DIABETIC FOOT Dr Mohit Jain Associate Professor Plastic Surgery MLN Medical College Allahabad

WHO – 1995 Group of syndromes in which neuropathy, ischemia and infection lead to tissue breakdown resulting in morbidity and possible amputation

“PAIN – The gift nobody wants” Paul Brand

What we should know Pathophysiology Types of Ulcers Management Prevention

Predisposing factors Peripheral neuropathy – 80% - sensory - motor - autonomic Peripheral vascular disease - atherosclerosis of large vessels Combination of both - neuroischemic

Pathophysiology- neuropathy Increased intraneural concentration of sorbitol causes nerve damage Double crush syndrome Hyperglycemia causes decreased ability of neutrophils, macrophages and lymphocytes to destroy bacteria Decreased ability to coat bacteria with antibiotics

Pathophysiology - neuropathy autonomic neuropathy motor neuropathy sensory neuropathy anhidrosis / hyperkeratosis altered foot structure repeated trauma decreased pain Skin breakdown Wound/bacterial entry Infection

CHARCOT’S FOOT

Pathophysiology- vasculopathy Misconception - small vessels affected Outcome of ulcer dependant on existence of vascular disease Simple clinical examination clinches diagnosis Angiography required in some cases

Determine Aetiology Neuropathic? Vascular? Mixed? Predominant pathology Determine wound management Act quickly

Management of neuropathic ulcers Treat infection Debridement of callus Reduce pressure Restrict walking Dressings

Management of ischaemic ulcers Vascular assessment and treatment Treat infection Pain management Dressings Avoid compression/ bandaging

Treatment goals Control infection Improve blood supply Optimise wound healing environment Protect wound from trauma

LOCAL AGENTS “Never put anything in the wound, which you will NOT put in your eyes Adequate debridement Irrigation Normal saline dressings Chlorhexidine Antimicrobial ointments Paraffin dressings

Debridement (Act Quick) Clean bone margins must be achieved Revision surgery frequently needed Extensive unroofing in severe necrosis Rubber drains may not work Closure when infection is controlled

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