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

2. LUCKNOW

3. KING GEORGE MEDICAL UNIVERSITY

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

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

14. MAJOR ISSUES DETERMING SURGICAL OUTCOME & HEALING • INFECTION • VASCULARITY • NEUROPATHY • DEFORMITIES • EXTENT OF SURGERY AND DRESSINGS • AGGRESSIVE DEBRIDEMENTS VS AMPUTATIONS • PREVENTIVE AND PROPHYLACTIC SURGERY • 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

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. 1 Common deformities ignored: • Callus • Bunion • Hammer toes • Claw toes • Charcot foot • Nail deformities • Examination of foot is not complete without examination of Footwares

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

34. PEAK PRESSURE PLOT

35. Pressure Distribution Without and With Orthotic Red: High Pressure Blue: Low Pressure Hallux: Contact time below average range. Peak Pressure at 40 PSI Heel pressure reduced, contact time increased Hallux: Contact time increased to average range while pressure is reduced to 30 PSI

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. Toe Pressures Better predictors of wound healing Diabetics • toe pressure <40mmHg  • skin perfusion pressure healing 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 debridement

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