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Degree of tissue loss is measured by a combination of depth and area of the wound. Larger and deeper wounds have a lower healing rate compared to smaller, more shallow wounds. For instance, black spots on toes are quite different than larger, deeper wounds. Furthermore, a wound that has progressed to gangrene has less chance of healing than a wound that still harbors viable tissue. Tissue loss is among the variables that is most strongly associated with risk for amputation. It is noteworthy that recognition of the extent of gangrene is not alway easy. Sometimes dark discoloration of tissue may still be reversible, while at other times gangrene demarcates progressively with time.

3rd toe gangrene and two areas of yet undemarcated ischemia on the dorsum of a left foot

Infection and amputation in critical limb ischemia

It may come as a surprise to some readers, but amputation is sometimes the better rehabilitation alternative for patients as compared with prolonged wound care and repeat local procedures. Also, compared to bypass, amputation is a lower risk surgery (when an endovascular approach is impossible). As patients who need amputation are often systemically frail (i.e. coronary artery disease, chronic kidney disease etc.), choosing the less aggressive of options may lead to more favorable outcomes. Furthermore, with modern rehabilitation techniques, and motivated patients, post-amputation rehabilitation may produce a high quality of life and close to normal independence.

With excellent wound care, even this wound healed

Appropriate wound care is central for avoiding amputation, specifically in those instances when it can be avoided. Patient and family cooperation are usually paramount. Next, the ability to offload the affected foot to reduce pressure injury. This is done by a combination of expert footwear (usually provided by podiatrists with specific expertise in the field) and by the use of crutches and a wheelchair for mobility. Then, there is specific intensive wound care. This is usually best provided by expert wound care centers that can identify progress or complications and react accordingly by changing their therapeutic strategy or by referring patients for acute care if superinfection is suspected.