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Diabetic foot

MANNS surgery of foot and ankle

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Diabetic foot

  1. 1. DIABETIC FOOT Dr. Akasha Amber JBRSC, LHR
  2. 2. MUSCLE LAYERS OF SOLE • Superficial to deep • 1: Flexor digitorum brevis, abductor halluces, abductor digiti minimi • 2: Flexor digitorum longus, it’s associated Qaudratus Plantae,lumbricals, Flexor halucis longus • 3: small flexors: Flexor Haluucis Brevis, Flexor digiti minimi brevis, adductor hallucis • 4: dorsal & plantar interosseii muscles
  3. 3. DEFINITION • A pathology from diabetes mellitus or any long-term (or "chronic") complication of diabetes mellitus. • Several characteristic diabetic foot pathologies : diabetic foot syndrome
  4. 4. PATHOLOGY • Metabolic disease (insulin lack/insensitivity) • Loss of neutrophil function in protecting from infection • Inability to coat bacteria with antibiotics, loss of PM Lukocyts,macrophages, lymphocyte ability to phagocytose bacteria • Neuropathy • Sensory neuropathy • glycosylation products accumulation in vesa nervorum & ischemia to nerves • accumulation of sorbitol inside neurons> direct damage to neurons> inflammation> neurons swelling> double crush syndrome effect on nerves if they are present in a tight osseofibrous compartments(e.g tibial N in flexor tunnel ) • Autonomic neuropathy: • loss of skin sweating-dry,stiff scaly and callous with cracks; infection • loss of temp regulation • Motor neuropathy: • loss of foot intrinsic muscle function: loss of MP flexion and IP extension • Muscle atrophy>fibrosis and contractures-clawing of toes- dorsal toes ulceration (precedes hammer toe deformity) • Tightening of Achilles tendon • MONONEUROPATHY: most often peroneal nerve; foot drop ,equinus deformity
  5. 5. • Angiopathy: • Atherosclerotic changes in tunica media/calcified vessel wall • prox vessel occlusios,distal involvement • Hyperglycemia affects endothelial cells and smooth muscles in wall of vessel leading to microangipathies • Release of many vesocontricting mediators • End result: foor ischemia
  6. 6. • Structural changes: • Plantar skin Stiffness,callous formation • Prolonged contact plantar pressure • Joint changes: contracture, MTPJ extension, decreased range of motion, decreased subtalar motion
  7. 7. ULCERATION • Plantar pressure, size,location,depth of ulcer • neuropathy disability score, pulse palpation, and monofilament testing were the three most important tests in routine screening • Factors most significantly associated with ulceration included • neuropathy, • Joint/bone deformity, • callus, • elevated planta pressure, • peripheral vascular disease, • penetrating trauma, • footwear-related issues.
  8. 8. MODIFIED WAGNER MEGGITT CLASSIFICATION
  9. 9. SURGICAL PROBLEMS IN DIABETIC FOOT • Charcot’s joints • Ulceration • Bone infection • Exposed tendons • Gangrene
  10. 10. CHARCOT NEUROARTHROPATHY/CHARCOT JOINT, • NONINFECTIVE INFLAMMATION & DESTRCTION OF BONES AND JOINT as a result of peripheral neuropathy • Repeated trauma to neuropathic foot- continued weight bearing/gait cycles and hampering of repairdue to constant physical stress • Increased osteoclastic activity & osteopenia • DM(1&2), syphilis, leprosy or Hansen disease, charcoat marrie tooth disease, alcoholic or idiopathic peripheral neuropathy • Foot and ankle deformitites; abnormal shoe fitting, abnormal distribution of weight forces on foot • High pressure areas; ulceration; infection • Menifest as: Fracture,dislocation or subluxataion of joints or all
  11. 11. PATHOGENESIS OF CHARCOT JOINT Osteoclastic/osteopenia activity Repeated trauma,inflammation, joint abnormality, tight ahilles, abnormal mechanics,abnormal pressure distribution hence ulceration and continued injury
  12. 12. EICHENOLTZ(TEMPORAL) STAGING OF CHARCOT ARTHROPATHY • Stage 0: • only clinical signs of inflammation • No radiological sign on X-Ray but MRI scan shows bone edema • Stage 1: • acute inflammation (red,hot swollen foot) • Xray: fragmentation/dislocation/subluxation • Stage 2: • Coalescence (reparative), diminishing inflammation • New bone formation/sclerosis • Stage 3:
  13. 13. ANATOMIC CLASSIFICATION OF CHARCOT ARTHROPATHY • Brodsky classification on basis of region of foot involved • Type 1: midfoot- TMT joints or NaviculoCunieiform J • Type 2: hindfoot joints- TN, subtalar, calcaneocuboid • Type 3: • 3A: ankle joint , deformity, disability, surgical treatment/bracing • 3B: fracture of calcenum tubercle and secondary deformity &collapse of distal foot
  14. 14. • A: • minimal deformity with loss of arch height • B: • greater than A—with obvious plantar prominence • C: • severe destruction of both medial and lateral arch columns, • midfoot prominence more plantar than a line extrapolated from the heel to the ball of the foot beneath the metatarsal heads • Rocker bottom feet SEVERITY OF STAGE/COLLAPSE
  15. 15. EXAMINATION OF DIABETIC FOOT • Examine both limbs upto knee • Gait • Shoes fitting and type • Skin, nails, callous, cracks, shape of foot • Obvious deformity,heels, toe clawing, bunion, hallux valgus, charcot joint, loss of arches, cellulitic changes, ulcer(site,size, depth),tight Achilles tendon • Pulsations (palpate/Doppler) • Range of motion of all joints,strenth • Neurological exam: temperature, pin prick, vibration with tuning fork 128 HTz(vibratory perception threshold) , semmes Weinstein monofilament testing 5.07 with 10g pressure
  16. 16. MICHIGAN DIABETIC PERIPHERAL NEUROPATHY SCORE • Motor: • finger spread, extension of big toe, ankle dorsiflexion • Reflexes: • biceps,triceps, quadriceps, achilles • Sensory: • vibratory perception using tuning fork, pressure with semmes Weinstein monofilament testing • Pridicting ulceration in diabetic foot
  17. 17. INVESTIGATIONS • RBS,FBS, HbA1C, WBC, ESR • Culture swab • Xray foot • Doppler (arterial/venous) USG studies • Transcutaneous oxygen measurement • MRI (bone and soft tissue infection) • CT, Bone scan, Tc-labelled white blood cells scan, 2F-2D-dG PET SCAN
  18. 18. MANAGEMENT • Multiteam approach • Patient education about foot care • Painful peripheral neuropathies • Analgesic and anti-inflammatory combinations • (baclofen-preGabalin, TCA,tramal) • Motor neuropahy (mononeuropathy/foot drop; AFO splint) • Control of glucose level • Address the problem
  19. 19. PATIENT INSTRUCTIONS FOR DIABETIC FOOT CARE • Understand the Problem • Inspecting Your Feet • Washing Your Feet • Beware of Burns • Skin Care • Nail Care • Calluses and Corns • Stockings and Socks • Wearing Shoes
  20. 20. DIABETIC FOOT ULCER • Assess and grade, extent of wound, foot perfusion,infection • Modicfication of weight bearing/ pressure • Total contact cast(pressure relieving cast), AFO braces, custom fitting shoes, crutch/walker • Local wound care, NPWT • HBO therapy • Debridements, dressings,antibiotic according to culture/treat infection • Achilles tendon lengthening • Flexor tenotomies • Osteotomies • Amputations, soft tissue coverage
  21. 21. PRINCIPALS OF CARE OF DIABETIC FOOT
  22. 22. GRADE 0 • Treatment: • Education & prevention • Self foot care & proper shoes • Antibiotics for cellulitis
  23. 23. GRADE 1 • Treatment: • Wound care + antibiotics • Radiological evaluation • Modified weight bearing bone resection
  24. 24. GRADE 2 Treatment: Hospitalisation Debridement and IV antibiotics Joint resection
  25. 25. GRADE 3 • Treatment: • Debridement and IV antibiotics • bone resection
  26. 26. GRADE 4 • Treatment: • Similar to that for grade 3 + Local amputation
  27. 27. GRADE 5 • Major amputation
  28. 28. AMPUTATIONS
  29. 29. COVERAGE OPTIONS • Primary closure • Secondary healing • STSG • NPWT • Local flaps • Free flaps • Apligraf, demagraft, integra and other skin substitutes
  30. 30. THANKS
  • kunalsayani

    Nov. 28, 2019
  • way95

    Aug. 12, 2018
  • PoojaSaikia1

    Jun. 16, 2018
  • AymanAlkayyal

    May. 30, 2018
  • idrisUsman3

    May. 29, 2018
  • akashaamber

    May. 15, 2018

MANNS surgery of foot and ankle

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