This document discusses the surgical treatment of diabetic foot. It provides information on various aspects of diabetic foot including causes of foot problems in diabetes, pathways of diabetic foot ulcer, reasons foot lesions are often missed, importance of high clinical suspicion, concept of plantar spaces, assessment of vascular status, principles of debridement in diabetic foot with vasculopathy, wound healing in diabetes including advantages of moist wound environment and ideal dressing methods, causes of delayed healing, agents that can delay healing, importance of antibiotic therapy and domiciliary wound care services. It also discusses local/regional anesthesia techniques for diabetic foot surgery.
3. WHY DO DIABETES PATIENTSWHY DO DIABETES PATIENTS
GET FOOT PROBLEMS?GET FOOT PROBLEMS?
REASONSREASONS::
NEUROPATHYNEUROPATHY
VASCULOPATHYVASCULOPATHY
INJURYINJURY
Dr.bal
4. PATHWAYS FOR DIABETIC FOOT ULCER
VASCULOPATHY NEUROPATHY
MICROVASCULAR MACROVASCULAR AUTONOMIC MOTOR
SENSORY
SKIN ISCHAEMIA
SKIN DEVITALIZATION LARGE VESSEL
THROMBOSIS
DRY SKIN
PRURITIS
SMALL MUSCLE
WEAKNESS
FOOT DEFORMITY
EXTRA PRESSURE
POINT
LOSS OF
PAIN SENSATION
PAINLESS TRAUMA
FOOT
5. WHY DIABETIC FOOT LESIONSWHY DIABETIC FOOT LESIONS
ARE MANY A TIMES MISSED?ARE MANY A TIMES MISSED?
USUAL SIGNS AND SYMPTOMSUSUAL SIGNS AND SYMPTOMS
OF INFECTION ARE ABSENTOF INFECTION ARE ABSENT
PATIENT DOES NON COMPLAINPATIENT DOES NON COMPLAIN
OF PAINOF PAIN
LOW LEVEL OF AWARENESS ATLOW LEVEL OF AWARENESS AT
PRIMARY HEALTHCARE LEVELPRIMARY HEALTHCARE LEVEL
DIABETIC FOOT LESIONS AREDIABETIC FOOT LESIONS ARE
SILENTSILENT
Dr.bal
20. WHY FOOT NEEDS TO BEWHY FOOT NEEDS TO BE
SAVED IN DIABETES?SAVED IN DIABETES?
BK AMPUTATION REQUIRESBK AMPUTATION REQUIRES
40% MORE KCAL/MIN40% MORE KCAL/MIN
NET OXYGEN CONSUMPTIONNET OXYGEN CONSUMPTION
INCREASESINCREASES
NEEDS 5 -10 % EXTRANEEDS 5 -10 % EXTRA
CARDIAC RESERVECARDIAC RESERVE
85% MORTALITY AT THE END85% MORTALITY AT THE END
OF 5 YEARSOF 5 YEARS
21. HOW EARLY CON.AMPT.
SHOULD BE DONE?
• AS SOON AS PT.IS
HAEMODYNAMICALLY STABLE
• WITHIN 18-24 HOURS
• REGIONAL/LOCAL ANASTHESIA
• SEPTECEMIA CAN NOT BE
CONTROLLED WITHOUT EARLY
SURGERY
Dr.bal
22. GUIDELINES FOR EARLY
CON.AMPUTATION
• INDOOR CARE
• IMMEDIATE HAEMODYNAMIC
CONTROL
• EARLY SURGERY UNDER
REGIONAL/LOCALANASTHESIA
• PRE OP PARENTERAL ANTIBIOTICS
• PRE OP CREPE/COMP.BANDAGE
Dr.bal
23. GUIDELINES FOR EARLY
CON.AMPUTATION
• TOTAL DEROOFING OF AFFECTED
PLANTAR SPACE
• EXCISION OF ALL DEVITALISED
TISSUE AT THE FIRST ATTEMPT
• EXCISION OF AFFECTED TENDONS
TO ITS PROXIMAL EXTENT
• POST OP POST.PLANTAR SLAB
Dr.bal
24. GUIDELINES FOR EARLY
CON.AMPUTATION
• STRICT OFF LOADING OF THE
AFFECTED FOOT
• DRESSINGS WITH AGENTS WHICH
PROMOTE MOIST WOUND
ENVIRONMENT
• ORAL ANTIBIOTICS FOR 8-10
WEEKS
• RECONSTRUCTION/SSG
Dr.bal
25. GUIDELINES FOR EARLY
CON.AMPUTATION
• FOOTWEAR PLANNING
• FOOT EXCERCISES
• SCAR STRETCHING &
MANIPULATION
• GRADUAL MOBALISATION
• PATIENT EDUCATION FOR
PREVENTION OF FURTHER INJURY
Dr.bal
27. Why regional anaesthesia ?
1] Ideal for day-care patients
2] Safety in high risk patients
3] No intra-op regurgitation & aspiration
4] No PONV
5] Minimal alteration in drug schedule
-specially in diabetics
6) No change in diet schedule
28. Why regional anaesthesia ? Continued….
6] Minimal effects on vital parameters
7] Safer in emergency situations
8] Can be repeated frequently
9] Conscious & arousable patient
at the end of the surgery
10] Reduction in morbidity & mortality
29. Why not other modes of Anesthesia ??
General Anesthesia: [besides usual precautions]
a] Risk of Aspiration and PONV
b] Difficult intubations
c] Resistant hypotension which may last for longer time
d] Management of ischaemic changes and arrhythmias
e] Management of blood sugar
30. Why not other modes of Anesthesia ??
Spinal & Epidural Anesthesia
a] Prevention and management of hypotension
b] Cannot be repeated frequently
[ except in continuous epidural analgesia ]
especially for small but painful procedures.
31. Limitations
1] Surgical time limit is between
1-3 hrs.
2] Patient’s co-operation is must
3] Failure or partially acted block
32. Pre-block preparation
Counseling the patient
regarding the procedure
and the expectation from the patient
(compliance and accurate replies
regarding paresthesia)
33. Lower leg block or modified ankle block
Deep peroneal nerve – can be
blocked by injecting
subcutaneously
3-5 mm along the lat border
of the shin with 2 ml 2%
xylocaine with 24 g 1.5 inch
needle
34. Lower leg block or modified ankle block
Post. Tibial nerve –
Blocked by injecting
3-5 ml 2% xylocaine
at the junction of proximal 1/3rd
with distal 2/3rd of medial
malleolus to calcaneum, where
normally pulsations of post.
Tibial artery is felt.
35. Sural nerve
Inject 2% xylocaine
between the tendoachilles
and the calcaneaum on
the lateral aspect
Lower leg block or modified ankle block
36. Calcaneal nerve block
2 Finger breadths
proximal to the
medial malleolus
Inject along the
direction of the nerve
Lower leg block or modified ankle block
37. Practice regularly
Your patience
The surgeons’ patience
The patients’ patience!
Steps to success with local blocks
Patients’ comfort
The surgeons comfort
Your comfort
AND SAFETY!!
38. SURGICAL TREATMENT OFSURGICAL TREATMENT OF
DIABETIC FOOTDIABETIC FOOT
POST OPPOST OP
PLANTAR SLABPLANTAR SLAB
TO STABILIZETO STABILIZE
ANKLE JOINTANKLE JOINT
Dr.bal
43. ASSESSMENT OFASSESSMENT OF
VASCULAR STATUS INVASCULAR STATUS IN
DIABETIC FOOTDIABETIC FOOT
A/B INDEXA/B INDEX
SEGMENTAL PRESSURESEGMENTAL PRESSURE
MEASUREMENTMEASUREMENT
COLOUR DOPPLERCOLOUR DOPPLER
DUPLEX SCANDUPLEX SCAN
ANGIOGRAPHYANGIOGRAPHY
44. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC
FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY
PRE OP VASCULAR ASSESSMENTPRE OP VASCULAR ASSESSMENT
MANDATORYMANDATORY
LOCAL DEBRIDEMENT BEFORELOCAL DEBRIDEMENT BEFORE
REVASCULARIZATION IF WOUND ISREVASCULARIZATION IF WOUND IS
INFECTEDINFECTED
TOTAL DEBRIDEMENT AFTERTOTAL DEBRIDEMENT AFTER
REVASCULARIZATION TOREVASCULARIZATION TO
REDUCE/REMOVE NECROTIC LOADREDUCE/REMOVE NECROTIC LOAD
TOTAL OFF LOADING TILL WOUNDTOTAL OFF LOADING TILL WOUND
HEALSHEALS
45. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC
FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY
DIABETIC FOOTDIABETIC FOOT
GANGREME WITHGANGREME WITH
VASCULOPATHYVASCULOPATHY
46. DEBDRIDEMENT IN DIABETICDEBDRIDEMENT IN DIABETIC
FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY
MRANGIOGRAPHYMRANGIOGRAPHY
SHOWING BELOWSHOWING BELOW
KNEE VASCULARKNEE VASCULAR
BLOCKBLOCK
47. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC
FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY
POST OPPOST OP
RECURRENTRECURRENT
TENOSYNOVITISTENOSYNOVITIS
48.
49.
50.
51.
52.
53.
54.
55.
56. WOUND HEALING INWOUND HEALING IN
DIABETESDIABETES
ADVANTAGESADVANTAGES
OF MOISTOF MOIST
WOUNDWOUND
ENVIRONMENTENVIRONMENT
Dr.bal
57. PRINCIPLES OF DRESSING IN
DIABETIC FOOT WOUNDS
• MAINTAIN MOIST ENVIRONMENT
• NON ADEHERENT
• ABSORBABLE
• EASY TO USE MATERIAL
• COST EFFECTIVE
• PROMOTES HEALING
• REDUCES COLONISATION OF
BACT.
Dr.bal
58. CAUSES OF DELAYED/NON
HEALING IN DIABETIC FOOT
PRIMARY CAUSES
• INADEQUATE OFF LOADING
• INCORRECT VASCULAR
ASSESSMENT
• INADEQUATE PRELIMINARY
DEBRIDEMENT
Dr.bal
59. CAUSES OF DELAYED/NON
HEALING IN DIABETIC FOOT
SECONDARY CAUSES
• INADEQUATE ANTIBIOTIC
THERAPY
• NEPHROPATHY
• DRUGS
• ASSOCIATED TUBERCULOSIS
• INCORRECT METHOD OF
DRESSING Dr.bal
60. AGENTS THAT DELAY
WOUND HEALING IN
DIABETES
CORTICOSTEROIDS
NITROFURANTOIN
LIQUID DETERGENTS
NEOMYCIN SULPHATE
Dr.bal
61. AGENTS THAT DELAY WOUND
HEALING IN DIABETES
CHLORHEXIDINE 2%
POVIDONE IODINE 10%
EUSOL SOLUTION
HYDROGEN PEROXIDE
Dr.bal
62. IDEAL METHOD OF DRESSING
IN DIABETIC FOOT
• IRRIGATE WITH STERILE SALINE
• IMMEDIATE POST OP USE PARAFFIN
GAUZE
• FREQUENCY OF DRESSINGS DEPEMDS
UPON AMOUNT OF EXUDATE
• USE ANTI BACTERIAL OINT. TO REDUCE
COLONIZATION
• USEAFFIRDABLE, ACCESIBLE
MATERIAL TO MAINTAIN MOIST
WOUND ENVIRONMENT
Dr.bal
63. DIABETIC FOOT WOUNDSDIABETIC FOOT WOUNDS
NEED TO BENEED TO BE IRRIGATEDIRRIGATED
AND NOTAND NOT CLEANEDCLEANED
Dr.bal
65. ANTIBIOTIC THERAPY INANTIBIOTIC THERAPY IN
DIABETIC FOOTDIABETIC FOOT
NEEDED FOR PROLONGED DURATIONNEEDED FOR PROLONGED DURATION
COST OF THE ANTIBIOTICS ISCOST OF THE ANTIBIOTICS IS
IMPORTANT FACTORIMPORTANT FACTOR
ANEROBIC CULTUREANEROBIC CULTURE
DEERPER TISSUE CULTURESDEERPER TISSUE CULTURES
ANTIBIOTICS PROTOCOL FORANTIBIOTICS PROTOCOL FOR
INSTITUTIONSINSTITUTIONS
Dr.bal
66. MEDIAL ASPECT OF FOOT DEROOFED,
WIDELY DRAINED & EXICISION OF FLEXOR HALLLUSIS
LONGUS
Dr.bal
67. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC
FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY
PRE OP VASCULAR ASSESSMENTPRE OP VASCULAR ASSESSMENT
MANDATORYMANDATORY
LOCAL DEBRIDEMENT BEFORELOCAL DEBRIDEMENT BEFORE
REVASCULARIZATION IF WOUND ISREVASCULARIZATION IF WOUND IS
INFECTEDINFECTED
TOTAL DEBRIDEMENT AFTERTOTAL DEBRIDEMENT AFTER
REVASCULARIZATION TOREVASCULARIZATION TO
REDUCE/REMOVE NECROTIC LOADREDUCE/REMOVE NECROTIC LOAD
TOTAL OFF LOADING TILL WOUNDTOTAL OFF LOADING TILL WOUND
HEALSHEALS
Dr.bal
68.
69.
70.
71.
72. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC
FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY
DIABETIC FOOTDIABETIC FOOT
GANGREME WITHGANGREME WITH
VASCULOPATHYVASCULOPATHY
73. DEBDRIDEMENT IN DIABETICDEBDRIDEMENT IN DIABETIC
FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY
MRANGIOGRAPHYMRANGIOGRAPHY
SHOWING BELOWSHOWING BELOW
KNEE VASCULARKNEE VASCULAR
BLOCKBLOCK
74. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC
FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY
POST OPPOST OP
RECURRENTRECURRENT
TENOSYNOVITISTENOSYNOVITIS
86. SURGICAL TREATMENT OFSURGICAL TREATMENT OF
DIABETIC FOOTDIABETIC FOOT
HEALEDHEALED
BILATERALBILATERAL
PLANTARPLANTAR
ABCESS WITHABCESS WITH
TOTAL OFFTOTAL OFF
LOADING ANDLOADING AND
MOISTMOIST
ENVIRONMENTENVIRONMENT
DRESSINGSDRESSINGS
Dr.bal
89. SURGICAL TREATMENT OFSURGICAL TREATMENT OF
DIABETIC FOOTDIABETIC FOOT
DEFORMEDDEFORMED
FOOT IS BETTERFOOT IS BETTER
THAN ATHAN A
SOPHISTICATEDSOPHISTICATED
PROSTHESISPROSTHESIS
Dr.bal
90. SURGICAL TREATMENT OFSURGICAL TREATMENT OF
DIABETIC FOOTDIABETIC FOOT
REMOVAL OFREMOVAL OF
TENDONS OF FHLTENDONS OF FHL
AND T.POST FORAND T.POST FOR
TENOSYNOVITISTENOSYNOVITIS
WITH ABCESSWITH ABCESS
Dr.bal
129. THE DIABETIC FOOT
• IF OFF LOADING OF THE
AFFECTED FOOT IS NOT DONE
THEN PATIENT
WALKS TO DEATH
Dr.bal
130. TAKE HOME MESSAGESTAKE HOME MESSAGES
EARLY RADICAL DEBRIDEMENTEARLY RADICAL DEBRIDEMENT
UNDER REGIONAL/LOCALUNDER REGIONAL/LOCAL
ANASTHESIA CAN PREVENT LEGANASTHESIA CAN PREVENT LEG
AMPUTATION IN DIABETESAMPUTATION IN DIABETES
CORRECT VASCULARCORRECT VASCULAR
ASSESSMENT AND STRICT OFFASSESSMENT AND STRICT OFF
LOADING ARE KEYS TO SUCCESSLOADING ARE KEYS TO SUCCESS
IN DIABETIC FOOT SURGERYIN DIABETIC FOOT SURGERY
131. TAKE HOME MESSAGESTAKE HOME MESSAGES
AVOID USE OF DRESSINGAVOID USE OF DRESSING
MATERIAL WHICH PREVENTSMATERIAL WHICH PREVENTS
MOIST WOUND ENVIRONMENTMOIST WOUND ENVIRONMENT
CORRECTION OF FOOTCORRECTION OF FOOT
BIOMECHANICS AFTER WOUNDBIOMECHANICS AFTER WOUND
HELASHELAS
132. NEED TONEED TO
REVIVE THEREVIVE THE
AGE OLDAGE OLD
CULTURE OFCULTURE OF
FOOTCAREFOOTCARE
ANDAND
FOOTWEARFOOTWEAR
Dr.Bal