SURGICAL ASPECTS AND THEIR

MANAGEMENT IN DIABETIC FOOT

DR. KAILASH CHANDRA MOHAPATRA

ENDOCRINE & DIABETIC FOOT SURGEON

PROFESSOR,
POST GRADUATE DEPT. OF SURGERY
S.C.B MEDICAL COLLEGE,CUTTACK
73 million diabetics = 146 million feet
in India !!!
to be cared for
 BACKGROUND
 The commonest reason for hospitalization of
diabetic patients.
 India ranks second (after China) with more than
73 million diabetics.
 Lifetime risk of a person with diabetes having a
foot ulcer could be as high as 25%.
 One-fourth of diabetic foot ulcers ultimately leads
to amputation.
 85% of non-traumatic lower limb amputations are
seen in patients with prior history of diabetic foot
ulcer.
 The vast majority of these are preventable.
 A TEAM CONCEPT-
 Many medical and surgical specialties come together in
the treatment of diabetic foot.
 Vascular surgeon.
 Plastic & reconstructive surgeon
 Orthopaedician
 Physician
 Endocrinologist
 Podiatrist
 Orthotist
 Microbiologist
 Above all general surgeon devoted for diabetic foot
surgery.
“MULTIDISCIPLINARY APPROACH”
 ROLE OF SURGEON IN DIABETIC
FOOT MANAGEMENT
 From pre-operative assessment through
debridement - foot sparing amputation -
wound care – complete closure of wound –
rehabilitation & prevention of recurrent
ulceration.
 Through out this period the diabetic foot
care surgeon makes an integrated approach
taking help of diabetologist, reconstructive
surgeon,vascular surgeon podiatrist,
orthotist etc…
 FAST TRACK CLINIC

 Prompt diagnosis and early institution of

treatment is cornerstone of management to
save limb.
 Surgery conducted as early as possible as
soon as the hemodynamic stability is
achieved
 Preferably in 24 hours of admission
 Delay leads to spread of infection, necrosis
and gangrene
 Non-emergent surgical procedures
 Bunionectomy
 Hammer toe repair
 Ingrowing toe nail removal
 Metatarsal osteotomy
 Sesamoidectomy
 Metatarsal osteotomy
 Charcot exostectomy
 Achilles tendon lengthening
 Metatarsal head resection(single)
 Panmetatarsal head resection
 Keller arthoplasty
 Metatarsophalangeal or inter phallangeal joint resection
 Plantar mid-foot exostectomy
 Partial foot amputation like-digital, ray and syme
 Partial calcanectomy
 Emergent surgical procedures
 Diabetic foot infections :
-Moderate to severe.
-Limb to life threatening.
(Except mild or non limb threatening)
 Necrotising fascitis.
 Abscess.
 Osteomyelitis.
 Goal is to arrest progression of infection to save life,
to bring back the patient from sepsis to normalcy and
to keep as much of viable tissue as possible in the
foot to achieve a mechanically stable functional foot.
 DIABETIC FOOT INFECTIONS – AN
ICEBERG PHENOMENON
 Most unwarranted & dreaded
complications of diabetic foot,
 Limb as well as life is at risk.
 Should be accomplished as early as
possible & aggressively.
 Aim is to remove all grossly necrotic tissues and
drain abscess cavity leaving behind apparently
healthy tissues.
 A quick vascular assessment (noninvasive), like
ABI should be undertaken.
 Compartmental syndrome
 Compartmental syndrome leading to
thrombosis of vessels (end arteries); acute
strangulation, extensive necrosis and
gangrene may ensue hence early
intervention to salvage the foot.
 Knowledge of surgical anatomy of the foot
& patho-physiological behavior of
infection is essential for successful surgical
debridement .
Compartmental syndrome
 Anatomy of the foot and
foot spaces

Transverse section of the foot:

1, lateral compartment; 2, central
compartment; 3, medial compartment;
4, interosseous compartment. Arrows
indicate the high-pressure areas that
often lead to foot ulceration.
The plantar surface of the foot:
1, lateral compartment; 2, central
compartment; 3, medial
compartment.
TRIPLE JEOPARDY

Neuropathy

Vasculopathy

Immunopathy
 March of events

Ulcer Infection Necrosis Gangrene Amputation

Point of no return
IMAGING MODALITIES REQUIRED FOR
SURGICAL TREATMENT PLANNING :

 Plain radiography.
 Ultrasonography.
 CT scan.
 M.R.I scan.
Microbiology of diabetic foot infection

NON LIMB-THREATENING INFECTION:

 Mostly Gm(+) cocci, like Staph aureus &
Group B Streptococcus.

LIMB-THREATENING INFECTION
 Polymicrobial – 4.1 - 5.8 bacterial
species/culture.
 Gm(+) cocci & Gm(-) rods are predominant
pathogens, anaerobes in 40% cases.
 Pre-ulcerative signs
Blister

Callus Ingrown nail

 Surgical debridement of
diabetic foot
 Is a challenging & skillful technique .
 Understanding foot anatomy is essential.
 Experience of the surgeon.
 Debridement means foot exploration,
removal of all macroscopic devitalized
tissues is the key to the success of
healing.
 Debridement(contd…)

 Should always be done surgically

(scalpel) rather than by chemical or
enzymatic agents.
 Early surgical intervention will reduce
the duration of hospitalization and
amputation.
 Failure to decompress involving
compartments and excision of necrotic
tissues increases the risk of amputation.
 Debridement (contd…..)
 Preferred debridement technique is early
aggressive debridement with conservative
amputation. This is a highly acclaimed
procedure with a good success rate.
 Individualized approach considering age,
sex,socio-economic status of the patient as
partial foot is acceptable in indian context
than no foot.
 A remnant can be fitted to a good orthotic
device for carrying out day today activities.
 (C)
(A)

RADICAL DEBRIDEMENT

(D)

(B)
 MAINTENANCE DEBRIDEMENT

 Following first debridement.

 After initial surgery left out or newly

formed necrotic tissues are taken care of.

 This is carried out regularly till healthy

granulation.
 ADVANCED THERAPIES
 Growth factors
 Stem cell treatment
 Bioengineered skin
 New debriding instruments like ultrasonic,
versajet and Laser
 Maggots therapy
 Vacuum assisted closure therapy
VACUUM ASSISTED CLOSURE
DAILY INSPECTION AND CARE
OF THE WOUND
 OFF-LOADING.
 ANTIBIOTICS AS PER C/S.
 WET TO DRY DRESSING.
 THOROUGH CLEANSING WITH
NORMAL SALINE.
 ADVANCED WOUND CARE PRODUCTS
ESPECIALLY – GROWTH
FACTORS,HYDROCOLLOIDS,ALGINATE
S & NANO SILVER DEPENDING ON THE
SITUATION
HOW WOUND CLOSES AFTER
DEBRIDEMENT
 PRIMARY CLOSURE.
 SECONDARY CLOSURE.
 DELAYED PRIMARY.
 V.A.C (VACUUM ASSISTED
CLOSURE).
 SKIN GRAFTING.
 FLAPS.
 HEALING BY SKIN GRAFTING

HEALING BY SECONDARY
INTENTION RECURRENT ULCER

FLAP RECONSTRUCTION
TO COVER TENDO-ACHILLES
 ANAESTHESIA IN DIABETIC
FOOT SURGERY
 Regional and local anesthesia preferred
over GA.
 Early morning surgery.
 During surgery hypoglycemia to be
avoided.
 Close monitoring of the patient in peri-
operative period, preferably in surgical
ICU for 24-48 hrs.
 ANTIBIOTICS IN DIABETIC
FOOT

 Initially empiric followed by culture

specific antibiotic.
 Specimen for culture should be taken from
the depth of the wound such as necrotic
tissue, deep pus & necrotic bone or joint
component.
 Anaerobic culture also should be done.
Selected antibiotic regimens for initial
empiric therapy for foot infections in
diabetic patients
NON LIMB Cephalexin,Clindamycin,amoxycl
av,dicloxacillin,levocloxacillin &
THREATENING moxifloxacin,all oral for 1-2
weeks.
Ceftriaxone+clindamycin
LIMB THREATENING
Cipro+clindamycin
Ampicillin+sulbactam
Linezolide+floroqunolone
Piperacillin+tazobactam
Floroquinolone+metronidazole
Ertapenem

LIFE THREATENING Imipenem+cilastatin

Piperacillin/tazobactam+gentami
cin
Vancomycin+genta+metron
 Management of Osteomyelitis
 Incidence - around 30%.
 Probe test positive.
 In early stage imaging studies may be
negative.
 M.R.I is helpful.
Medical
 Long term antibiotic & rest.
 Amputation only if medical treatment
fails.
 Surgical management of Osteomyelitis

- Curettage of bone.
- Excision of bone
- Bone biopsy & C/S, followed by
antibiotics(6-12 weeks, depending on
sensitivity).
Recently medical management is preferred
over surgical management as later
involves removal of a part of foot.
 NECROTISING FASCITIS
 Severe form of infection characterized by extensive
& rapidly progressing large areas of necrosis of skin & soft
tissues with toxemia.
 Early recognition & prompt
institution of treatment with
antibiotics, rest, long incisions and
fasciotomy are essential.
 TREATMENT-
Long and multiple fasciotomies,
excision of gangrenous skin &
underlying necrotic tissues + C/S antibiotics
 ABSCESS
 Abscess may involve underlying tissues & may be limited to one
or several foot compartments.
 Large areas of necrosis of soft tissues with proximal extension is a
common finding.
 Ankle and foot tuberculosis – as non-healing sinus
 Plain X-ray shows gas & soft tissue
shadow.
 USG is helpful in deep seated
abscess or foreign body.
 TREATMENT-
-Deroofing with removal of
surrounding necrotic tissues.
-Heal secondarily
 De-roofing of abscess and excision of
necrotic tissues.

Ray amputation with clearance of all

necrotic tissues.
 Classification of amputation-
 Ray amputation.
 Transmetatarsal & lisfranc’s amputation.
 Chopart amputation –disarticulation through
mid tarsal joint.
 Syme’s amputation - transmalleolar.
 Below knee - trans tibial.
Sita washing feet of Ram
Krishna washing feet of Sudama