Staged Limb Salvage of a Diabetic Foot Infection: A Case Report
Upon admission of a 53-year-old male with diabetes for abdominal pain and sepsis, no one initially suspected a limb-threatening infection. But by day 4 of his hospital stay, a podiatry consult revealed an abscess on the left foot, later confirmed to be necrotizing fasciitis. Prompt surgical debridement took place, followed by staged wound reconstruction using a synthetic electrospun fiber matrix. This case demonstrates how early podiatric involvement and appropriate use of advanced wound care tools can lead to successful limb salvage, even in complex systemic cases.
Details of the Clinical Picture
The patient had a history of type 2 diabetes mellitus and hypertension. He presented to the emergency department with 2 days worsening left-sided abdominal pain radiating to his back, associated with fevers and chills. There was no nausea, vomiting, diarrhea or bloody bowel movements.
Physical examination revealed sinus tachycardia, clear lung fields, and left abdominal and back tenderness with guarding, but normal bowel sounds. The extremities were warm and intact bilaterally, with no documented foot examination. His vital signs in the emergency department included blood pressure 149/64, pulse 103, respiratory rate 18, and a temperature of 38.3 degrees Celsius. His white blood cell count was 23.6, and glucose 174. His HbA1c was 6.9%. Computed tomography revealed a nonobstructing renal calculus, and he began intravenous antibiotics for pyelonephritis.
On hospital day 4, the podiatry team was consulted by the primary medical service after observing purulent drainage from the left dorsolateral foot with persistent fevers and leukocytosis on intravenous antibiotics. Examination of the left foot revealed an abscess with purulent drainage from the fourth interdigital space, with a 10x5 cm dorsal area of erythema and edema, necrosis, diminished pulses, and sensory loss.
On hospital day 5, the patient underwent emergent debridement, clinically confirming necrotizing fasciitis due to necrosis extending to and beyond the fascia, with exposed tendons and joint capsule post wide local debridement. We performed extensive removal of devitalized tissue. After a second-look procedure to ensure a clean wound bed, we applied a synthetic electrospun fiber matrix (a fully synthetic scaffold designed to mimic the extracellular matrix) for coverage of exposed extensor tendons and joint capsule. We also implemented negative pressure wound therapy (NPWT) to support graft adherence and fluid control, and to promote granulation tissue. The sepsis resolved, and the patient was discharged to home, with weekly follow-up planned in the outpatient clinic.
Within 3 weeks, we noted that the matrix had fully integrated, supporting robust granulation tissue. On a readmission approximately 2 months later, we performed a meshed split-thickness skin graft to the dorsum of the foot, again supported by NPWT. The patient had more than 95% graft take and ambulated in diabetic shoe gear by the 6-week follow-up visit after the skin graft. No additional surgical intervention was required and he went on to wound closure.
Final Thoughts
This case highlights several important considerations for clinicians managing high-risk patients with diabetes. First, foot evaluations are essential during hospitalizations for systemic illness, especially for patients with high-risk conditions like diabetes. In this particular case, the synthetic electrospun matrix offered a nonbiologic, scaffold-based alternative to a flap in a patient with exposed structures and other comorbidities. This case also underscored the value of a staged limb salvage protocol, including early debridement, matrix application, and delayed grafting. Due to the severity of these infections, such pathways can be both limb- and life-saving.
Dr. Archer is a board-certified podiatrist and certified wound specialist at the University of Rochester Medical Center in the Department of Orthopaedics. She specializes in diabetic foot care, wound management, and limb preservation, and is actively involved in clinical education and surgical leadership.
Dr. Collins is a podiatric resident at Staten Island University Hospital /Northwell Health System in Staten Island, NY.
Dr. Lopez practices at Staten Island University Hospital /Northwell Health System in Staten Island, NY.
Dr. Cooper practices at Staten Island University Hospital /Northwell Health System in Staten Island, NY and is an Assistant Professor at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
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