1362566341 surgical treatment of diabetic foot
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Transcript of 1362566341 surgical treatment of diabetic foot
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
Dr.bal
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
Dr.bal
SURGICAL TREATMENT OF SURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT
RECONSTRUCTION RECONSTRUCTION OF CHRONIC HEEL OF CHRONIC HEEL ULCERULCER
Dr.bal
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
Dr.bal
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