This composite series of four images documents the clinical progression and surgical management of a severe diabetic foot infection and necrotizing gangrene. Panel (a) is a clinical photograph of the plantar surface of the foot showing dry and wet gangrene with extensive tissue necrosis affecting the 2nd, 3rd, and 4th digits, along with surrounding erythema and purulent exudate indicative of advanced infection. Panel (b) shows the postoperative state after a Chopart joint transection, featuring a large, open granulating wound with exposed deep tissues. Panel (c) illustrates the healed outcome following a Pirogoff amputation, showing a shortened, weight-bearing stump with a stable skin graft or healed plantar flap. Panel (d) is a lateral plain radiograph of the same site, demonstrating the modified Pirogoff technique where the calcaneus is rotated and fused to the distal tibia. The radiograph confirms arthrodesis and stable internal fixation with three cannulated compression screws. This sequence is representative of salvage procedures for the diabetic foot to preserve functional weight-bearing length and avoid transtibial amputation.

This series of clinical photographs (A-F) documents the surgical management and healing progression of a severely infected diabetic foot with localized gangrene. (A) Admission: Displays extensive dry and wet gangrene on the dorsal aspect of the foot, toes, and ankle with black necrotic eschar. (B) Post-debridement: Shows the removal of necrotic tissue and partial amputation of the second and third toes, revealing a raw, erythematous wound bed with viable granulation tissue. (C) mTTT Treatment: Illustrates the application of a metallic external fixator for transverse tibial bone transport to improve distal perfusion. (D) ABC Treatment: Shows the application of an Antibiotic-Loaded Bone Cement (ABC) spacer, appearing as a molded, perforated white material covering the wound surface for local infection control. (E) Discharge: Demonstrates significant wound contraction and the formation of a healthy pink epithelial layer. (F) Healing: Shows complete wound closure and re-epithelialization with residual hyperpigmentation and scarring. The sequence highlights a multidisciplinary approach combining surgical debridement, antibiotic spacers, and micro-tibia transverse transport (mTTT).

Clinical photograph of a right lower limb demonstrating concurrent dry and wet gangrene secondary to acute arterial insufficiency. The distal foot, including all phalanges, the dorsum, and the plantar surface, exhibits characteristic dry gangrene, visualized as mummified, shriveled, and dark black tissue with distinct demarcation. Proximal to the ankle, the lower leg shows signs of wet gangrene, characterized by significant edema, skin maceration, and the presence of multiple large, fluid-filled bullae and blisters. Notable tissue breakdown and serosanguinous discharge are visible on the pretibial and lateral surfaces of the leg. A clear line of demarcation is emerging below the knee, separating the necrotic, infected tissue from the viable proximal limb. This visual illustrates the progression of critical limb-threatening ischemia and the transformation from dry to infected wet gangrene, a surgical emergency requiring urgent intervention such as amputation to prevent systemic sepsis.

Clinical photographs (A and B) showing a severe diabetic foot ulcer with extensive necrosis and vascular occlusion in the left lower extremity. Image A (dorsal view) reveals significant tissue destruction of the first and second toes, characterized by dry gangrene (blackened, desiccated appearance) and a deep ulceration exposing underlying subcutaneous structures. The wound base contains yellow-green purulent exudate, suggesting secondary infection. Image B (plantar view) demonstrates a large, approximately 9cm x 5cm wound with a central area of black necrotic eschar and slough, involving two-thirds of the plantar surface. There is circumferential erythema (redness) and significant edema (swelling) extending from the wound margins toward the ankle. These clinical features illustrate Wagner Grade 4 diabetic foot complication, indicating critical limb ischemia and a high risk of amputation. Key educational concepts include the recognition of wet and dry gangrene, management of infected diabetic ulcers, and the visual assessment of peripheral arterial disease in chronic diabetic patients.