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1362566341 surgical treatment of diabetic foot

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surgical treatment of diabetic foot

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1362566341 surgical treatment of diabetic foot

  1. 1. SURGICALSURGICAL TREATMENT OFTREATMENT OF DIABETIC FOOTDIABETIC FOOT DR.ARUN BALDR.ARUN BAL MUMBAIMUMBAI
  2. 2. MANAGEMENT OFMANAGEMENT OF DIABETIC FOOTDIABETIC FOOT DIABETICDIABETIC FOOTFOOT TREATMENTTREATMENT IN 19IN 19THTH CENTURYCENTURY Dr.bal
  3. 3. WHY DO DIABETES PATIENTSWHY DO DIABETES PATIENTS GET FOOT PROBLEMS?GET FOOT PROBLEMS? REASONSREASONS:: NEUROPATHYNEUROPATHY VASCULOPATHYVASCULOPATHY INJURYINJURY Dr.bal
  4. 4. PATHWAYS FOR DIABETIC FOOT ULCER VASCULOPATHY NEUROPATHY MICROVASCULAR 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
  5. 5. WHY DIABETIC FOOT LESIONSWHY DIABETIC FOOT LESIONS ARE MANY A TIMES MISSED?ARE MANY A TIMES MISSED? USUAL SIGNS AND SYMPTOMSUSUAL SIGNS AND SYMPTOMS OF INFECTION ARE ABSENTOF INFECTION ARE ABSENT PATIENT DOES NON COMPLAINPATIENT DOES NON COMPLAIN OF PAINOF PAIN LOW LEVEL OF AWARENESS ATLOW LEVEL OF AWARENESS AT PRIMARY HEALTHCARE LEVELPRIMARY HEALTHCARE LEVEL DIABETIC FOOT LESIONS AREDIABETIC FOOT LESIONS ARE SILENTSILENT Dr.bal
  6. 6. HIGH INDEX OFHIGH INDEX OF SUSPICIONSUSPICION Dr.bal
  7. 7. DIABETIC FOOT LESIONSDIABETIC FOOT LESIONS ARE LIKEARE LIKE ICEBERGICEBERG ONLY SMALL PART IS VISIBLEONLY SMALL PART IS VISIBLE
  8. 8. SURFICAL TREATMENT OFSURFICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT CENTRALCENTRAL PLANTARPLANTAR SPACESPACE ABCESSABCESS Dr.bal
  9. 9. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT CENTRALCENTRAL PLANTARPLANTAR SPACESPACE ABCESS AFTERABCESS AFTER TOTALTOTAL DEROOFINGDEROOFING ICEBERGICEBERG PHENOMENONPHENOMENON Dr.bal
  10. 10. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT CENTRALCENTRAL PLANTARPLANTAR SPACESPACE ABCESSABCESS PREPRE OPERATIVEOPERATIVE Dr.bal
  11. 11. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT CENTRALCENTRAL PLANTARPLANTAR SPACESPACE ABCESS AFTERABCESS AFTER TOTALTOTAL DEROOFINGDEROOFING ICE BERGICE BERG PHENOMENONPHENOMENON Dr.bal
  12. 12. NO COMPLAINTNO COMPLAINT NONO EXAMINATIONEXAMINATION
  13. 13. TYPES OF INJURIES INTYPES 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
  14. 14. DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES HOMEHOME SURGERYSURGERY Dr.bal
  15. 15. DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES THERMALTHERMAL INJURYINJURY Dr.bal
  16. 16. DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES THERMALTHERMAL INJURYINJURY
  17. 17. DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES CHEMICALCHEMICAL INJURYINJURY dlDr.bal
  18. 18. DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES GANGRENEGANGRENE FOLLOWINGFOLLOWING VIGOROUSVIGOROUS MASSAGEMASSAGE Dr.bal
  19. 19. DIABETIC FOOT INJURIESDIABETIC FOOT INJURIES SHOE BITESHOE BITE Dr.bal
  20. 20. WHY FOOT NEEDS TO BEWHY FOOT NEEDS TO BE SAVED IN DIABETES?SAVED IN DIABETES? BK AMPUTATION REQUIRESBK AMPUTATION REQUIRES 40% MORE KCAL/MIN40% MORE KCAL/MIN NET OXYGEN CONSUMPTIONNET OXYGEN CONSUMPTION INCREASESINCREASES NEEDS 5 -10 % EXTRANEEDS 5 -10 % EXTRA CARDIAC RESERVECARDIAC RESERVE 85% MORTALITY AT THE END85% MORTALITY AT THE END OF 5 YEARSOF 5 YEARS
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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/SSG Dr.bal
  25. 25. GUIDELINES FOR EARLY CON.AMPUTATION • FOOTWEAR PLANNING • FOOT EXCERCISES • SCAR STRETCHING & MANIPULATION • GRADUAL MOBALISATION • PATIENT EDUCATION FOR PREVENTION OF FURTHER INJURY Dr.bal
  26. 26. LOCAL/REGIONALLOCAL/REGIONAL ANASTHESIA FORANASTHESIA FOR DIABETIC FOOTDIABETIC FOOT SURGERYSURGERY Dr.bal
  27. 27. Why regional anaesthesia ? 1] Ideal for day-care patients 2] Safety in high risk patients 3] No intra-op regurgitation & aspiration 4] No PONV 5] Minimal alteration in drug schedule -specially in diabetics 6) No change in diet schedule
  28. 28. Why regional anaesthesia ? Continued…. 6] Minimal effects on vital parameters 7] Safer in emergency situations 8] Can be repeated frequently 9] Conscious & arousable patient at the end of the surgery 10] Reduction in morbidity & mortality
  29. 29. 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
  30. 30. 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.
  31. 31. Limitations 1] Surgical time limit is between 1-3 hrs. 2] Patient’s co-operation is must 3] Failure or partially acted block
  32. 32. Pre-block preparation Counseling the patient regarding the procedure and the expectation from the patient (compliance and accurate replies regarding paresthesia)
  33. 33. 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
  34. 34. 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.
  35. 35. Sural nerve Inject 2% xylocaine between the tendoachilles and the calcaneaum on the lateral aspect Lower leg block or modified ankle block
  36. 36. 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
  37. 37. Practice regularly Your patience The surgeons’ patience The patients’ patience! Steps to success with local blocks Patients’ comfort The surgeons comfort Your comfort AND SAFETY!!
  38. 38. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT POST OPPOST OP PLANTAR SLABPLANTAR SLAB TO STABILIZETO STABILIZE ANKLE JOINTANKLE JOINT Dr.bal
  39. 39. CONCEPT OFCONCEPT OF PLANTAR SPACESPLANTAR SPACES
  40. 40. CONCEPT OF PLANTAR SPACES
  41. 41. PLANTAR SPACES
  42. 42. ASSESSMENT OFASSESSMENT OF VASCULAR STATUS INVASCULAR STATUS IN DIABETIC FOOTDIABETIC FOOT A/B INDEXA/B INDEX SEGMENTAL PRESSURESEGMENTAL PRESSURE MEASUREMENTMEASUREMENT COLOUR DOPPLERCOLOUR DOPPLER DUPLEX SCANDUPLEX SCAN ANGIOGRAPHYANGIOGRAPHY
  43. 43. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY  PRE OP VASCULAR ASSESSMENTPRE OP VASCULAR ASSESSMENT MANDATORYMANDATORY  LOCAL DEBRIDEMENT BEFORELOCAL DEBRIDEMENT BEFORE REVASCULARIZATION IF WOUND ISREVASCULARIZATION IF WOUND IS INFECTEDINFECTED  TOTAL DEBRIDEMENT AFTERTOTAL DEBRIDEMENT AFTER REVASCULARIZATION TOREVASCULARIZATION TO REDUCE/REMOVE NECROTIC LOADREDUCE/REMOVE NECROTIC LOAD  TOTAL OFF LOADING TILL WOUNDTOTAL OFF LOADING TILL WOUND HEALSHEALS
  44. 44. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY DIABETIC FOOTDIABETIC FOOT GANGREME WITHGANGREME WITH VASCULOPATHYVASCULOPATHY
  45. 45. DEBDRIDEMENT IN DIABETICDEBDRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY MRANGIOGRAPHYMRANGIOGRAPHY SHOWING BELOWSHOWING BELOW KNEE VASCULARKNEE VASCULAR BLOCKBLOCK
  46. 46. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY POST OPPOST OP RECURRENTRECURRENT TENOSYNOVITISTENOSYNOVITIS
  47. 47. WOUND HEALING INWOUND HEALING IN DIABETESDIABETES ADVANTAGESADVANTAGES OF MOISTOF MOIST WOUNDWOUND ENVIRONMENTENVIRONMENT Dr.bal
  48. 48. 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
  49. 49. CAUSES OF DELAYED/NON HEALING IN DIABETIC FOOT PRIMARY CAUSES • INADEQUATE OFF LOADING • INCORRECT VASCULAR ASSESSMENT • INADEQUATE PRELIMINARY DEBRIDEMENT Dr.bal
  50. 50. CAUSES OF DELAYED/NON HEALING IN DIABETIC FOOT SECONDARY CAUSES • INADEQUATE ANTIBIOTIC THERAPY • NEPHROPATHY • DRUGS • ASSOCIATED TUBERCULOSIS • INCORRECT METHOD OF DRESSING Dr.bal
  51. 51. AGENTS THAT DELAY WOUND HEALING IN DIABETES  CORTICOSTEROIDS NITROFURANTOIN LIQUID DETERGENTS NEOMYCIN SULPHATE Dr.bal
  52. 52. AGENTS THAT DELAY WOUND HEALING IN DIABETES CHLORHEXIDINE 2% POVIDONE IODINE 10% EUSOL SOLUTION HYDROGEN PEROXIDE Dr.bal
  53. 53. 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
  54. 54. DIABETIC FOOT WOUNDSDIABETIC FOOT WOUNDS NEED TO BENEED TO BE IRRIGATEDIRRIGATED AND NOTAND NOT CLEANEDCLEANED Dr.bal
  55. 55. DOMICIALLARY WOUND CARE SERVICES Dr.bal
  56. 56. ANTIBIOTIC THERAPY INANTIBIOTIC THERAPY IN DIABETIC FOOTDIABETIC FOOT NEEDED FOR PROLONGED DURATIONNEEDED FOR PROLONGED DURATION COST OF THE ANTIBIOTICS ISCOST OF THE ANTIBIOTICS IS IMPORTANT FACTORIMPORTANT FACTOR ANEROBIC CULTUREANEROBIC CULTURE DEERPER TISSUE CULTURESDEERPER TISSUE CULTURES ANTIBIOTICS PROTOCOL FORANTIBIOTICS PROTOCOL FOR INSTITUTIONSINSTITUTIONS Dr.bal
  57. 57. MEDIAL ASPECT OF FOOT DEROOFED, WIDELY DRAINED & EXICISION OF FLEXOR HALLLUSIS LONGUS Dr.bal
  58. 58. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY  PRE OP VASCULAR ASSESSMENTPRE OP VASCULAR ASSESSMENT MANDATORYMANDATORY  LOCAL DEBRIDEMENT BEFORELOCAL DEBRIDEMENT BEFORE REVASCULARIZATION IF WOUND ISREVASCULARIZATION IF WOUND IS INFECTEDINFECTED  TOTAL DEBRIDEMENT AFTERTOTAL DEBRIDEMENT AFTER REVASCULARIZATION TOREVASCULARIZATION TO REDUCE/REMOVE NECROTIC LOADREDUCE/REMOVE NECROTIC LOAD  TOTAL OFF LOADING TILL WOUNDTOTAL OFF LOADING TILL WOUND HEALSHEALS Dr.bal
  59. 59. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY DIABETIC FOOTDIABETIC FOOT GANGREME WITHGANGREME WITH VASCULOPATHYVASCULOPATHY
  60. 60. DEBDRIDEMENT IN DIABETICDEBDRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY MRANGIOGRAPHYMRANGIOGRAPHY SHOWING BELOWSHOWING BELOW KNEE VASCULARKNEE VASCULAR BLOCKBLOCK
  61. 61. DEBRIDEMENT IN DIABETICDEBRIDEMENT IN DIABETIC FOOT WITH VASCULOPATHYFOOT WITH VASCULOPATHY POST OPPOST OP RECURRENTRECURRENT TENOSYNOVITISTENOSYNOVITIS
  62. 62. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT RECONSTRUCTION OFRECONSTRUCTION OF FORE FOOT ULCERFORE FOOT ULCER WITHWITH NEUROVASCULARNEUROVASCULAR FLAPFLAP Dr.bal
  63. 63. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT RECONSTRUCTIONRECONSTRUCTION OF CHRONIC MIDOF CHRONIC MID FOOT ULCER INFOOT ULCER IN CHARCOT`S FOOTCHARCOT`S FOOT Dr.bal
  64. 64. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT CLOSURE OF FORECLOSURE OF FORE FOOT ULCERFOOT ULCER Dr.bal
  65. 65. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT RECONSTRUCTIONRECONSTRUCTION OF CHRONIC HEELOF CHRONIC HEEL ULCERULCER Dr.bal
  66. 66. SURGICAL TREATMENT OF CHARCOT`S FOOT
  67. 67. SURGICAL TREATMENT OF CHARCOT`S FOOT
  68. 68. SURGICAL TREATMENT OF CHARCOT`S FOOT
  69. 69. SURGICAL TREATMENT OF CHARCOT`S FOOT
  70. 70. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT BILATERALBILATERAL FOOTFOOT ABCESSESSABCESSESS Dr.bal
  71. 71. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT HEALEDHEALED BILATERALBILATERAL PLANTARPLANTAR ABCESS WITHABCESS WITH TOTAL OFFTOTAL OFF LOADING ANDLOADING AND MOISTMOIST ENVIRONMENTENVIRONMENT DRESSINGSDRESSINGS Dr.bal
  72. 72. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT BILATERALBILATERAL DEFORMEDDEFORMED WALKABLEWALKABLE FOOTFOOT Dr.bal
  73. 73. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT DEFORMEDDEFORMED FOOT IS BETTERFOOT IS BETTER THAN ATHAN A SOPHISTICATEDSOPHISTICATED PROSTHESISPROSTHESIS Dr.bal
  74. 74. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT REMOVAL OFREMOVAL OF TENDONS OF FHLTENDONS OF FHL AND T.POST FORAND T.POST FOR TENOSYNOVITISTENOSYNOVITIS WITH ABCESSWITH ABCESS Dr.bal
  75. 75. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT HEEL ABCESSHEEL ABCESS FOLLOWINGFOLLOWING INFECTEDINFECTED FISSURESFISSURES Dr.bal
  76. 76. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT TOTALTOTAL DEROOFINGDEROOFING OF HEELOF HEEL ABCESSABCESS Dr.bal
  77. 77. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT NECROTISINGNECROTISING FASCITISFASCITIS PREPRE OPERATIVEOPERATIVE Dr.bal
  78. 78. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT NECROTISINGNECROTISING FASCITISFASCITIS AFTER TOTALAFTER TOTAL DEROOFINGDEROOFING ICEBERGICEBERG PHENOMENONPHENOMENON Dr.bal
  79. 79. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT HEALEDHEALED MEDIALMEDIAL PLANTARPLANTAR SPACESPACE ABCESSABCESS Dr.bal
  80. 80. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIABETIC FOOTDIABETIC FOOT HEALEDHEALED CENTRALCENTRAL PLANTARPLANTAR SPACESPACE ABCESSABCESS Dr.bal
  81. 81. SURGICAL TREATMENT OFSURGICAL TREATMENT OF DIEBTIC FOOTDIEBTIC FOOT HEALEDHEALED LATERALLATERAL PLANTARPLANTAR SPACESPACE ABCESSABCESS Dr.bal
  82. 82. TEAM WORKTEAM WORK Dr.bal
  83. 83. PATIENT IS MOSTPATIENT IS MOST IMPORTANTIMPORTANT MEMBER OF THEMEMBER OF THE TEAMTEAM
  84. 84. DIABETIC FOOT SURGERY ADEQUATE DRAINAGE OF INFECTION
  85. 85. DIABTIC FOOT SURGERY FOOT EXPLORATION
  86. 86. ST.VINCENT`SST.VINCENT`S DECLARATIONDECLARATION TO REDUCE THETO REDUCE THE MAJOR AMPUTAIONSMAJOR AMPUTAIONS DUE TO DIABETES BYDUE TO DIABETES BY 50% IN 5 YEARS50% IN 5 YEARS Dr.bal
  87. 87. THE DIABETIC FOOT • IF OFF LOADING OF THE AFFECTED FOOT IS NOT DONE THEN PATIENT WALKS TO DEATH Dr.bal
  88. 88. TAKE HOME MESSAGESTAKE HOME MESSAGES EARLY RADICAL DEBRIDEMENTEARLY RADICAL DEBRIDEMENT UNDER REGIONAL/LOCALUNDER REGIONAL/LOCAL ANASTHESIA CAN PREVENT LEGANASTHESIA CAN PREVENT LEG AMPUTATION IN DIABETESAMPUTATION IN DIABETES CORRECT VASCULARCORRECT VASCULAR ASSESSMENT AND STRICT OFFASSESSMENT AND STRICT OFF LOADING ARE KEYS TO SUCCESSLOADING ARE KEYS TO SUCCESS IN DIABETIC FOOT SURGERYIN DIABETIC FOOT SURGERY
  89. 89. TAKE HOME MESSAGESTAKE HOME MESSAGES AVOID USE OF DRESSINGAVOID USE OF DRESSING MATERIAL WHICH PREVENTSMATERIAL WHICH PREVENTS MOIST WOUND ENVIRONMENTMOIST WOUND ENVIRONMENT CORRECTION OF FOOTCORRECTION OF FOOT BIOMECHANICS AFTER WOUNDBIOMECHANICS AFTER WOUND HELASHELAS
  90. 90. NEED TONEED TO REVIVE THEREVIVE THE AGE OLDAGE OLD CULTURE OFCULTURE OF FOOTCAREFOOTCARE ANDAND FOOTWEARFOOTWEAR Dr.Bal
  91. 91. THANK YOUTHANK YOU

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