"SOME INTERESTING SURGICAL ISSUES IN

DIABETIC FOOT",

"SOME INTERESTING SURGICAL ISSUES IN

DIABETIC FOOT",

Prof.Rama Prof.Rama KantKant

IF THEY ARE TREATED IF THEY ARE TREATED LIKE THIS-IT IS NO LIKE THIS-IT IS NO

BETTER……BETTER……

The Diabetic FootThe Diabetic Foot

Collection Collection of foot of foot problems problems which occur which occur more more commonly in commonly in diabetic diabetic patientspatients

FactsFacts

Commonest cause of Commonest cause of hospitalization in DMhospitalization in DM

US 2/3US 2/3rdrd of non of non traumatic amputationstraumatic amputations

MAJOR ISSUES DETERMING SURGICAL MAJOR ISSUES DETERMING SURGICAL OUTCOME & HEALINGOUTCOME & HEALING

• INFECTIONINFECTION• VASCULARITYVASCULARITY• NEUROPATHYNEUROPATHY• DEFORMITIESDEFORMITIES• EXTENT OF SURGERY AND DRESSINGSEXTENT OF SURGERY AND DRESSINGS• AGGRESSIVE DEBRIDEMENTS VS AGGRESSIVE DEBRIDEMENTS VS

AMPUTATIONSAMPUTATIONS• PREVENTIVE AND PROPHYLACTIC SURGERYPREVENTIVE AND PROPHYLACTIC SURGERY• PREVENTIVE SOCIETAL PROGRAMS PREVENTIVE SOCIETAL PROGRAMS

INNOVATIVE FLAPSINNOVATIVE FLAPSOFFLOADING DEVICESOFFLOADING DEVICESMODIFIED SHOEMODIFIED SHOECOUNSELINGCOUNSELING

Aetiology of the Diabetic FootAetiology of the Diabetic Foot

NeuropathyNeuropathy

Reduced response to infectionReduced response to infection

IschaemiaIschaemia

Deformities & Deformities & traumatrauma

InfectionInfection

METICULOUS METICULOUS PHYSICAL PHYSICAL EXAMINATION EXAMINATION OF FOOT AND OF FOOT AND FOOTWEARFOOTWEAR

Proper examination

NEUROPATHY,ISCHAEMIA, DEFORMITY, PRESSURE POINTS, ULCERATION, INFECTION, TOXAEMIA,MULTI ORGAN FAILURE.

EXAMINATION INCOMPLETE EXAMINATION INCOMPLETE WITHOUT PROBINGWITHOUT PROBING

EXAMINATION INCOMPLETE EXAMINATION INCOMPLETE WITHOUT PROBINGWITHOUT PROBING

Common deformities Common deformities ignored:ignored:

i.i. CallusCallusii.ii.BunionBunioniii.iii.Hammer toesHammer toesiv.iv.Claw toesClaw toesv.v. Charcot footCharcot footvi.vi.Nail deformitiesNail deformities

Examination of foot is not Examination of foot is not complete without examination complete without examination of Footwaresof Footwares

1

Neuropathic Foot ChangesNeuropathic Foot Changes

Clawing/Retraction of Clawing/Retraction of minor digitsminor digits

Atrophy of plantar fatty Atrophy of plantar fatty padpad

Restricted ROM of jointsRestricted ROM of joints

Muscle wastingMuscle wasting

Warm feet Warm feet

Changes to joint Changes to joint alignmentalignment

Skin anhydrosisSkin anhydrosis

Charcot ArthropathyCharcot Arthropathy

High Index of High Index of suspicionsuspicion

DiabeticDiabetic

Hot / red / swellingHot / red / swelling

Trauma - minor / Trauma - minor / majormajor

Pain + / -Pain + / -

Architectural Architectural DisruptionDisruption

Ulcer + / -Ulcer + / -

BASIC DIFFERENCE IN REACTION OF BASIC DIFFERENCE IN REACTION OF TISSUE IN DIABETICS AND NON TISSUE IN DIABETICS AND NON DIABETICS IN RESPONSE TO TRAUMA DIABETICS IN RESPONSE TO TRAUMA OR INFECTIONOR INFECTION

DIABETICS RESPOND BY DIABETICS RESPOND BY NECROSIS AND NECROSIS AND THROMBOSISTHROMBOSIS WHILEWHILE

NON DIABETICS RESPOND NON DIABETICS RESPOND BY INFLAMMATIONBY INFLAMMATION

COLOR DOPPLERCOLOR DOPPLER

• INVESTIGATIONS

BIOASTHESIOMETER

BIOASTHESIOMETER

PRESSURE STUDIES

The Foot ScanThe Foot Scan The Mat The Mat ScanScan

PEAK PRESSURE

PLOT

Red:High Pressure

Blue:Low Pressure

Heel pressure reduced, contact time increased

Hallux: Contact time

below average range. Peak

Pressure at 40 PSI

Hallux: Contact time increased to

average range while

pressure is reduced to

30 PSI

Pressure Distribution Without and With OrthoticPressure Distribution Without and With Orthotic

Diabetic Vascular DiseaseDiabetic Vascular Disease

Large vessel diseaseLarge vessel diseasecommoncommon

early age of onsetearly age of onset

rapid progressionrapid progression

Microvascular diseaseMicrovascular diseasepresence in limbs controversialpresence in limbs controversial

retinal and renal lesions commonretinal and renal lesions common

Assessment of Foot PerfusionAssessment of Foot Perfusion

SubjectiveSubjectivepalpation of pulsespalpation of pulses

ObjectiveObjectiveDoppler pressures (ankle/brachial index)Doppler pressures (ankle/brachial index)

toe pressurestoe pressures

NB:ABI unreliable in diabetes/renal failure/ NB:ABI unreliable in diabetes/renal failure/ rheumatoid arthritis/leg swellingrheumatoid arthritis/leg swelling

Toe Toe PressurPressur

eses

Toe PressuresToe Pressures

Better predictors of wound healingBetter predictors of wound healing

DiabeticsDiabetics toe pressuretoe pressure <40mmHg <40mmHg skin perfusion pressureskin perfusion pressure healing very healing very

unlikelyunlikely

40 to 60mmHg 40 to 60mmHg healing likelyhealing likely

Diabetic Foot InfectionDiabetic Foot Infection

Polymicrobial - gram (+) cocci, gram (-) Polymicrobial - gram (+) cocci, gram (-) bacilli and anaerobesbacilli and anaerobes

Redness and swelling may not be Redness and swelling may not be presentpresent

Suspect if deterioration in glycaemic Suspect if deterioration in glycaemic controlcontrol

Unusual foot pain with no fracture etcUnusual foot pain with no fracture etc

WHAT NOT TO DO?WHAT NOT TO DO?

AggressiveAggressive VS VS

Limited Limited

debridementdebridement

CHANGE YOUR PERCEPTION

STILL THERE IS HOPE…………

CHANGE YOUR PERCEPTION

STILL THERE IS HOPE…………

Aggressive debridement

Aggressive debridement

Debridement must be thorough Debridement must be thorough and include all dead tissue. and include all dead tissue. Tendons are best cut under Tendons are best cut under tension to allow them to retract tension to allow them to retract away from the open wound. away from the open wound.

Look for evidence of pus coming Look for evidence of pus coming down tendon sheaths this down tendon sheaths this indicates more extensive indicates more extensive debridement.debridement.

This might have to be done several times but when indicated it must be done promptly…..

This might have to be done several times but when indicated it must be done promptly…..

CENTRAL

PLANTAR

SPACE

ABSCESS

CENTRAL

PLANTAR

SPACE

ABSCESS

AFTER TOTAL DEROOFING

ICEBERG PHENOMENON

AFTER TOTAL DEROOFING

ICEBERG PHENOMENON

3 Days later

12 days later-USE OF PDGF STARTED

17 DAYS LATER17 DAYS LATER REFUSED SKIN

GRAFTING

REFUSED SKIN

GRAFTING

21 DAYS LATER21 DAYS LATER

27 DAYS LATER27 DAYS LATER

33 DAYS LATER33 DAYS LATER

MESH GRAFTINGMESH GRAFTING

Diabetic Foot SepsisDiabetic Foot Sepsis

Surgical principlesSurgical principles

Drain pus urgently / immediatelyDrain pus urgently / immediately

Xray foot Xray foot

Assess perfusionAssess perfusion

Debride necrotic tissueDebride necrotic tissue

Revascularise early if requiredRevascularise early if required

MRI useful to assess soft tissuesMRI useful to assess soft tissues

If ischemia present If ischemia present it must be corrected it must be corrected

OROR

measures to treat measures to treat infection/neuropathy infection/neuropathy

will failwill fail

The concept of small vessel disease The concept of small vessel disease is erroneous and has no place in is erroneous and has no place in management of diabetic footmanagement of diabetic foot

Distribution similar to Distribution similar to atherosclerosisatherosclerosis

Foot arteries almost always sparedFoot arteries almost always spared

Management - MedicalManagement - Medical ↓ ↓ Progression of diseaseProgression of disease

Stop smokingStop smoking

Rx predisposing factorsRx predisposing factors

Foot careFoot care

Treat Depression-Expert counseling Treat Depression-Expert counseling of Patient and relatives.of Patient and relatives.

Management - Management - interventionintervention

Endovascular Endovascular Balloon angioplasty +/- StentBalloon angioplasty +/- Stent

SurgerySurgery BypassBypass

Anatomical Anatomical

Aorto-bifemoralAorto-bifemoral

Ileo-femoralIleo-femoral

Femoro-popliteal Femoro-popliteal

Extra-anatomicalExtra-anatomical

Axillo-bifemoralAxillo-bifemoral

Femoro-femoralFemoro-femoral

• Impaired vasodilation in neuropathic Impaired vasodilation in neuropathic lower extremity leads to functional lower extremity leads to functional ischemiaischemia

• Which improves considerably but is Which improves considerably but is not completely corrected with not completely corrected with successful bypass grafting surgery.successful bypass grafting surgery.

• Thus, these patients may still be at Thus, these patients may still be at

high risk for foot ulceration or high risk for foot ulceration or failure to heal despite adequate failure to heal despite adequate correction of large vessel blood flow.correction of large vessel blood flow.

Concept of Concept of

supermicrosurgerysupermicrosurgery, , introduced by Koshima et al,introduced by Koshima et al,1 has has increased the popularity of increased the popularity of

perforator flaps and perforator flaps and lymphatic surgery.lymphatic surgery. It is now possible to anastomose It is now possible to anastomose smaller-caliber vessels and perform smaller-caliber vessels and perform microvascular dissection of vessels microvascular dissection of vessels ranging from 0.3 to 0.8 mm in ranging from 0.3 to 0.8 mm in diameter. diameter.

This is required for most distal This is required for most distal

digital amputations. digital amputations.

PROCEDURES

NEEDED QUITE

FREQUENTLY

BUT UNFORTUNATELY

DONE RARELY

PROCEDURES

NEEDED QUITE

FREQUENTLY

BUT UNFORTUNATELY

DONE RARELY

PARTIAL CALCANECTOMYPARTIAL CALCANECTOMY

X-RAY

SESAMOID BONE

FLEXOR TENOTOMYFLEXOR TENOTOMY

GROWTH FACTORSGROWTH FACTORS

HYPOTHESIS HYPOTHESIS

• GF have many activities that make them attractive agents for stimulating tissue repair.

• They attract cells into the wound, stimulate their proliferation, and have profound influence on extracellular matrix deposition.

• Hundreds of studies have demonstrated that growth factors can augment all aspects of tissue repair in normal and impaired healing models.

• GF have many activities that make them attractive agents for stimulating tissue repair.

• They attract cells into the wound, stimulate their proliferation, and have profound influence on extracellular matrix deposition.

• Hundreds of studies have demonstrated that growth factors can augment all aspects of tissue repair in normal and impaired healing models.

“In the old days we only had to know saline and gauze”

• HydrocolloidHydrocolloid

• HydrogelHydrogel

• Calcium alginateCalcium alginate

• FoamFoam

• CollagenaseCollagenase

• AntimicrobialsAntimicrobials

•Growth factorsGrowth factors • Matrix enhancing agentsMatrix enhancing agents

THEREFORETHEREFORE

•APPLICATION OF GROWTH FCATORS

•CHANGE IN DRESSING TECHNIQUES

•APPLICATION OF GROWTH FCATORS

•CHANGE IN DRESSING TECHNIQUES

• GF APPLICATION occasionally led to statistically significant improvements in tissue repair, but whether the results are clinically significant is

debatable.

• GF APPLICATION occasionally led to statistically significant improvements in tissue repair, but whether the results are clinically significant is

debatable.

Six wise men of Hindustan Six wise men of Hindustan

WOUND HEALING

CounselingCounseling by by expert expert PsychologistsPsychologists

Foot clinic reduces the

referral rate for Major

amputation to almost zero

Foot clinic reduces the

referral rate for Major

amputation to almost zero

Pressure Off-LoadingPressure Off-Loading

Total Contact CastDiabetic Air

Walker

MODIFIED SHOES OFFLOADING PRESSURE

POINTS

MODIFIED SHOES OFFLOADING PRESSURE

POINTS

• Skin careSkin care• Regular ChiropodyRegular Chiropody• Nail careNail care• Diabetic FootwearDiabetic Footwear• Diabetic SocksDiabetic Socks• Diabetic InsolesDiabetic Insoles• Oedema controlOedema control

• Skin careSkin care• Regular ChiropodyRegular Chiropody• Nail careNail care• Diabetic FootwearDiabetic Footwear• Diabetic SocksDiabetic Socks• Diabetic InsolesDiabetic Insoles• Oedema controlOedema control

Socks

SILICONE SILICONE INSOLEINSOLE

TCI Insole

WALKING AIDSWALKING AIDS

Circulator Boot SystemsHeart Monitor, Valve Assemblies and Miniboots and Long Boots

WALKING AIDSWALKING AIDS

Depression Therapy: Can It Facilitate Improved Self-Care Among People With Diabetes

Depression Therapy: Can It Facilitate Improved Self-Care Among People With Diabetes

SURE IT CAN CHANGE RESULTS

One day everything will be well — that is our hope. Everything is fine today — that is our illusion.

One day everything will be well — that is our hope. Everything is fine today — that is our illusion.

THANK YOU !!THANK YOU !!