Sunday, 1 April 2012


Gangrene is the most serious symptomatic feature or cardinal sign of arterial insufficiency, after intermittent claudication and rest pain. Gangrene is necrosis or death of tissue, and commonly affects the extremities of the hands and feet (Hoffman 1992). 

 When presented with gangrene, the clinician must determine the cause of the pathology, so as to address it and prevent further damage. Whilst ischaemia may be evaluated as being the cause, it should be determined whether it was from atherosclerosis, myocardial infarct, valvular heart disease or emboli. Also ascertain if they are a smoker, have diabetes mellitus, and history of vascular problems. Treating gangrene is beyond the scope of a podiatrist, so if gangrene is found, refer to a vascular surgeon. 

 The podiatrist may see gangrene as dry or moist (Hoffman 1992). Dry gangrene is most commonly due to ischaemia and is often a secondary complication of type 2 diabetes mellitus. It presents as cold, dry, shriveled and blackened tissue, often running deep into the fascia, but first appearing on the distal apices. 

 Wet or moist gangrene is the more serious condition, as it usually indicates a bacterial infection that may quickly spread and be fatal. Most commonly caused by an acute occlusion, such as tourniquet, restrictive bandage or trauma. It present like dry gangrene, but is softer to touch with an offensive odour, and the foot may be swollen, red and warm (Lorimer et al, 1997, Hoffman 1992). 

As mentioned previously, presence of gangrene must be taken seriously and appropriate referrals made immediately


Patient A

Case report: Treatment of Diabetic Ulcers and Gangrene with Complex therapy Surgery and Ozone Therapy.

Patient A female 58 years old has visited us in May 2007 for treatment with diagnosis of gangrene of the left foot and toes, diabetic angiopathy. The patient had been on standard medical treatment of antibiotics and wound sanitation with minimal or no effect.
Brief history: the patient suffers from diabetes mellitus type 2 for the last 10 years, and was on treatment of Glucophage 500mg tablets 3 times/day, for the last 10 years. On an angiogram performed at that time it was found that the patient had a full block in her vessels in the left leg foot and terminal segment of the leg.
Complaints: the patient mainly complained of pain in the left foot and no sensation in the left leg, lower knee region, weakness, patient’s daily life activities were limited as the patient had to use a wheelchair to move, due to this the patient also had depression, bad appetite and intoxication like general condition.
Physical examination: the patient feels severe pain on any contact near the gangrene site and from the gangrene wound on the left foot there is strong bad smell.
The patient’s gangrene started about 5 months before the first consultation at our institute, it was initially spread to the 2nd, 3rd, 4th, and 5th small toe leaving out the hallux or the big toe. Amputation surgery was performed to stop the spread of gangrene but the surgical wound was not able to heal properly and the gangrene spread from the phalanges to the metatarsal region. In consultation with surgeon Dr. Andreas Demitrou it was decided not to amputate above the tarsal region {because the patient is of a very small physical stature and is obese, if the amputation was performed till the knee joint the stub will be small after surgery and it will be difficult to place a prosthetic support on it. Meaning that the patient will have severe limitations of life activities}. Thus the treatment regime for the patient was planned in such way, so as to maximize the patient’s abilities and minimize tissue loss.
Treatment: -presurgical- The patient was started initially on high dosage I.V. ozone therapy once a day accompanied by direct superficial ozone application in the form of ozone bags at the site of the gangrene on the left foot and as prophylaxis for small ulcers that were present on the right leg.
The surgical operation was performed by senior surgeon Dr. Andreas Demitrou, and was a success, all gangrenous tissue and surrounding affected tissue zone was meticulously removed leaving healthy tissue, thereby saving maximum possible. This surgery was optimal keeping in mind the patient’s future and life and was done without any complications. Thereby providing the patient with an excellent chance of walking again with the help of prosthetic implants. Postsurgical-the patient was given I.V. ozone therapy.
Result: the patient received in all more than 40 sessions of high dosage I.V. ozone therapy pre and post surgical and an excellent surgical intervention by Dr. Andreas Demitrou. This combination proved to be beneficial for the patient as it gave the patient a chance to resume maximum of her physical and daily life activities with the help of a prosthetic implant.

·       For the next four and a half months (18 weeks), all wounds on the patient were healed.
·       She was recommended special orthopedic shoes.
·       The patient was also recommended to loose weight as she is of a small stature with a body weight of over 100 kgs and a height of 157 meters.
·       The patient has also been advised prophylactic ozone therapy every 6-8 months. Ozone therapy is given here to decrease cholesterol accumulation in her blood vessels thereby decreasing the chances of vascular blockages being formed.
·       Present day: the patient has resumed all life activities and walks small distance of about 200metres without any kind of support. 
Report prepared by Institute of Medical Rehabilitation:
Director: Dr. Nikolenko Yuri M.D. PhD 
Dr. Andreas Demitrou M.D. PhD (President, Cyprus Medical Association)
Dr. Mayank Gaur M.D.; Dr. Valentina Nikolenko M.D.; Dr. Nikoletta Nikolenko M.D.

Patient B

Case report: Treatment of Diabetic ulcer with Ozone Therapy.

Patient B male, 62 years old has visited us in July 2004 for treatment with diagnosis of diabetic ulcer on the right metatarsal region just under the hallux (big toe). The patient has been suffering from diabetes mellitus type 2 for the last 15 years and has been receiving insulin and Glucophage tablets for it during this time.
The patient had been undergoing standard medical treatment for gangrenes of antibiotic therapy plus wound sanitation for the last 7 months with no effect. During this time as result of the medical treatment was not satisfactory a decision for amputation was taken.
Complaints: The patient came to our institute about 5 years ago with primary complaints of pain in the right foot.
Physical examination: on examination the patient was found to have a big ulcer on the metatarsal region of the foot with gangrene formation in the initial stages.
Treatment: High dosage I.V. Ozone therapy – 20 sessions accompanied by ozone bag for superficial wound healing.

·       On the 60th day of treatment initiation the patient started walking and wears shoes and works in an industrial unit.·       On the 22nd day of treatment initiation – the ulcer healed and scar formation was observed.
·       For the last 5 years the patient has been coming for prophylactic ozone therapy every 8 months.
·       Residive has not occurred for all this time.
Report prepared by Institute of Medical Rehabilitation:
Director: Dr. Nikolenko Yuri M.D. PhD 
Dr. Mayank Gaur M.D.; Dr. Valentina Nikolenko M.D.; Dr. Nikoletta Nikolenko M.D.

Patient C

Case report: Treatment of Trophic Ulcer in a diabetic patient with ozone therapy and surgical sanitation of the wound.

Patient C male, 72years old, has visited us for treatment of post amputative trophic ulcer of the right leg big toe. The Trophic ulcer did not heal with conservative treatment for a time period of two years. The patient suffered from severe pain and could not stand on his legs due to which he had to use crutches to move around, thereby, limiting his daily life activities.
Anamnesis: the patient suffers from diabetes mellitus type 2 and was taking Glucophage 500mg tablets 3times/day with insulin. The patient suffered from gangrene of the big toe about 6 months ago and surgical amputation procedure was performed. But the gangrene wound did not heal completely.
Treatment: High dosage I.V. Ozone therapy accompanied by ozone bags for superficial wound healing- 25 sessions were done. Pain was completely relieved by the end of the therapy.
Result: after 45 days of treatment initiation the gangrene/ulcer site was healed and the only visible sign was the presence of crusting over it.

·       Present day, the patient has only a keloid scar at the site of the ulcer.·       After 65 days of treatment initiation the ulcer completely closed and the patient started to walk without support and could wear shoes normally without any discomfort.
Report prepared by Institute of Medical Rehabilitation:
Director: Dr. Nikolenko Yuri M.D. PhD 
Dr. Mayank Gaur M.D.; Dr. Valentina Nikolenko M.D.; Dr. Nikoletta Nikolenko M.D.

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