orthopaedic aspect of diabetic foot

1. Diabetic Foot & Ankle
Dr. Vijay Kumar Loya
JR, JIPMER

2. EPIDEMOLOGY
Diabetic foot ulcers were found in 4.54% newly diagnosed
patients(Sinharay K et. al, 2012)
Prevalence of DFU is about 14.3% in Indian population (according to
a study done in Northern India, Shahi SK et. al)

3. RISK FACTORS
NEUROPATHY
SENSORY
MOTOR
AUTONOMIC
PVD
DELAYED BONE
HEALING
ALTERED
IMMUNE
FUNCTION

4. Large sensory fibres – protective sensation is lost
Small fibres can lead to increased pain sensation, allodynia.
Sensory disturbances show a length related pattern with
stocking & glove distribution due to dying back distal
axonopathy
Motor neuropathy can cause claw toes from intrinsic muscle
weakness & equinus contracture of Achilles tendon→ stress on
fore-foot→high focal pressure & skin breakdown.
Sweat gland dysfunction allows the skin to dry & crack→microbe
entry

5. DIAGNOSIS
PHYSICAL EXAMINATION
EMG/NCS
LOSS OF PROTECTIVE SENSATION IS
THRESHOLD AT WHICH NEUROPATHIC
ULCERS/CHARCOT ARTHOPATHY
OCCUR

6. PVD
ABI is unreliable in diabetics as
calcification can lead to high results
masking the severity of disease.
Toe pressure or TcpO2 better indicator.
Angiography is gold standard, but
requires IV contrast infusion.
ABI >0.45 & TcpO2 >40mm Hg
necessary for ulcer to heal.

10. TREATMENT
NON-OPERATIVE
TCC – TOTAL CONTACT CASTING
REMOVABLE DIABETIC BOOTS
NEGATIVE PRESSURE WOUND THERAPY
HYPERBARIC WOUND THERAPY
EXTRA CORPOREAL SHOCK WAVE TREATMENT

13. TCC is the gold standard for off-loading of plantar
ulcerations.
ii. Patients with grade 3 or greater ulcers should
undergo incision and drainage and antibiotic therapy,
with wound improvement before TCC application.
iii. Casts should be changed every 2 to 4 weeks until
erythema and edema have resolved and the
temperature of the affected limb has decreased and
become similar to that of the contralateral limb. Ulcers
should be evaluated and debridement should be
performed at the time of cast changes.
iv. Radiographs should be repeated every 4 to 6 weeks,
or more often if there is an acute change.
v. TCC commonly continues for up to 4 months; when
the active disease phase is complete, the patient can be
fitted with a Charcot restraint orthotic walker, later
followed by a custom shoe with orthoses.

15. OPERATIVE TREATMENT –
URGENT SURGICAL INDICATION – NECROTISING FASCITTIS/
GANGRENE/ DEEP ABSCESS
LESS URGENT INDICATIONS ARE - COMPROMISED SOFT TISSUE
ENVELOPE
NEED TO AVOID PROLNGED ANTIBOTICS
LOSS OF MECHANICAL FUNCTION
BONE INVOLVEMENT THAT IS LIMB THREATENING

16. OPERATIVE TREATMENT
DEBRIDEMENT
EXOSECTOMY OR REALIGNMENT ARTHODESIS
AMPUTATION AT APPROPRIATE LEVEL
RESECTION ARTHOPLASTY
ACHILLES TENDON Z-PLASTY

19. THANK YOU