1. "SOME INTERESTING SURGICAL ISSUES IN DIABETIC FOOT", "SOME INTERESTING SURGICAL ISSUES IN DIABETIC FOOT", Prof.Rama Kant

6. IF THEY ARE TREATED LIKE THIS-IT IS NO BETTER……

8. The Diabetic Foot Collection of foot problems which occur more commonly in diabetic patients Collection of foot problems which occur more commonly in diabetic patients

9. Facts Commonest cause of hospitalization in DM US 2/3 rd of non traumatic amputations

14. MAJOR ISSUES DETERMING SURGICAL OUTCOME & HEALING INFECTION INFECTION VASCULARITY VASCULARITY NEUROPATHY NEUROPATHY DEFORMITIES DEFORMITIES EXTENT OF SURGERY AND DRESSINGS EXTENT OF SURGERY AND DRESSINGS AGGRESSIVE DEBRIDEMENTS VS AMPUTATIONS AGGRESSIVE DEBRIDEMENTS VS AMPUTATIONS PREVENTIVE AND PROPHYLACTIC SURGERY PREVENTIVE AND PROPHYLACTIC SURGERY PREVENTIVE SOCIETAL PROGRAMS PREVENTIVE SOCIETAL PROGRAMS INNOVATIVE FLAPS OFFLOADING DEVICES MODIFIED SHOE COUNSELING

16. Aetiology of the Diabetic Foot Neuropathy Reduced response to infection Ischaemia Deformities & trauma Infection Infection

17. METICULOUS PHYSICAL EXAMINATION OF FOOT AND FOOTWEAR

19. Proper examination

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

25. EXAMINATION INCOMPLETE WITHOUT PROBING

27. Common deformities ignored: i. Callus ii. Bunion iii. Hammer toes iv. Claw toes v. Charcot foot vi. Nail deformities Examination of foot is not complete without examination of Footwares Examination of foot is not complete without examination of Footwares 1

28. Neuropathic Foot Changes Clawing/Retraction of minor digits Atrophy of plantar fatty pad Restricted ROM of joints Muscle wasting Warm feet Changes to joint alignment Skin anhydrosis

29. Charcot Arthropathy High Index of suspicion Diabetic Hot / red / swelling Trauma - minor / major Pain + / - Architectural Disruption Ulcer + / -

30. BASIC DIFFERENCE IN REACTION OF TISSUE IN DIABETICS AND NON DIABETICS IN RESPONSE TO TRAUMA OR INFECTION DIABETICS RESPOND BY NECROSIS AND THROMBOSIS WHILE NON DIABETICS RESPOND BY INFLAMMATION

31. COLOR DOPPLER

32. INVESTIGATIONS BIOASTHESIOMETER

33. PRESSURE STUDIES The Foot Scan The Mat Scan The Foot Scan The Mat Scan

34. PEAK PRESSURE PLOT

35. 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 Orthotic

36. Diabetic Vascular Disease Large vessel disease common early age of onset rapid progression Microvascular disease presence in limbs controversial retinal and renal lesions common

37. Assessment of Foot Perfusion Subjective palpation of pulses Objective Doppler pressures (ankle/brachial index) toe pressures

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

40. Toe Pressures

41. Better predictors of wound healing Diabetics Diabetics toe pressure<40mmHg  toe pressure<40mmHg  skin perfusion pressurehealing very unlikely skin perfusion pressurehealing very unlikely 40 to 60mmHg  healing likely

42. Diabetic Foot Infection Polymicrobial - gram (+) cocci, gram (-) bacilli and anaerobes Redness and swelling may not be present Suspect if deterioration in glycaemic control Unusual foot pain with no fracture etc

44. WHAT NOT TO DO?

48. Aggressive VS Limited Limited debridement debridement

50. CHANGE YOUR PERCEPTION STILL THERE IS HOPE………… CHANGE YOUR PERCEPTION STILL THERE IS HOPE…………

51. Aggressive debridement Debridement must be thorough and include all dead tissue. Tendons are best cut under tension to allow them to retract away from the open wound. Look for evidence of pus coming down tendon sheaths this indicates more extensive debridement.

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

53. CENTRAL PLANTAR SPACE ABSCESS

54. AFTER TOTAL DEROOFING ICEBERG PHENOMENON

62. 3 Days later

63. 12 days later-U SE OF PDGF STARTED

64. 17 DAYS LATER REFUSED SKIN GRAFTING

65. 21 DAYS LATER

66. 27 DAYS LATER

67. 33 DAYS LATER

76. MESH GRAFTING

79. Diabetic Foot Sepsis Surgical principles Drain pus urgently / immediately Xray foot Assess perfusion Debride necrotic tissue Revascularise early if required MRI useful to assess soft tissues

92. If ischemia present it must be corrected If ischemia present it must be corrected OR OR measures to treat infection/neuropathy measures to treat infection/neuropathy will fail will fail

93. The concept of small vessel disease is erroneous and has no place in management of diabetic foot The concept of small vessel disease is erroneous and has no place in management of diabetic foot Distribution similar to atherosclerosis Distribution similar to atherosclerosis Foot arteries almost always spared Foot arteries almost always spared

94. Management - Medical ↓ Progression of disease ↓ Progression of disease Stop smoking Rx predisposing factors Foot care Treat Depression-Expert counseling of Patient and relatives. Treat Depression-Expert counseling of Patient and relatives.

95. Management - intervention Endovascular Balloon angioplasty +/- Stent SurgeryBypassAnatomicalAorto-bifemoralIleo-femoralFemoro-popliteal Extra-anatomical Extra-anatomical Axillo-bifemoral Axillo-bifemoral Femoro-femoral Femoro-femoral

96. Impaired vasodilation in neuropathic lower extremity leads to functional ischemiaImpaired vasodilation in neuropathic lower extremity leads to functional ischemia Which improves considerably but is not completely corrected with successful bypass grafting surgery.Which improves considerably but is not completely corrected with successful bypass grafting surgery. Thus, these patients may still be at high risk for foot ulceration or failure to heal despite adequate correction of large vessel blood flow.Thus, these patients may still be at high risk for foot ulceration or failure to heal despite adequate correction of large vessel blood flow.

104. Concept of supermicrosurgery, introduced by Koshima et al, 1 has increased the popularity of perforator flaps and lymphatic surgery. 1 It is now possible to anastomose smaller- caliber vessels and perform microvascular dissection of vessels ranging from 0.3 to 0.8 mm in diameter. This is required for most distal digital amputations.

105. PROCEDURES NEEDED QUITE FREQUENTLY BUT UNFORTUNATELY DONE RARELY PROCEDURES NEEDED QUITE FREQUENTLY BUT UNFORTUNATELY DONE RARELY

107. PARTIAL CALCANECTOMY

110. X-RAY SESAMOID BONE

112. FLEXOR TENOTOMY

114. GROWTH FACTORS GROWTH FACTORS

115. 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.

120. “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

121. THEREFORE APPLICATION OF GROWTH FCATORS CHANGE IN DRESSING TECHNIQUES APPLICATION OF GROWTH FCATORS CHANGE IN DRESSING TECHNIQUES

124. 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.

125. Six wise men of Hindustan WOUND HEALING

126. Counseling by expert expert Psychologists Psychologists

127. Foot clinic reduces the referral rate for Major amputation to almost zero

128. Pressure Off-Loading Total Contact Cast Diabetic Air Walker

131. MODIFIED SHOES OFFLOADING PRESSURE POINTS

132. 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

133. Socks

134. SILICONE INSOLE

135. TCI Insole

139. WALKING AIDS

140. Circulator Boot Systems Heart Monitor, Valve Assemblies and Miniboots and Long Boots

141. WALKING AIDS

142. Depression Therapy: Can It Facilitate Improved Self-Care Among People With Diabetes SURE IT CAN CHANGE RESULTS

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

146. THANK YOU !! THANK YOU !!