AMPUTATION IN DIABETIC FOOT ULCERS: A CASE REPORT AND REVIEW OF THE LITERATURE

Case report AMPUTATION IN DIABETIC FOOT ULCERS: A CASE REPORT AND REVIEW OF THE LITERATURE Keywords Diabetes mellitus, Diabetic foot ulcer, Amputation Volume: 3 Issıue: 3 Page: 146 - 156 Received: 18.07.2025 Accepted: 11.09.2025 Available online: 21.10.2025 The prevalence of diabetes in the global population continues to rise each year, leading to an increase in diabetes-related complications and healthcare costs worldwide. Diabetic foot ulcers (DFUs) may develop due to various factors; however, the presence of infection and progressive necrosis are among the primary causes of lower extremity amputations. We present the case of a patient with a 17-year history of type 2 diabetes mellitus and hypertension, who was admitted to the hospital with a black, crusted wound that had started as a small pustule on the second toe of the right foot one week earlier. The patient had poorly controlled blood glucose levels, with irregular glycemic regulation and elevated HbA1c values for more than 10 years. Failure to achieve glycemic control, poor adherence to treatment, and worsening living conditions due to the destruction caused by the February 6 earthquake, which significantly altered socioeconomic and environmental factors, contributed to inadequate self-care and ultimately resulted in amputation. Recognizing the critical points in treatment and care, as well as implementing preventive measures to protect diabetic patients from severe complications, is of utmost importance to improve both quality and expectancy of life. INTRODUCTION Senem Güneş Kara1* ABSTRACT DOI: 10.5281/zenodo.17406189 Diabetes is one of the most common endocrine disorders worldwide and represents a group of metabolic abnormalities resulting from insufficient insulin production, impaired insulin activity, or a combination of both. It can be classified as type 1 or type 2 diabetes. Type 1 diabetes is characterized by hyperglycemia caused by autoimmune destruction and damage to pancreatic βcells, whereas type 2 diabetes is primarily associated with obesity, insulin resistance due to β-cell dysfunction, and a progressive decline in pancreatic insulin secretion¹⁻⁴. Diabetes is a significant health concern with an increasing prevalence both globally and in our country. Currently, more than 550 million people worldwide are living with diabetes, and approximately 18.6 million of them develop diabetic foot ulcers (DFUs) each year. It has been reported that nearly 34% of individuals with type 1 or type 2 diabetes experience at least one episode of DFU during their lifetime⁵˒⁶. Diabetic foot ulcers (DFUs) may develop due to a variety of factors, including neurological, vascular, and biomechanical causes. However, the presence of infection and progressive necrosis are among the primary reasons for lower extremity amputation. Approximately 50–60% of patients with DFUs present with moderate infection, and nearly 20% of these patients undergo either minor (i.e., partial foot) or major (i.e., above the foot) lower extremity amputations. Around 20% of individuals with DFUs require hospitalization, and among hospitalized patients, 15–20% undergo lower extremity amputation⁷˒⁸. According to the literature, more than 150,000 non-traumatic lower extremity amputations are performed annually in individuals with diabetes in the United States. Globally, approximately 1.6 million amputations occur each year, of which about 33% are classified as major amputations⁵˒⁹˒¹⁰. The five-year mortality rate among individuals with diabetic foot ulcers (DFUs) is approximately 30%, and this rate may exceed 70% as the extent of amputation increases. A meta-analysis conducted on patients with diabetes reported a mortality rate of 231 per 1000 person-years in those with DFUs, compared to 182 per 1000 person-years in individuals without DFUs¹¹. In another 1*-Hatay Training and Research Hospital, Hatay Turkey, [email protected] , ORCID: 0000-0001-7481-1138 147 study involving 66,323 patients with DFUs, gangrene was observed in 3% of cases, and the presence of comorbidities such as cerebrovascular disease, cardiovascular disease, and renal failure was found to further increase mortality risk¹². In individuals with diabetic foot ulcers (DFUs), ulcer characterization, risk assessment, and classification of ulcers according to tissue loss, ischemia, and infection severity are essential methods to identify the risk of limb-threatening amputation. Additionally, the use of pressure-relieving footwear, skin temperature monitoring to detect “hot spots” (i.e., a temperature difference greater than 2 °C between the affected and unaffected foot), and surveillance of pre-ulcerative signs have been shown to effectively reduce the risk of ulcer development compared with standard care⁷. The primary approach in the treatment of DFUs is local wound care combined with mechanical debridement. However, when mechanical debridement fails to achieve the desired outcome, surgical debridement should be considered to prevent disease progression and further complications. In advanced and severe DFUs, the risk of amputation increases significantly. Amputation is generally regarded as an unfavorable therapeutic option, as it has profound negative effects on patients’ psychological well-being and real-life productivity. Therefore, the main goal in the management of severe DFUs is to promote wound healing with modern therapeutic methods and to minimize the need for amputation. Nevertheless, in cases where DFUs are accompanied by severe comorbid pathologies, amputation may become an unavoidable treatment option. This case report was designed to evaluate the treatment process of a patient who initially presented with a small pustule but, due to 15 years of poor adherence to diet and medication and failure to achieve glycemic regulation, ultimately required amputation. Case presentation A 74-year-old female patient with a 17-year history of type 2 diabetes mellitus was admitted to our chronic wound care outpatient clinic on September 11, 2024. The patient was receiving both oral antidiabetic and insulin therapy, including Jardiance 10 mg twice daily (PO) and Novopen 2 at 15 units (SC). Her medical history was also notable for hypertension, for which she was taking Coversyl 10 mg once daily (PO), in addition to antiplatelet therapy with Ecopirin 100 mg once daily (PO) and Plavix 75 mg once daily (PO). According to the patient’s account, the wound had begun one week earlier as a pustule on the second toe of the right foot, which subsequently developed into a black, crusted lesion. Routine laboratory investigations, foot radiography, and arterial/venous Doppler ultrasonography were ordered. Daily wound dressing with silver sulfadiazine and thiocilline ointment was prescribed, and the patient was advised to return for follow-up after one week. She was also informed to immediately seek hospital care in case of wound enlargement, discoloration, discharge, or malodor. However, due to inadequate self-care and psychosocial difficulties following the February 6 earthquake—during which the patient lost most of her relatives and had been living in a temporary container settlement—the deterioration of the wound was not recognized in time. Upon follow-up, progression of the wound was observed, with necrosis involving the fourth and fifth toes of the right foot secondary to impaired circulation. The patient was hospitalized, and it was decided that her condition would be evaluated at the first chronic wound care council meeting on September 24, 2024. Past Medical History A review of the patient’s medical history revealed persistently elevated HbA1c levels over the years: 8.67% in 2009, 14.54% in 2010, 9.09% in 2011, 12.8% in 2013, 9.5% in 2014, 10% in 2015, 9% in 2018 (twice), 6.5% in 2019, 9% in 2020, 9.4% in 2022, and 10% in 2023. These findings indicated longstanding poor glycemic control. DATE Fasting Blood Sugar AST/ALT Urea/ Creatinine WBC CRP Hmg HbA1C 11/09/2024 276 6/11 19/0.9 11 24 12.4 9,1 30/12/2024 POST-AMPLUTATION OUTPATIENT FOLLOW-UP 110 5/15 16/0.8 8 19 12.5 5.6 Laboratory Findings 148 Lower Extremity Arterial Doppler Ultrasound Atherosclerotic changes were observed in the vessel walls. Both ATP fillings could not be evaluated due to shadowing from calcified plaques. Both ADPs were not visualized. Low-velocity monophasic flow was observed in the right popliteal vein. Triphasic flow was present in the other arteries. Lower Extremity Venous Doppler Ultrasound Bilateral main, deep, and superficial femoral veins, popliteal veins, and the great saphenous veins are observed to be patent. On B-mode examination, the veins have normal caliber, and the vessel walls are regular. Color Doppler imaging shows that all venous structures are fully filled with color. PW Doppler demonstrates normal respiratory phasic flow. There is a complete response to augmentation. The venous structures are compressible throughout all segments, and no thrombus is detected in the lumen. Thrombosis has been ruled out in the examined venous system. Radiological Imaging (Initial Visit - 19/09/2024) Figure 1. Initial presentation to the outpatient clinic (11 September 2024) Figure 2. Follow-up after one week (18 September 2024) Following hospitalization and in consideration of the anticipated decision for amputation, simultaneous surgical preparations were initiated to avoid any delay. Additional laboratory tests, including coagulation parameters and infectious disease screening, were ordered. An electrocardiogram (ECG) and chest radiography were also performed. On 24 September 2024, the patient was evaluated by the medical board, and the consultant physicians’ assessments were as follows: Infectious Diseases Specialist: The patient was evaluated by the wound care board. The lateral side of the foot, including the 4th and 5th toes, was found to be necrotic, foul-smelling, with surrounding redness and increased temperature. Initiation of Tazocin 4x4.5 grams IV was recommended. If an osteomyelitis line remains after surgery, re-consultation is advised. If the margins are completely cleaned, a 5-day postoperative antibiotic treatment is considered appropriate. Orthopedics Specialist: The patient's foot X-ray was evaluated. No signs of osteomyelitis were observed. It was decided to perform amputation of the 4th and 5th toes of the right foot. Internal Medicine Specialist: To achieve blood glucose regulation, a 7-times-daily blood glucose monitoring schedule was initiated. Insulin therapy was adjusted to 10 units of NovoRapid three times a day and 24 units of Lantus once daily. Cardiovascular Surgery Specialist: The patient has positive popliteal pulses, and amputation of the 4th and 5th toes of the right foot is deemed appropriate. 149 Date Fasting Blood Sugar (mg/dL) AST/ALT (U/L) Urea/Creatinine WBC (x10³/µL) CRP (mg/L) Hb (g/dL) 19/09/2024 135 8/12 31/123 11 109 9.7 24/09/2024 151 10/21 26/1.27 24 154 10.6 27/09/2024 108 19 173 10 30/09/2024 148 13 107 04/10/2024 119 10/14 11.9/1.83 16 187 9.2 06/10/2024 209 13 174 11/10/2024 189 12 44 14/10/2024 205 11 37 17/10/2024 180 12 57 21/10/2024 175 10 162 Table 1. Laboratory Test Results During The Patient’s Hospitalization Date 06:00 12:00 18:00 24:00 24/09/2024 150 226 191 216 25/09/2024 238 205 180 209 26/09/2024 98 168 155 146 27/09/2024 102 166 210 180 28/09/2024 143 195 193 214 29/09/2024 132 186 179 203 30/09/2024 212 148 230 148 01/10/2024 206 88 176 160 02/10/2024 154 143 208 178 03/10/2024 132 140 210 165 04/10/2024 145 151 95 271 06/10/2024 187 177 190 300 09/10/2024 163 230 136 195 11/10/2024 215 157 189 248 13/10/2024 221 171 192 99 17/10/2024 140 209 186 201 20/10/2024 188 216 215 190 Table 2. Blood Glucose Monitoring Form Figure 3. Postoperative initial appearance. Daily dressing with povidone-iodine was performed. (October 3–4, 2024) Figure 4. Appearance of the foot one week after surgery. Daily dressing with povidone-iodine was continued. 150 DISCUSSION A multidisciplinary team approach is of utmost importance for the care and management of patients with diabetic foot ulcers (DFUs). Such a team typically includes a vascular surgeon, orthopedic surgeon, endocrinologist, a dedicated assistant physician, a wound care nurse, and a prosthetics specialist. In addition, for inpatients, a plastic surgeon should be incorporated into the team when necessary. Infectious disease specialists and orthopedic surgeons may also be consulted on a case-by-case basis¹³. In brief, all patients presenting with diabetic foot ulcers or gangrene should be evaluated by the entire team at their initial visit, and diagnostic testing should be performed comprehensively, including non-invasive vascular laboratory studies and radiographs of the affected foot. When radiographic findings are inconclusive, magnetic resonance imaging (MRI) may be used to detect the presence of osteomyelitis as needed. In accordance with the literature, our patient was evaluated by our multidisciplinary team with a holistic approach during her first admission to the chronic wound care outpatient clinic, and all necessary tests were performed. Her HbA1c level was 9.1%, and fasting blood glucose was 267 mg/dL. Furthermore, hospital electronic records revealed that the patient had persistently elevated HbA1c values for more than 10 years. The internal medicine specialist recommended blood glucose regulation through seven-point daily monitoring and insulin therapy consisting of Novorapid 10 units three times daily and Lantus 24 units once daily. The infectious disease specialist noted necrosis, malodor, erythema, and warmth involving the lateral aspect of the right foot, affecting the 4th and 5th toes, and initiated intravenous Tazocin 4 × 4.5 g. Postoperatively, if osteomyelitic tissue was suspected, re-consultation was planned; if the margins were completely clear, antibiotic therapy would be continued for five days. The cardiovascular surgeon confirmed palpable popliteal pulses and Figure 5. Appearance of the foot two months after surgery. It was decided to extend the level of amputation and perform a heelsparing amputation. Figure 6. Appearance of the foot after the second amputation surgery. 151 recommended amputation of the 3rd, 4th, and 5th toes of the right foot. The orthopedic surgeon reported no radiographic evidence of osteomyelitis and concurred with the decision for toe amputation of the 3rd, 4th, and 5th digits of the right foot. The initial approach to a patient with diabetic foot ulcers (DFUs) should include a comprehensive assessment of the ulcer (size, depth, and signs of infection), evaluation of peripheral arterial disease with non-invasive vascular laboratory tests, laboratory investigations (erythrocyte sedimentation rate, C-reactive protein, complete blood count, biochemistry, and HbA1c), and radiological imaging for suspected osteomyelitis (plain radiographs followed by magnetic resonance imaging when necessary). Classification of DFUs according to tissue loss, ischemia, and infection severity can assist in estimating the risk of amputation⁷. Consistent with the literature, our patient’s elevated HbA1c level, necrosis involving the 4th and 5th toes of the right foot with malodor, erythema, and local warmth, and the absence of osteomyelitis on radiological imaging guided the treatment decision. Consequently, the patient was spared from major limb amputation and underwent amputation of the 3rd, 4th, and 5th toes instead. The treatment of diabetic foot ulcers (DFUs) involves debridement of necrotic tissue, wound care, offloading to reduce pressure on the affected area, glycemic regulation with a target hemoglobin A1c ideally below 8%, appropriate antibiotic therapy for infection, and evaluation for revascularization in cases of peripheral arterial disease. In selected patients, advanced wound therapies may be employed to accelerate healing. A multidisciplinary team approach in primary care settings has been shown to improve patient outcomes⁷. Consistent with the literature, a DFU that initially developed as a small pustule represents a severe complication that can ultimately lead to limb loss or even death. In our patient, initial toe amputation was performed, followed by revision surgery resulting in a heel-sparing amputation. Among patients whose diabetic foot ulcers (DFUs) have healed, 42% will develop another ulcer within one year; therefore, such patients should undergo regular foot examinations and be evaluated by a certified wound care nurse for callus formation and other pre-ulcerative signs. Patients should be educated on proper foot self-care, advised to monitor skin temperature of their feet and reduce load when “hot spots” are detected, and encouraged to wear well-fitted, pressure-relieving footwear to minimize the risk of recurrence⁷. Consistent with the literature, our patient’s inadequate self-care, compounded by the consequences of the February 6 earthquake—which led to displacement into container settlements with increased risk of trauma, the loss of many family members, and significant challenges in transportation and access to resources—contributed to impaired wound healing after the first surgery. Consequently, a second surgery was planned to increase the level of amputation. Diabetic foot ulcers (DFUs) develop as a consequence of diabetic sensory, motor, and autonomic neuropathy. Sensory neuropathy leads to loss of protective sensation; motor neuropathy causes foot deformities and biomechanical abnormalities; while autonomic neuropathy results in viscoelastic changes in the skin, such as dryness. These changes frequently lead to callus formation. With weightbearing, repetitive trauma and inflammation beneath the callus can result in bleeding that presents as a full-thickness ulcer (i.e., damage extending below the epidermis and dermis into the subcutaneous tissue). Other mechanisms contributing to DFU development include sustained low pressure, such as that caused by ill-fitting shoes leading to tissue necrosis, or excessive high pressure, such as direct mechanical injury from a sharp object⁶. Consistent with the literature, in our patient, inadequate self-care, neglect of proper foot care, and inappropriate footwear selection contributed to the rapid development of necrosis, which ultimately necessitated amputation. To assess the risk of ulceration in individuals with diabetes, an annual foot examination should be performed by the specialist physician responsible for follow-up. This evaluation should include assessment for neuropathy leading to loss of protective sensation, peripheral arterial disease, and skin breakdown¹⁴. In a study conducted by Tolson et al. (2024) among patients with newly diagnosed diabetic foot ulcers, those who had seen a podiatrist for preventive care in the year preceding ulcer development had a lower risk of major lower extremity amputation compared with those who had not consulted a podiatrist¹⁵. Patients diagnosed with neuropathy or peripheral arterial disease should undergo a comprehensive foot examination by a podiatry specialist¹⁶. In contrast to these recommendations in the literature, our patient, despite 152 adhering to annual follow-ups prior to the earthquake, was unable to attend medical check-ups for more than two years following the severe damage sustained in her city. Consequently, she was unable to maintain adequate self-care, diet, and treatment adherence. Clinically, diabetic foot ulcers (DFUs) present as an open lesion of the epidermis and, in some cases, a portion of the dermis. Pre-ulcerative lesions are closed or superficial changes confined to the epidermis (e.g., blisters, calluses, erythema, or localized warmth) but carry a high risk of progression to ulceration. Repetitive minor trauma is a frequent cause of ulcer development, often resulting from increased pressure on plantar weight-bearing areas, abnormal gait patterns, inappropriate footwear, or unnoticed injuries in an insensate foot (such as ingrown toenails, puncture wounds, or burns) that lead to friction and shear forces¹⁷. Consistent with the literature, in our patient, the use of inappropriate footwear resulted in friction and shear on the second toe of the right foot, leading to the initial appearance of a small pustule that progressed to ulceration and ultimately a poor prognosis requiring amputation. The physical examination of a patient should include evaluation for callus formation, interdigital maceration and fungal infections, as well as thickened toenails that may be associated with increased pressure on the nail bed. Digital deformities such as hammer toe or claw toe manifest as prominence of the interphalangeal joints dorsally and the metatarsal heads on the plantar surface, both of which are common sites of ulceration. The tips of the toes, when exposed to increased pressure from ground contact or footwear, are also frequent sites of ulceration¹⁶. Assessment of ankle dorsiflexion and plantarflexion range of motion may reveal equinus deformity (i.e., less than 0° dorsiflexion at the ankle joint), which increases forefoot plantar pressure. Consistent with the literature, physical examination of the patient’s right foot revealed callus formation and thickened toenails. However, there were no findings of fungal infection or hammer toe deformities. It should also be emphasized that in patients with diabetes and DFUs, annual physical examination and follow-up are essential—not only to protect the contralateral foot from ulceration but also to prevent recurrence in the previously affected foot. Palpation of ankle and foot pulses is a central component of vascular examination; however, the literature reports that palpable pulses have relatively low sensitivity (71.7%) and specificity (72.3%) for detecting peripheral arterial disease (PAD)¹⁸˒¹⁹. Since PAD affects nearly half of individuals with diabetic foot ulcers (DFUs), clinicians should consider performing non-invasive testing with the ankle–brachial index (ABI) or toe–brachial index and/or referring patients to vascular specialists⁷. Consistent with the literature, our patient’s pedal pulses were positive. She was evaluated by vascular surgery for PAD, and given the presence of palpable popliteal pulses, amputation of the 3rd, 4th, and 5th toes of the right foot was deemed appropriate. Hemoglobin A1c (HbA1c) is the gold-standard laboratory test used to evaluate glycemic control in patients with diabetes mellitus (DM)²⁰. Given that the average lifespan of erythrocytes is approximately 120 days, HbA1c provides a quantitative index of glycemic control over the preceding 8–12 weeks. The literature highlights a strong association between HbA1c levels and diabetic complications that represent major risk factors for the development of diabetic foot, such as peripheral neuropathy and peripheral arterial disease (PAD)²¹. It has also been reported that in individuals with DFUs, an HbA1c level above 6.5% is associated with an increased risk of lower extremity amputation²². Therefore, one of the fundamental goals in the management of patients with DFUs is to achieve appropriate glycemic targets and maintain HbA1c levels within the recommended range throughout all stages of clinical care. Consistent with the literature, our patient’s HbA1c level was 9.1%, and review of hospital records revealed that her HbA1c levels had been persistently elevated (≥9%) for more than 10 years. As a result of this long-term poor glycemic control, the patient initially underwent toe amputation, which was later revised to a heel-sparing amputation at a higher level. In the management of diabetes and diabetic foot ulcers (DFUs), monitoring long-term glycemic control, predicting the risk of complications, planning treatment, and assessing the quality of diabetic care primarily rely on HbA1c measurement. Current data in the literature show a linear relationship between serum glucose measurements and mean HbA1c values, as well as strong correlations between HbA1c levels and complication risks²¹. A meta-analysis conducted by Tang et al. (2023) demonstrated that HbA1c is one of the predictive factors for the 153 development of DFUs²³. Similarly, a study by Lin et al. (2020) reported that higher HbA1c levels increased the risk of amputation²⁴. A meta-analysis of 11 studies investigating HbA1c levels in patients with DFUs, including 43,566 participants divided into two groups (those with and without lower extremity amputations), revealed that HbA1c levels ranged between 8.3% and 12.5% in patients who underwent amputation²². In a cohort study examining risk factors for transmetatarsal amputation failure in patients with diabetes, HbA1c was identified as the most significant predictor of surgical success²⁵. Another meta-analysis by Zhou et al. (2015), which included six studies with 109,933 patients, found a significant association between HbA1c and amputation risk, reporting that each 1% increase in HbA1c raised the likelihood of amputation by 1.229 times²². Moreover, the literature emphasizes that poor glycemic control substantially increases the rates of both minor and major amputations²⁶. Akyüz et al. (2023) also predicted that higher HbA1c levels may be associated with more proximal levels of surgical amputation²¹. These findings highlight the critical importance of reducing HbA1c levels to lower amputation rates in patients with diabetes. Additionally, Shatnawi et al. (2018) reported that HbA1c ≥8%, a diabetes duration of ≥15 years, and insulin therapy were independent predictors of major lower extremity amputation²⁷. Consistent with the literature, review of the patient’s hospital records revealed an average HbA1c level ≥9 for more than 10 years. Furthermore, due to the severe damage to her city caused by the February 6 earthquake, the patient was unable to attend hospital follow-ups for more than two years, during which she also experienced the loss of multiple family members. Despite having multiple risk factors for amputation, the earthquake-related disruptions led to a lack of medical follow-up and treatment, inadequate self-care, and significant barriers to accessing healthcare and basic needs. In patients with diabetic foot ulcers (DFUs), the use of wound classification scales is highly important for characterizing the ulcer and planning appropriate care and treatment. Although numerous wound classification systems exist, most primarily focus on the degree of tissue loss and are insufficient in assessing the presence of infection and ischemia. In the literature, the Wound, Ischemia, and Foot Infection (WIfI) classification system has been developed as a method to combine three variables—wound, ischemia, and foot infection—in order to accurately assess the risk of limb loss in patients with DFUs. This system evaluates the severity of tissue loss, ischemia, and foot infection as absent, mild, moderate, or severe. Higher WIfI scores are directly correlated with lower extremity amputation and morbidity²⁸. The Wagner classification system, which assesses ulcer depth and bone involvement, is also useful in predicting potential outcomes and is commonly employed to guide appropriate treatment and care planning²¹. The Wagner method helps classify the severity of the ulcer and assigns a score ranging from 0 to 5 (Table 1). Table 3. Wagner classification for diabetic foot ulcers (DFUs)²⁹. In the study conducted by Akyüz et al. (2023), it was reported that HbA1c levels ≥10.1% in hospitalized patients with type 2 diabetes mellitus (T2DM) due to diabetic foot ulcers (DFUs) were associated with Wagner grade 4 ulcers. The study further emphasized that as HbA1c levels increased, the severity of amputation and tissue loss also increased, thereby threatening patients’ functional foot health²¹. Similarly, in a study by Farooque et al. (2020) evaluating the correlation between Wagner grading and HbA1c levels, the mean HbA1c level of included diabetic foot patients was 9.07 ± 1.65%, with values >8.5% observed in Wagner grades 4 and 5. Additionally, 59.08% of patients had DFUs classified as Wagner grade ≥4³⁰. One of the significant findings of this study was the linear relationship between HbA1c levels and Wagner grades. Consistent with the literature, our patient had an HbA1c level of 9.1% and a Wagner grade of 4. The diagnosis of diabetic foot infection (DFI) is primarily based on clinical evaluation and is established by the presence of more than two signs of inflammation, such as erythema, Grade Clinical presentation 0 Intact skin, no ulcer but high-risk foot 1 Superficial ulcer involving the skin or subcutaneous tissue 2 Ulcer extending to joint, tendon, ligament, or capsule without abscess or osteomyelitis 3 Deep ulcer with abscess or osteomyelitis 4 Localized gangrene of the hallux or forefoot 5 Extensive gangrene of the entire foot 154 swelling, exudate, or lymphangitis. There is no randomized clinical trial evidence supporting routine wound cultures in all patients with DFUs. In the absence of clinical signs of infection, an erythrocyte sedimentation rate (ESR) greater than 70 mm/h may aid in improving the diagnostic accuracy for osteomyelitis. Magnetic resonance imaging (MRI) is the preferred modality when clinical assessment and plain radiographs are inconclusive for diagnosing osteomyelitis, as well as for detecting occult abscesses or defining the extent of deeper infections. Bone biopsy and culture remain the gold standard for the diagnosis of osteomyelitis³¹⁻³⁴. Consistent with the literature, at the time of clinical presentation, our patient was diagnosed with DFI based on findings of exudate, swelling, necrosis, and malodor in the 4th and 5th toes of the right foot. The clinical spectrum of diabetic foot ulcers (DFUs) ranges from uncomplicated cellulitis to limb-threatening and/or lifethreatening necrotizing fasciitis. Poor glycemic control leads to impaired leukocyte activity and complement function, resulting in immune dysfunction and facilitating the development of invasive soft tissue infections. Hyperglycemia induces oxidative stress in nerve cells, leading to neuropathy that affects sensory, motor, and autonomic nerves. In the study by Akyüz et al. (2023), it was noted that most DFUs are accompanied by moderate infections that threaten limb viability²¹. Similarly, Critchley et al. (2018), in a study on patients with type 1 and type 2 diabetes, reported a strong correlation between poor glycemic control and severe infections, with HbA1c levels identified as strong predictors of infection risk³⁵. Consistent with the literature, our patient presented with irregular blood glucose levels, elevated CRP and WBC values, and local signs of infection. As a result of more than 10 years of poor glycemic control, the patient developed diabetic neuropathy accompanied by DFI, which ultimately resulted in amputation. Individuals with diabetes who are at the lowest risk category for foot ulceration—defined as having no loss of protective sensation, no peripheral arterial disease, and no history of foot complications—should undergo a routine foot examination annually by their responsible physician. Patients with increased risk of foot ulceration should be educated on proper foot self-care and the use of appropriate footwear. Those with two or more risk factors, such as loss of protective sensation, peripheral arterial disease, and foot deformity, are considered at moderate risk and should be referred to a specialist (e.g., podiatrist, orthotist, or orthopedic specialist) for therapeutic footwear to reduce pressure. Individuals at moderate risk should be assessed by a podiatry specialist every 3 to 6 months¹⁶. In light of this evidence, our patient was considered to be at moderate risk and should have been evaluated by a podiatry specialist every 3–6 months. However, due to residing in a region heavily affected by the February 6 earthquake—the most severely damaged city in the area—she was unable to attend follow-ups, monitoring, or treatment for more than two years. Early management of diabetic foot infection (DFI) reduces the risk of hospitalization and amputation. In a study of 668 patients treated for DFIs at a single hospital, it was reported that the risk of major amputation or death increased by 0.6% for each day of delayed referral to a medical center³⁶. Although most DFIs are superficial, some may require surgical intervention to eliminate deep soft tissue infection. In cases of forefoot osteomyelitis without acute soft tissue infection, antibiotic therapy may be as effective as surgical treatment³¹. Consistent with the literature, our patient’s delayed hospital visits and missed follow-up appointments resulted in the progression of a DFU, which, due to ischemia and necrosis, ultimately necessitated amputation. Vasculopathy is a circulatory disorder clinically associated with reduced blood flow to the lower extremities due to arterial stenosis or atherosclerotic occlusion. Insufficient blood flow to the extremities impairs wound healing, further worsening the condition. Moreover, this state increases the susceptibility of the wound area to anaerobic bacterial growth, leading to severe complications such as gangrene and amputation¹⁷. Consistent with the literature, following toe amputation performed in September 2024, our patient’s wound healing did not occur due to inadequate tissue oxygenation. At her three-month follow-up, a CT angiography was planned. The angiography report showed normal lumen opacification and calibration in the distal aorta and both common iliac arteries. At the level of the celiac trunk, a mixed-type plaque formation causing 50–69% stenosis was observed. In the superior mesenteric artery, a plaque formation causing <50% stenosis was noted. At the level of the inferior mesenteric artery, areas of severe narrowing were detected. Doppler