 2 diabetes mellitus, hypertension, and hypothyroidism, and was on regular medication for the same. She was also known to be Hepatitis B surface antigen (HBsAg) positive. The patient had a significant past history of debridement for a right great toe interphalangeal joint ulcer. 

On examination, the patient was conscious, coherent, and cooperative. General examination revealed no pallor, icterus, cyanosis, clubbing, lymphadenopathy, or pedal edema. Her vital signs were stable. Local examination revealed discolouration and gangrenous changes involving the right 3rd and 4th toes, associated with cellulitis and wound discharge. Systemic examination showed normal cardiovascular and respiratory findings, while the abdomen was soft and non-tender on examination.

Following the clinical examination, the Plastic Surgery team conducted a detailed assessment of the patient’s complaints of discolouration of the right 3rd and 4th toes associated with wound discharge, weakness, fever, and hypoglycaemic episodes. A focused evaluation of the right foot revealed cellulitis with gangrenous involvement of the affected toes, suggestive of diabetic foot infection with tissue necrosis.

Considering the patient’s known history of type 2 diabetes mellitus, hypertension, hypothyroidism, previous diabetic foot ulcer requiring debridement, and HBsAg positivity, a comprehensive clinical and laboratory evaluation was performed to assess the extent of infection and associated systemic involvement. 

Laboratory investigations revealed elevated random blood sugar levels and HbA1c of 8.5%, indicating poor glycaemic control. Complete blood picture showed microcytic hypochromic anemia with leucocytosis, suggestive of active infection and inflammatory response. Renal parameters and electrolytes were within acceptable limits for surgical management. Viral screening showed HBsAg positivity, while HIV and HCV screening were non-reactive.

Based on the confirmed diagnosis, the patient was advised to undergo Diabetic Foot Cellulitis Treatment in Hyderabad, India, with gangrene of the right 3rd and 4th toes, under the care of the Plastic and Reconstructive Surgery team, ensuring removal of infected and gangrenous tissue, control of infection, promotion of wound healing, and preservation of healthy surrounding tissue and limb function. 

After a detailed consultation by Dr. Kantamneni Lakshmi, Consultant Plastic Surgeon, Dr. Suresh Kumar S, Consultant Surgical Gastroenterologist, and Dr. Tripti Sharma, Consultant Endocrinologist, a comprehensive clinical evaluation was performed focusing on the patient’s presentation of discoloration and gangrenous changes involving the right 3rd and 4th toes, associated with wound discharge, weakness, fever, and hypoglycaemic episodes in the background of type 2 diabetes mellitus, hypertension, hypothyroidism, and previous diabetic foot ulcer requiring debridement.

All relevant laboratory investigations and clinical findings were thoroughly reviewed, including glycaemic status, complete blood picture, viral screening, and systemic assessment. The investigations demonstrated uncontrolled diabetes mellitus with elevated HbA1c levels, leucocytosis suggestive of active infection, and anemia indicating ongoing inflammatory changes. Clinical evaluation confirmed diabetic foot cellulitis with gangrene involving the right 3rd and 4th toes.

Based on the severity of infection, tissue necrosis, and gangrenous involvement, it was determined that Debridement with Ray Amputation of the right 3rd and 4th toes was the most appropriate surgical intervention. This decision was made with the aim of removing gangrenous and infected tissue, controlling the spread of infection, promoting wound healing, and preserving the healthy surrounding foot tissue and overall limb function.

The patient and family members were counselled regarding the diagnosis, planned surgical procedure, expected postoperative recovery, wound care, glycaemic control, possible risks and complications, and the importance of regular follow-up and diabetic foot care for optimal recovery outcomes. 

Following the decision, the patient was scheduled for Debridement with Ray Amputation of the Right 3rd and 4th Toes in Hyderabad at PACE Hospitals, under the care and supervision of the expert Plastic and Reconstructive Surgery team.

The surgical procedure involved the following steps:

• Preoperative Preparation and Anaesthesia: The patient was taken up for surgery under spinal anaesthesia (S.A). The right lower limb was prepared and draped under strict aseptic precautions. A detailed intraoperative assessment of the gangrenous toes, surrounding cellulitis, ulceration, and tissue involvement was performed before proceeding with the surgery.

• Surgical Exposure and Assessment: The operative field involving the right 3rd and 4th toes and adjacent soft tissue was carefully exposed. Intraoperative evaluation revealed gangrenous and infected tissue involving the affected toes, along with ulceration over the medial aspect of the foot. The extent of devitalized tissue and local infection was assessed to achieve adequate surgical clearance while preserving healthy surrounding tissue.

• Ray Amputation and Debridement: Ray amputation of the right 3rd and 4th toes was performed, and all gangrenous, infected, and non-viable tissue was completely excised. Debridement of the ulcers present on the medial aspect of the foot was also carried out to remove unhealthy soft tissue and reduce the infective burden. Care was taken to preserve viable adjacent structures and obtain a healthy wound bed suitable for healing.

• Hemostasis and Wound Irrigation: Following amputation and debridement, the surgical site was thoroughly inspected. Adequate hemostasis was secured, and a wound wash was given to clear residual infected and devitalized tissue. The operative field was reassessed to ensure satisfactory removal of gangrenous tissue and control of local infection.

• Wound Management and Dressing: After completion of the procedure, an aseptic dressing was applied to the surgical site. 
  

Following the procedure, the patient received regular aseptic wound dressings with close monitoring of the surgical site for infection control and wound healing progression. Postoperative vacuum-assisted closure (VAC) dressing was also performed as part of wound management. Infection control measures, pain management, glycaemic regulation, and supportive care were continued throughout the hospital stay. Blood sugar levels were closely monitored, and diabetic medications were adjusted appropriately to support infection control and wound healing. 

At the time of discharge, the patient was prescribed medications for infection control, pain relief, gastric protection, glycaemic management, lipid control, neuropathic symptom relief, hypothyroidism management, antifungal care, and nutritional supplementation. Oral antidiabetic medications were advised for optimal blood sugar control. Additional medications were prescribed to support wound healing, reduce infection risk, and prevent further diabetic complications.

Upon discharge, the patient was advised to elevate the limb and undergo regular sterile wound care to promote healing and prevent further infection. She was instructed to follow a strict diabetic diet, maintain optimal glycaemic control, and continue all prescribed medications regularly. Active knee and ankle exercises were advised to improve circulation and support recovery. The patient was also counselled regarding proper diabetic foot care and the importance of regular monitoring to prevent recurrence or progression of foot complications. 

The patient was advised to contact the emergency ward at PACE Hospitals in case of fever, increasing wound pain, swelling, redness, wound discharge, vomiting, uncontrolled blood sugar levels, or any worsening symptoms suggestive of infection or systemic complications. 

The patient was advised to return for follow-up consultation with the Consultant Plastic, Reconstructive & Aesthetic Surgeon in Hyderabad at PACE Hospitals after 1 week in the outpatient department for wound assessment, dressing review, and monitoring of postoperative recovery. Regular follow-up was advised for continued diabetic foot care, glycaemic management, and evaluation of wound healing progress. 

This case highlights the successful multidisciplinary management of right diabetic foot cellulitis with gangrene in a patient with multiple comorbidities. Early identification of infection, prompt surgical intervention with debridement and ray amputation, and appropriate antimicrobial therapy played an important role in controlling infection and preventing further tissue loss.

Comprehensive postoperative care, including wound management, glycaemic control, VAC dressing, nutritional support, and rehabilitation, contributed significantly to clinical improvement and recovery. The patient remained stable throughout the postoperative period and was discharged in satisfactory condition with advice for continued wound care, diabetic management, and regular follow-up to support healing and prevent future complications.