Diabetic foot refers to a range of complications that can occur in individuals with diabetes, particularly those who have poor blood sugar control over an extended period of time. It is a serious condition that can lead to various foot problems, such as ulcers, infections, and even amputations if not properly managed. The underlying cause of diabetic foot is neuropathy, which is nerve damage that occurs due to high blood sugar levels. Neuropathy can lead to loss of sensation in the feet, making it difficult for individuals to detect injuries or areas of pressure. Additionally, diabetes can impair blood circulation, which reduces the body's ability to heal wounds effectively.

2. Diabetic Foot
Dr Faiz Naeem
House Officer
Surgical unit II

3. References
• International working group on diabetic foot( IWGDF)
• European Wound Management Association (EWMA)
• World Federation of Societies of Anesthesiologist's (WFSA)
• American diabetic association (ADA)
• The Society of vascular surgery (SVS)
• Canadian journal of cardiology (CJC)
• Schwartz principle of surgery
• Bailey and love’s
• Medscape
• Davidson principle of surgery

4. CONTENTS
• Definition
• Classification
• Pathophysiology
• History and examination
• Diagnosis
• Management
• Foot Care

5. DEFINITION
Diabetic foot is infection, ulceration or destruction of tissues of the foot
associated with neuropathy and/or peripheral artery disease in the lower
extremity of a person with (a history of) diabetes mellitus.

6. Classification
Wegner Classification

8. Pathophysiology

9. Mechanism
• Activation of polyol pathway
• Down-regulation of intracellular myoinositol
• Dysfunction of protein kinase C
• Inhibition of Na/K/ ATPase
• Increased free radical
• Nerve blood flow degradation

11. Sensory Neuropathy
• Loss of pain sensation
• Unnoticed trauma
• Progressive Callous formation
• Tissue damage and necrosis
• Subcutaneous fluid collection and hemorrhage
• Tissue breakdown
• Ulcer formation

12. Motor Neuropathy
• Weakness of intrinsic foot muscles
• Progressive muscle wasting
• Foot deformities and joint subluxations
• Limited joint mobility
• Abnormal gait
• Chronic internal pressure
• Ulceration

13. Autonomic Neuropathy
• Decreased sweating
• Dry and brittle skin
• Fissures and Cracks
• Secondary infections
• Ulceration

14. Diabetic Vasculopathy
In Diabetes, there is microangiopathy and macroangiopathy that contributes to the ulcer formation and non-healing of the
diabetic foot.
1. Macroangiopathy:
Atherosclerosis of large arteries
2. Microangiopathy:
Increased thickness of basement membrane
• Decreased local blood flow means
• Poor antibiotic penetration
• Poor wound healing

17. History
In the diagnosis of diabetic foot ulcers or pre-ulcerative lesions, the following should be taken into account:
• History of trauma
• History of puncture wound (with or without shoe gear)
• History of change in shoe gear
• History of deformity, either acquired or congenital
• History of callus or blister
• History of wound care management
• History of offloading
• Local signs of infection
• Systemic signs of infection

18. Examination of Ulcer
Accomplish the following in examination of ulceration
• Determine the location of the ulceration, as ulcers are typically located around bony prominences and
weight-bearing surfaces; typical locations include the dorsal interphalangeal joints of hammertoes and distal
tips of digits, below metatarsal heads in claw toes, the medial and lateral forefoot in patients with bunions
and bunionettes, plantar lateral wounds in Charcot foot, and the lateral foot and lateral malleoli in varus
deformities
• Measure the size, including the depth of the wound
• Describe the wound base (granular, fibrotic, necrotic, eschar)
• Inspect for probing to bone
• Inspect for any undermining or tunneling of the wound
• Describe any drainage
• Describe the periwound area (maceration, hyperkeratotic tissue)

19. Examination of Feet
• Inspect the static posture of the feet on the examination table, as well as when weight-bearing.
• ​Assess for gross deformities and determine if they are reducible or rigid
• Assess ankle range of motion using the Silfverskiöld test - If there is limited ankle dorsiflexion
(cannot pass neutral) with the knee both flexed and extended, it is considered gastrocsoleal
tightness; if there is increased dorsiflexion with the knee flexed, however limited with the knee
in extension, it is considered gastrocnemius equinus
• Assess range of motion at the interphalangeal joints, metatarsophalangeal joints, midtarsal
joints, and subtalar joints
• Evaluate muscle power of dorsiflexors, plantar flexors, invertors, and evertors to identify any
muscular imbalances
• Examine the skin for dryness and fissures, as well as for discrete calluses; hemorrhagic
calluses in particular are a sign of impending foot ulceration.

20. Assessment of Peripheral Neuropathy
The nylon monofilament test helps diagnose the presence of sensory
neuropathy.
• Loss of vibratory and position sense
• Loss of deep tendon reflexes (especially loss of the ankle jerk)
• Trophic ulceration
• Foot drop
• Muscle atrophy
• Excessive callous formation

21. IWGDF Guidelines
In 2019, the International Working Group on the Diabetic Foot (IWGDF) published
an update to its evidence-based guidelines on diabetic foot disease prevention and
management.
• An individual with diabetes who is at very low risk for foot ulceration (IWGDF risk
0) should, to assess the subsequent risk for ulcers, be examined annually for
signs or symptoms of protective sensation loss and peripheral artery disease
• A patient with diabetes who has protective sensation loss or peripheral artery
disease (IWGDF risk 1-3) should undergo a more comprehensive examination,
with the following taken into account: history, vascular status, skin, bone/joint,
protective sensation loss, footwear, poor foot hygiene, physical limitations that
may hinder self care of the feet (eg, problems with visual acuity, obesity), and
foot care knowledge

23. Workup
• CBC
• RBS
• RFTs
• HbA1C
• ESR &CRP
• Plain Radiography
• CT&MRI
• Bone scan
• Ankle Brachial index
• Ultrasonography
• Transcutaneous tissue oxygen studies
• Angiography

24. Management
• Offloading the wound
• Daily saline or similar dressings to provide a moist wound environment
• Debridement when necessary
• Antibiotic therapy with or without surgical intervention if osteomyelitis or
soft tissue infection is present
• Control of blood glucose
• Evaluation and correction of peripheral arterial insufficiency.

25. Pressure Offloading
For patients with a neuropathic plantar ulcer, a nonremovable knee-high offloading device—ie,
either a total contact cast (TCC) or a removable walker that is rendered irremovable by the
provider who fits the device—is the preferred offloading treatment
In patients who cannot tolerate a nonremovable, knee-high offloading device, or if such a device is
contraindicated, a removable version can be considered.
In the absence of other forms of biomechanical relief, felted foam, in combination with appropriate
footwear, can be considered.
While offloading remains important in the presence of infection or ischemia, greater caution is
necessary.

27. Restoration of tissue perfusion
• When ankle pressure is below 50 mmHg or the ankle brachial index (ABI) is less
than 0.5, urgent vascular imaging and, in the presence of appropriate findings,
revascularization, should be considered; revascularization should also be
considered if the toe pressure is below 30 mmHg or the transcutaneous pressure
of oxygen (TcpO 2) is less than 25 mmHg; however, revascularization may be
considered at higher pressures should extensive tissue loss or infection occur
• If optimal treatment does not result in ulcerative healing signs within 6 weeks,
revascularization should be considered, regardless of the outcomes of the
above-mentioned vascular tests
• If an above-the-ankle amputation is being contemplated, revascularization should
first be considered as an option.

32. EWMA Local wound care
The European Wound Management Association (EWMA) states that the emphasis in
wound care for DFUs should be on radical and repeated debridement, frequent
inspection and bacterial control and careful moisture balance to prevent maceration.
Its position document on wound bed preparation suggests the following TIME
framework for managing DFUs.
• Tissue debridement
• Inflammation and infection control
• Moisture balance (optimal dressing selection)
• Epithelial edge advancement.

33. Treatment of Infection
• For a superficial ulcer with limited soft tissue (mild) infection - The ulcer
should be cleansed and all necrotic tissue and surrounding callus should
be debrided; start empiric oral antibiotic therapy directed
against Staphylococcus aureus and streptococci.
• For deep or extensive infection - The need for surgical intervention to
remove necrotic tissue, including infected bone, should be urgently
evaluated, empiric, parenteral, broad-spectrum antibiotic therapy aimed
at common gram-positive and gram-negative bacteria, including obligate
anaerobes, should be initiated; the clinical response to empirical therapy,
along with culture and sensitivity results, should be used to adjust the
antibiotic regimen

38. Debridement
• Debridement is a procedure for treating a wound in the skin. It
involves thoroughly cleaning the wound and removing all
hyperkeratotic (thickened skin or callus), infected, and nonviable
(necrotic or dead) tissue, foreign debris, and residual material.

39. SHARP DEBRIDEMENT
Hyperkeratotic, infected, and nonviable tissue is surgically removed using a
scalpel or special scissors. The benefits of sharp debridement are
• Removes necrotic tissue and callus
• Reduces pressure
• Helps drainage of secretion or pus
• Stimulates healing

40. Autolytic Debridement
This uses the body's own enzymes
and moisture to re-hydrate, soften, and
liquefy non-viable tissue. Autolytic
debridement is selective so that only
necrotic tissue is liquefied. Autolytic
debridement can be achieved with
hydrocolloids, hydrogels and
transparent films.

41. Enzymatic Debridement
Chemical enzymes, derived from
microorganisms including clostridium,
histolyticum, collagenase, varidase,
papain, and Bromelian, are used
to slough off necrotic tissue.

42. Mechanical Debridement
Wet-to-dry dressings, such as wet gauze
dressings, are the most common treatment.
Wet gauze treatments are also a treatment
option for some necrotizing wounds because
they pull necrotic debris out of the wound and
transfer it into the gauze.

43. Maggots Debridement
A small number of a special species of
maggots are introduced into the ulcer.
These eat only the dead skin and
produce chemicals that promote
healing.

44. Epithelial edge advancement
• It is important to debride the edges of the ulcer to remove potential physical
barriers to the growth of the epithelium across the ulcer bed.
• The demarcation line between any necrotic tissue or gangrene and healthy
tissue may become a site of infection.
• Similar problems can be seen when a gangrenous toe touches a
healthy toe.

45. Wound Dressing
• The role of a wound dressing is to provide the optimum conditions
for wound healing, whilst protecting the wound from further trauma
and invasion by pathogenic microorganisms.

48. Amputation
There are three broad indications for
amputation of any body part, as
follows :
Dead
Deadly
Dead loss

49. • TOE AMPUTATION: At level of proximal phalanx. It should not be done
through the joint because it exposes cartilage and the fluid secreted there
and causes delayed wound healing.
• RAY AMPUTATION: Through metatarsal bone, a racket shaped incision
through the metatarsal head
• TRANSMETATARSAL AMPUTATION: Metatarsals at mid shaft level,
done when there is gangrene of several toes
• SYME’s AMPUTATION: Tibia and fibula are separated

50. • Ankle disarticulation: removing the foot after separating it from the lower leg at the ankle
• Below-the-knee amputation: removing the foot and part of the lower leg by cutting across
the bones of the lower leg (tibia and fibula)
• Knee disarticulation: removal of the lower leg by separating it from the upper leg at the
knee
• Above-the-knee amputation: removal of the lower leg, the knee and part of the upper leg by
cutting across the upper leg bone (femur)
• Hip disarticulation: removal of the entire leg by separating it from the pelvis at the hip joint
• Pelvic amputation, or hemipelvectomy: removal of the entire leg and part of the pelvis

51. Amputation Levels

52. Ray Amputation

53. Trans metatarsal Amputation

54. Symes Amputation

55. Lisfranc Amputation

57. Stump care
• It's very important to keep the skin on the surface of your stump clean to reduce the risk of
it becoming irritated or infected.
• Gently wash your stump at least once a day (more frequently in hot weather) with mild
unscented soap and warm water, and dry it carefully.
• If you have a prosthetic limb, you should also regularly clean the socket using soap and
warm water.
• When taking a bath, avoid leaving your stump submerged in water for long periods because
the water will soften the skin on your stump, making it more vulnerable to injury.
• If your skin becomes dry, use an unscented moisturizing cream before bedtime or when
you're not wearing your prosthesis.

58. Post Operative complications
Early Complications
• Hemorrhage which requires return to operation theater for homeostasis.
• Hematoma needs evacuation.
• Abscess needs drainage and antibiotics cover .
• DVT and PE needs prophylaxis with subcutaneous heparin.

59. Late complications
• Phantom limb
• Phantom pain
• Unresolved infection
• Bone spur
• Scar adherent to bone
• Amputation Neuroma