MANNS surgery of foot and ankle

1. DIABETIC FOOT
Dr. Akasha Amber
JBRSC, LHR

4. 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

6. DEFINITION
• A pathology from diabetes mellitus or any long-term (or
"chronic") complication of diabetes mellitus.
• Several characteristic diabetic foot pathologies : diabetic
foot syndrome

7. 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

8. • 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

9. • Structural changes:
• Plantar skin Stiffness,callous formation
• Prolonged contact plantar pressure
• Joint changes: contracture, MTPJ extension, decreased range of
motion, decreased subtalar motion

11. 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.

13. MODIFIED WAGNER MEGGITT
CLASSIFICATION

15. SURGICAL PROBLEMS IN DIABETIC FOOT
• Charcot’s joints
• Ulceration
• Bone infection
• Exposed tendons
• Gangrene

16. 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

17. PATHOGENESIS OF CHARCOT JOINT
Osteoclastic/osteopenia activity
Repeated trauma,inflammation,
joint abnormality, tight ahilles,
abnormal mechanics,abnormal
pressure distribution hence
ulceration and continued injury

18. 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:

19. 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

22. • 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. PRINCIPALS
OF CARE OF
DIABETIC
FOOT

30. GRADE 0
• Treatment:
• Education & prevention
• Self foot care & proper shoes
• Antibiotics for cellulitis

31. GRADE 1
• Treatment:
• Wound care + antibiotics
• Radiological evaluation
• Modified weight bearing bone resection

32. GRADE 2
Treatment:
Hospitalisation
Debridement and IV antibiotics
Joint resection

33. GRADE 3
• Treatment:
• Debridement and IV antibiotics
• bone resection

34. GRADE 4
• Treatment:
• Similar to that for grade 3 + Local
amputation

35. GRADE 5
• Major amputation

36. AMPUTATIONS

37. COVERAGE OPTIONS
• Primary closure
• Secondary healing
• STSG
• NPWT
• Local flaps
• Free flaps
• Apligraf, demagraft, integra and other skin substitutes

38. THANKS