SURGICAL SURGICAL TREATMENT OF TREATMENT OF DIABETIC FOOTDIABETIC FOOT

DR.ARUN BALDR.ARUN BALMUMBAIMUMBAI

MANAGEMENT OF MANAGEMENT OF DIABETIC FOOTDIABETIC FOOT

DIABETIC DIABETIC

FOOTFOOT TREATMENT TREATMENT

IN 19IN 19THTH CENTURYCENTURY

Dr.bal

WHY DO DIABETES PATIENTS WHY DO DIABETES PATIENTS GET FOOT PROBLEMS?GET FOOT PROBLEMS?

REASONSREASONS::

NEUROPATHYNEUROPATHY VASCULOPATHYVASCULOPATHY INJURYINJURY

Dr.bal

PATHWAYS FOR DIABETIC FOOT ULCER

VASCULOPATHY NEUROPATHYMICROVASCULAR 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 ULCERATIONDr.bal

WHY DIABETIC FOOT LESIONS WHY DIABETIC FOOT LESIONS ARE MANY A TIMES MISSED?ARE MANY A TIMES MISSED?

USUAL SIGNS AND SYMPTOMS USUAL SIGNS AND SYMPTOMS OF INFECTION ARE ABSENTOF INFECTION ARE ABSENT

PATIENT DOES NON COMPLAIN PATIENT DOES NON COMPLAIN OF PAINOF PAIN

LOW LEVEL OF AWARENESS AT LOW LEVEL OF AWARENESS AT PRIMARY HEALTHCARE LEVELPRIMARY HEALTHCARE LEVEL

DIABETIC FOOT LESIONS ARE DIABETIC FOOT LESIONS ARE SILENTSILENT

Dr.bal

HIGH INDEX OF HIGH INDEX OF SUSPICIONSUSPICION

Dr.bal

DIABETIC FOOT LESIONS DIABETIC FOOT LESIONS ARE LIKEARE LIKE

ICEBERGICEBERG ONLY SMALL PART IS VISIBLEONLY SMALL PART IS VISIBLE

Dr.bal

SURFICAL TREATMENT OF SURFICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

CENTRAL CENTRAL PLANTAR PLANTAR SPACE SPACE ABCESSABCESS

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

CENTRAL CENTRAL PLANTAR PLANTAR SPACE ABCESS SPACE ABCESS AFTER TOTAL AFTER TOTAL DEROOFINGDEROOFING

ICEBERG ICEBERG PHENOMENONPHENOMENON

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

CENTRAL CENTRAL PLANTAR PLANTAR SPACE SPACE ABCESS ABCESS

PRE PRE OPERATIVEOPERATIVE

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

CENTRAL CENTRAL PLANTAR PLANTAR SPACE ABCESS SPACE ABCESS AFTER TOTAL AFTER TOTAL DEROOFING DEROOFING ICE ICE BERG BERG PHENOMENONPHENOMENON

Dr.bal

NO COMPLAINT NO COMPLAINT NO NO

EXAMINATIONEXAMINATION

Dr.bal

TYPES OF INJURIES IN TYPES OF INJURIES IN DIABETIC FOOTDIABETIC FOOT

SHOE BITESHOE BITE HOME SURGERYHOME SURGERY INSECT/RAT BITEINSECT/RAT BITE THERMAL INJURYTHERMAL INJURY FOREIGN BODY INJURYFOREIGN BODY INJURY VIGOROUS MASSAGEVIGOROUS MASSAGE CHEMICAL INJURYCHEMICAL INJURY

Dr.bal

DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES

HOME HOME SURGERYSURGERY

Dr.bal

DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES

THERMAL THERMAL INJURYINJURY

Dr.bal

DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES

THERMAL THERMAL INJURYINJURY

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DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES

CHEMICAL CHEMICAL INJURYINJURY

dlDr.bal

DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES

GANGRENE GANGRENE

FOLLOWING FOLLOWING VIGOROUS VIGOROUS MASSAGEMASSAGE

Dr.bal

DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES

SHOE BITESHOE BITE

Dr.bal

WHY FOOT NEEDS TO BE WHY FOOT NEEDS TO BE SAVED IN DIABETES?SAVED IN DIABETES?

BK AMPUTATION REQUIRES 40% BK AMPUTATION REQUIRES 40% MORE KCAL/MINMORE KCAL/MIN

NET OXYGEN CONSUMPTION NET OXYGEN CONSUMPTION INCREASESINCREASES

NEEDS 5 -10 % EXTRA CARDIAC NEEDS 5 -10 % EXTRA CARDIAC RESERVERESERVE

85% MORTALITY AT THE END OF 85% MORTALITY AT THE END OF 5 YEARS5 YEARS

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

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

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

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/SSGDr.bal

GUIDELINES FOR EARLY CON.AMPUTATION

• FOOTWEAR PLANNING• FOOT EXCERCISES• SCAR STRETCHING &

MANIPULATION• GRADUAL MOBALISATION• PATIENT EDUCATION FOR

PREVENTION OF FURTHER INJURY

Dr.bal

LOCAL/REGIONAL LOCAL/REGIONAL ANASTHESIA FOR ANASTHESIA FOR DIABETIC FOOT DIABETIC FOOT

SURGERYSURGERY

Dr.bal

Why regional anaesthesia ?

1] Ideal for day-care patients2] Safety in high risk patients3] No intra-op regurgitation & aspiration4] No PONV5] Minimal alteration in drug schedule -specially in diabetics6) No change in diet schedule

Why regional anaesthesia ? Continued….

6] Minimal effects on vital parameters7] Safer in emergency situations8] Can be repeated frequently9] Conscious & arousable patient at the end of the surgery10] Reduction in morbidity & mortality

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

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.

Limitations

1] Surgical time limit is between1-3 hrs.

2] Patient’s co-operation is must3] Failure or partially acted block

Pre-block preparation

Counseling the patient regarding the procedureand the expectation from the patient(compliance and accurate replies regarding paresthesia)

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

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.

Sural nerve

Inject 2% xylocaine between the tendoachilles and the calcaneaum on the lateral aspect

Lower leg block or modified ankle block

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

Practice regularlyYour patienceThe surgeons’ patienceThe patients’ patience!

Steps to success with local blocks

Patients’ comfortThe surgeons comfortYour comfortAND SAFETY!!

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

POST OP POST OP PLANTAR SLAB PLANTAR SLAB TO STABILIZE TO STABILIZE ANKLE JOINTANKLE JOINT

Dr.bal

CONCEPT OF CONCEPT OF PLANTAR SPACESPLANTAR SPACES

CONCEPT OF PLANTAR SPACES

PLANTAR SPACES

ASSESSMENT OF ASSESSMENT OF VASCULAR STATUS IN VASCULAR STATUS IN

DIABETIC FOOTDIABETIC FOOTA/B INDEXA/B INDEXSEGMENTAL PRESSURE SEGMENTAL PRESSURE

MEASUREMENTMEASUREMENTCOLOUR DOPPLERCOLOUR DOPPLERDUPLEX SCANDUPLEX SCANANGIOGRAPHYANGIOGRAPHY

DEBRIDEMENT IN DIABETIC DEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY

PRE OP VASCULAR ASSESSMENT PRE OP VASCULAR ASSESSMENT MANDATORYMANDATORY

LOCAL DEBRIDEMENT BEFORE LOCAL DEBRIDEMENT BEFORE REVASCULARIZATION IF WOUND IS REVASCULARIZATION IF WOUND IS INFECTEDINFECTED

TOTAL DEBRIDEMENT AFTER TOTAL DEBRIDEMENT AFTER REVASCULARIZATION TO REVASCULARIZATION TO REDUCE/REMOVE NECROTIC LOADREDUCE/REMOVE NECROTIC LOAD

TOTAL OFF LOADING TILL WOUND TOTAL OFF LOADING TILL WOUND HEALSHEALS

DEBRIDEMENT IN DIABETIC DEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY

DIABETIC FOOT DIABETIC FOOT GANGREME WITH GANGREME WITH VASCULOPATHYVASCULOPATHY

DEBDRIDEMENT IN DIABETIC DEBDRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY

MRANGIOGRAPHY MRANGIOGRAPHY SHOWING BELOW SHOWING BELOW KNEE VASCULAR KNEE VASCULAR BLOCKBLOCK

DEBRIDEMENT IN DIABETIC DEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY

POST OP POST OP RECURRENT RECURRENT TENOSYNOVITISTENOSYNOVITIS

WOUND HEALING IN WOUND HEALING IN DIABETESDIABETES

ADVANTAGES ADVANTAGES OF MOIST OF MOIST WOUND WOUND ENVIRONMENTENVIRONMENT

Dr.bal

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

CAUSES OF DELAYED/NON HEALING IN DIABETIC FOOT

PRIMARY CAUSES• INADEQUATE OFF LOADING• INCORRECT VASCULAR

ASSESSMENT• INADEQUATE PRELIMINARY

DEBRIDEMENT

Dr.bal

CAUSES OF DELAYED/NON HEALING IN DIABETIC FOOT

SECONDARY CAUSES• INADEQUATE ANTIBIOTIC

THERAPY• NEPHROPATHY• DRUGS• ASSOCIATED TUBERCULOSIS• INCORRECT METHOD OF

DRESSINGDr.bal

AGENTS THAT DELAY WOUND HEALING IN

DIABETES

CORTICOSTEROIDSNITROFURANTOINLIQUID DETERGENTSNEOMYCIN SULPHATE

Dr.bal

AGENTS THAT DELAY WOUND HEALING IN DIABETES

CHLORHEXIDINE 2%POVIDONE IODINE 10%EUSOL SOLUTIONHYDROGEN PEROXIDE

Dr.bal

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

DIABETIC FOOT WOUNDS DIABETIC FOOT WOUNDS NEED TO BE NEED TO BE IRRIGATED IRRIGATED

AND NOTAND NOT CLEANED CLEANED

Dr.bal

DOMICIALLARY WOUND CARE SERVICES

Dr.bal

ANTIBIOTIC THERAPY IN ANTIBIOTIC THERAPY IN DIABETIC FOOTDIABETIC FOOT

NEEDED FOR PROLONGED DURATIONNEEDED FOR PROLONGED DURATIONCOST OF THE ANTIBIOTICS IS COST OF THE ANTIBIOTICS IS

IMPORTANT FACTORIMPORTANT FACTORANEROBIC CULTUREANEROBIC CULTUREDEERPER TISSUE CULTURESDEERPER TISSUE CULTURESANTIBIOTICS PROTOCOL FOR ANTIBIOTICS PROTOCOL FOR

INSTITUTIONSINSTITUTIONS

Dr.bal

MEDIAL ASPECT OF FOOT DEROOFED,

WIDELY DRAINED & EXICISION OF FLEXOR HALLLUSIS LONGUS

Dr.bal

DEBRIDEMENT IN DIABETIC DEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY

PRE OP VASCULAR ASSESSMENT PRE OP VASCULAR ASSESSMENT MANDATORYMANDATORY

LOCAL DEBRIDEMENT BEFORE LOCAL DEBRIDEMENT BEFORE REVASCULARIZATION IF WOUND IS REVASCULARIZATION IF WOUND IS INFECTEDINFECTED

TOTAL DEBRIDEMENT AFTER TOTAL DEBRIDEMENT AFTER REVASCULARIZATION TO REVASCULARIZATION TO REDUCE/REMOVE NECROTIC LOADREDUCE/REMOVE NECROTIC LOAD

TOTAL OFF LOADING TILL WOUND TOTAL OFF LOADING TILL WOUND HEALSHEALS

Dr.bal

DEBRIDEMENT IN DIABETIC DEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY

DIABETIC FOOT DIABETIC FOOT GANGREME WITH GANGREME WITH VASCULOPATHYVASCULOPATHY

DEBDRIDEMENT IN DIABETIC DEBDRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY

MRANGIOGRAPHY MRANGIOGRAPHY SHOWING BELOW SHOWING BELOW KNEE VASCULAR KNEE VASCULAR BLOCKBLOCK

DEBRIDEMENT IN DIABETIC DEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY

POST OP POST OP RECURRENT RECURRENT TENOSYNOVITISTENOSYNOVITIS

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

RECONSTRUCTION OF RECONSTRUCTION OF FORE FOOT ULCER FORE FOOT ULCER WITH WITH NEUROVASCULAR NEUROVASCULAR FLAPFLAP

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

RECONSTRUCTION RECONSTRUCTION OF CHRONIC MID OF CHRONIC MID FOOT ULCER IN FOOT ULCER IN CHARCOT`S FOOTCHARCOT`S FOOT

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

CLOSURE OF FORE CLOSURE OF FORE FOOT ULCERFOOT ULCER

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SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

RECONSTRUCTION RECONSTRUCTION OF CHRONIC HEEL OF CHRONIC HEEL ULCERULCER

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SURGICAL TREATMENT OF CHARCOT`S FOOT

SURGICAL TREATMENT OF CHARCOT`S FOOT

SURGICAL TREATMENT OF CHARCOT`S FOOT

SURGICAL TREATMENT OF CHARCOT`S FOOT

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

BILATERAL BILATERAL FOOT FOOT ABCESSESSABCESSESS

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

HEALED HEALED

BILATERAL BILATERAL PLANTAR PLANTAR ABCESS WITH ABCESS WITH TOTAL OFF TOTAL OFF LOADING AND LOADING AND MOIST MOIST ENVIRONMENT ENVIRONMENT DRESSINGSDRESSINGS

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

BILATERAL BILATERAL DEFORMED DEFORMED WALKABLE WALKABLE FOOTFOOT

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

DEFORMED DEFORMED FOOT IS BETTER FOOT IS BETTER THAN A THAN A SOPHISTICATED SOPHISTICATED PROSTHESISPROSTHESIS

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

REMOVAL OF REMOVAL OF TENDONS OF FHL TENDONS OF FHL AND T.POST FOR AND T.POST FOR TENOSYNOVITIS TENOSYNOVITIS WITH ABCESSWITH ABCESS

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

HEEL ABCESS HEEL ABCESS FOLLOWING FOLLOWING INFECTED INFECTED FISSURESFISSURES

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

TOTAL TOTAL

DEROOFING DEROOFING OF HEEL OF HEEL ABCESSABCESS

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SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

NECROTISING NECROTISING

FASCITISFASCITIS PRE PRE

OPERATIVEOPERATIVE

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

NECROTISING NECROTISING FASCITIS FASCITIS AFTER TOTAL AFTER TOTAL DEROOFING DEROOFING ICEBERG ICEBERG PHENOMENONPHENOMENON

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

HEALED HEALED MEDIAL MEDIAL PLANTAR PLANTAR SPACE SPACE ABCESSABCESS

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT

HEALED HEALED CENTRAL CENTRAL PLANTAR PLANTAR SPACE SPACE ABCESSABCESS

Dr.bal

SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIEBTIC FOOTDIEBTIC FOOT

HEALED HEALED

LATERAL LATERAL PLANTAR PLANTAR SPACE SPACE ABCESSABCESS

Dr.bal

TEAM WORKTEAM WORK

Dr.bal

PATIENT IS MOST PATIENT IS MOST IMPORTANT IMPORTANT

MEMBER OF THE MEMBER OF THE TEAMTEAM

DIABETIC FOOT SURGERY

ADEQUATE DRAINAGE OF INFECTION

Dr.bal

DIABTIC FOOT SURGERY

FOOT EXPLORATION

ST.VINCENT`S ST.VINCENT`S DECLARATIONDECLARATION

TO REDUCE THE TO REDUCE THE MAJOR AMPUTAIONS MAJOR AMPUTAIONS DUE TO DIABETES BY DUE TO DIABETES BY 50% IN 5 YEARS50% IN 5 YEARS

Dr.bal

THE DIABETIC FOOT

• IF OFF LOADING OF THE AFFECTED FOOT IS NOT DONE THEN PATIENT

WALKS TO DEATH

Dr.bal

TAKE HOME MESSAGESTAKE HOME MESSAGESEARLY RADICAL DEBRIDEMENT EARLY RADICAL DEBRIDEMENT

UNDER REGIONAL/LOCAL UNDER REGIONAL/LOCAL ANASTHESIA CAN PREVENT LEG ANASTHESIA CAN PREVENT LEG AMPUTATION IN DIABETESAMPUTATION IN DIABETES

CORRECT VASCULAR CORRECT VASCULAR ASSESSMENT AND STRICT OFF ASSESSMENT AND STRICT OFF LOADING ARE KEYS TO SUCCESS LOADING ARE KEYS TO SUCCESS IN DIABETIC FOOT SURGERYIN DIABETIC FOOT SURGERY

TAKE HOME MESSAGESTAKE HOME MESSAGESAVOID USE OF DRESSING AVOID USE OF DRESSING

MATERIAL WHICH PREVENTS MATERIAL WHICH PREVENTS MOIST WOUND ENVIRONMENTMOIST WOUND ENVIRONMENT

CORRECTION OF FOOT CORRECTION OF FOOT BIOMECHANICS AFTER WOUND BIOMECHANICS AFTER WOUND HELAS HELAS

NEED TO NEED TO REVIVE THE REVIVE THE AGE OLD AGE OLD CULTURE OF CULTURE OF FOOTCARE FOOTCARE AND AND FOOTWEARFOOTWEAR

Dr.Bal

THANK YOUTHANK YOU