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Handbook of Diabetic Foot Care
Dr Arun Bal
Dr A K Das
Dr Sharad Pendsey
Dr K R Suresh
Dr Vijay Viswanathan
Dr Prakash Ambardekar
Dr Sanjeev Kelkar
Published by :
Diabetic Foot Society of India
Bhagwan Mahaveer Jain Hospital
Dept. of Vascular Surgery, Podiatry Division
Millers Road, Vasanth Nagar
Bangalore - 560 052
Phone : +91-80-22207188
Ó Diabetic Foot Society of India
First Published November 2005
Printed at :
Repromen Offset Printers Pvt. Ltd.
No. 17, Krishnareddy Colony
Bangalore - 560 071.
In our country there was a considerable lack of Diabetic Foot Care, just a few years
ago. It was not an important part of the diabetic practice. Consequently we did not
have professionals with an insight in this art and science. Nor were they trained to
extend Diabetic Foot Care to the population nor could they train their paramedics to
participate in the foot care. There were few tools available to diagnose foot at risk,
something every medical setting should be or able to do. India made significant
progress in these areas and diabetic foot care is now a focus for thousands and many
of them are trained for the same to varying degree. Number of persons with diabetes
is rising at a disturbing rate that makes Diabetic Foot Care an even more important
branch of diabetes care.
Diabetic Foot Care is well developed in the western European world as in USA and
Australia. The knowledge needs to be adopted for the conditions in our country. The
potential of care in preventing morbidity associated with diabetic foot and reducing
the rate of amputation is known. The simple technology transferred to the
professionals will go a long way in reducing amputations.
Over 1200 professionals have received structured training mainly from Novo Nordisk
Education Foundation. These popular programs aroused the interest of the profession.
The topics on diabetic foot became a part of most educational activities and countless
others have received some insights in this area over the last few years through these
inclusions. Many of these exposures were one off or interspersed with time gaps. A
need for reinforcing their training and creating a handy reference book for practical
issues faced by them, doubts raised, became apparent for some time. With the
formation of DFSI more issues surfaced as people met over the conferences and such
a handbook looked even more relevant.
“Handbook of Diabetic Foot Care” is an attempt to bring together the essential
information for giving meaningful care in primary, secondary or tertiary settings,
answer issues faced by the professional and give a momentum to the work that has
been put in improving diabetic foot care in the last few years in India. The expertise
available in our country evolved and enlarged as a group after the formation of
Diabetic Foot Society of India. They have jointly contributed to this handbook,
directed towards the solutions of problems faced by individuals in India and would
also hold for South East Asian countries where the expert group has gone as faculty to
train the professionals of Sri Lanka and Malaysia.
We hope it serves the desired purpose and becomes useful to all concerned with
diabetes foot care. We would be very happy to receive active feedback on the contents
to improve upon this book. We are also proud to announce that this handbook is a gift
to any one interested in doing something for this gigantic problem of diabetic foot.
Secretary, Diabetic Foot Society of India
Know the authors:
Dr. Arun Bal after his MS in surgery devoted himself to Diabetic Foot for the last
twenty years. He is the premiere surgical authority on diabetic foot and also has an in
depth understanding of various dimensions of diabetic foot care in India. Dr Bal has
been the mainstay of diabetic foot movement in India over the past several years. He
is the founder president of Diabetic Foot Society of India.
Dr. Ashok Kumar Das, Additional Director General, Govt of India, Dean of the
prestigious JIPMER for long, Vice President of Diabetic Foot Society of India has in
Diabetic Foot his main interest. Having worked in King's College for quite some time,
the commitment that started then has continued. In diabetic foot Dr Das is a support,
an authority and a reference point to rally around.
Dr. Sharad Pendsey, Vice President of Diabetic Foot Society of India has had a long
commitment to Diabetic Foot and arranged the first three day educational workshop in
September 1999, sharing his ideas developed over years. He drew the public and
professional attention to diabetic foot first time in India, which is where his special
contribution lies. He has won several awards for his work in diabetic foot, nationally
Dr. K R Suresh, Treasurer, Diabetic Foot Society of India, was trained in USA as a
vascular surgeon, a specialty he practised for 17 years before returning to India about
seven years ago. At Mahaveer Jain Hospital in Bangalore the frequent problem of
diabetic foot could not escape his notice. What started as a necessity to deal with
became a passion, then an obsession to do more for the diabetic foot disease and is
now a mission for him. His Center in Bangalore has actualized many ideas in routine
Dr. Prakash Ambardekar is an anaesthetist working closely with Dr Arun Bal. The
singular contribution of the duo is the solution to the most vexing and frequent
problem of serious diabetic foot infection requiring surgery. It is in the highly
destabilized metabolic and hemodynamic state due to serious foot infections that
risks involved with anaesthesia and surgery are significant. His contribution based on
his extensive experience in this area in the handbook will come as a huge relief to
many surgeon physician anaesthetist teams faced with these issues.
Dr. Vijay Viswanathan, Joint Secretary of Diabetic Foot Society of India was among
the firsts who started looking in the problem profile of Indian Diabetic Foot and
published on the same. He has contributed considerably to the educational efforts in
this area with Novo Nordisk Education Foundation, Diabetes Research Center,
Chennai and other initiatives like Indo American Workshops. His emphasis on relying
on basics in diabetic foot care has served as a reference in thinking about the
dimensions of diabetic foot disorder.
Dr. Sanjeev Kelkar is the lynchpin holding the diabetic foot work together.
Many hands have served the preparation of this volume. The first and foremost would
be the authors who have contributed to the material. The implicit encouragement from
the Institutions they work with and help from their colleagues who have helped them
to do the work is placed on record. The support received from the Members of the
Board of Management of Diabetic Foot Society of India and other core group
members is acknowledged. We thank them. We also wish to thank Dr Tarun Sahani
from Apollo Hospitals New Delhi for his contribution to the note on hyperbaric
oxygen therapy, Dr Johny Kannampilli from Lakeshore Hospital Cochin for Maggots
therapy and Dr Harishkumar from AIMS Cochin for osteomyeltis. Thanks are also
due to Dr M V Srishyla, Novo Nordisk India for his contribution to the relationship of
insulin sufficiency and nerve fiber integrity. Dr V B N Murthy Adjunct Professor IIT
Madras and Consulting plastic surgeon, Sundaram Medical Foundation, Chennai,
contributed to the aspects of wound care, wound healing and biomechanics and
Dhansai Laboratories for providing information that could be incorporated on some
topics on biomechanics, and pressure measurements..
DFSI acknowledges the technical support of Mrs Anandhi Singh, Executive Projects
and Mr M V Prasad the Information and Documentation Officer for his untiring
support in uncovering reference materials, matching the references and figures in the
text (which is by far the most intricate job in writing a monograph), both from NNEF.
We thank the following experienced professionals who have reviewed the book and
expressed themselves for the improvement of the volume, viz Dr Samir Warty, Dr
Sanjay Vaidya, diabetic foot surgeons, Mumbai, Dr Harishkumar, Endocrinologist
and Dr Sudhindran, vascular surgeon from Amrita Institute of Medical Sciences,
Cochin, Dr V B N Murthy from Chennai.
The strongest but unseen force behind the completion of this volume are those
enthusiastic but unrelenting professionals who pressed us, the editor in particular to
come out with a volume that will support their learning in diabetic foot so far, in their
own practice, clear the doubts and help them deliver the care better. This book is for
those who have taken up diabetic foot care as a labour of love. It is they who have
made Diabetic Foot Society of India and the Diabetic Foot work in this country in to a
movement. The publication of this volume we believe will be a shot in the arm for
this movement, which will grow and sustain itself for a higher performance. The book
is written for and dedicated to them.
We thank lastly our printers Repromen for the excellent job they have done.
TEN COMMANDMENTS OF DIABETIC FOOT CARE
1. DO NOT walk barefoot.
2. INSPECT the feet daily for blisters, wounds, bleeding, smell, increased
temperature at pressure points of feet and edema.
3. DO NOT apply hot fomentation / cold compresses / electric heating pads /
strong counter irritant ointments to legs and feet.
4. USE correct footwear. Choose your footwear after consulting your doctor.
Always wear footwear with socks with loose elastic.
5. DO NOT walk bearing weight on an affected / ulcerated foot or after surgery.
6. DO NOT sit cross-legged for long time.
7. DO NOT remove foot wear during travel and place your feet on any hot
surface. This can cause burns.
8. CUT the nails regularly, trimmed square.
9. DO NOT cut corns / calluses with a blade or a knife. Home surgery is
10. CLEAN the feet twice a day with soap and water. Wipe the web spaces dry
and apply softening agent to feet. Do not use the Pumis Stone.
11. The eleventh commandment (if you can help it ) DO NOT AMPUTATE.
1. The Art and Science of Diabetic Foot Care 1
2. Magnitude of the Problem in India and A Note For 3
Policy Makers and Professionals
3. Surgical Anatomy and Functional Correlations 7
4. Pathophysiology of Diabetic Foot 11
5. Biomechanics and Foot Pressures 22
6. Clinical Assessment 26
7. Laboratory Assessment 34
8. Minimum Care Protocol 41
9. Medical Polytherapy 46
10. Peripheral Arterial Disease (PAD) 58
of The Lower Extremities In Diabetes Mellitus
11. Wound Healing 65
12. Wound Dressing in Diabetic Foot 70
13. Diabetic Foot and Foot Wear Choices 77
14. Early Conservative Amputation 79
15. Regional Anesthesia for Lower Limb Surgery 83
or Anesthesia Management of a Diabetic Foot
16. Starting Diabetic Foot Clinic 92
Appendix 1, 2 & 3 102