1. Diabetic Foot Linda Ferris Foot and Ankle Centre, North Adelaide Presented at the combined SAON & SAWMA Education meeting May 2006

2. Goal Maintain a viable plantigrade foot Maintain a viable plantigrade foot Functional Functional Free of Infection Free of Infection

3. Prevention LEAP = Lower extremity amputation prevention program Education program for patients and all primary health care providers of the foot Education program for patients and all primary health care providers of the foot Not really geared to surgeons Not really geared to surgeons Who looks after foot surgery very variable based on location ?Multidisciplinary teams Who looks after foot surgery very variable based on location ?Multidisciplinary teams

4. Priorities If no infection first priority is to check circulation If no infection first priority is to check circulation If pus under pressure it needs to be released first If pus under pressure it needs to be released first –then check circulation –if adequate circulation then can address underlying pathology

5. Forefoot _Amputations Indications- Dead, dirty, devitalized, dangerous An early amputation of a small area may save more of the foot in the long run

6. Deformity in the presence of neuropathy Forefoot deformities such as bunion, claw toes especially if inappropriate shoes Forefoot deformities such as bunion, claw toes especially if inappropriate shoes High risk for developing ulcers High risk for developing ulcers Key is education and regular podiatry, shoe fitting Key is education and regular podiatry, shoe fitting

7. Ulcer - forefoot Heal first by unloading: may include Achilles lengthening Heal first by unloading: may include Achilles lengthening If can prevent recurrence without surgery if not then options include Kellers and Metatarsal head excision If can prevent recurrence without surgery if not then options include Kellers and Metatarsal head excision

8. Role of prevention In presence of diabetes and bunions risk/reward more complex in that higher risk of complications In presence of diabetes and bunions risk/reward more complex in that higher risk of complications Dont recommend surgery unless all other options considered first but if any ulceration, infection then often simplest procedure Dont recommend surgery unless all other options considered first but if any ulceration, infection then often simplest procedure

9. Midfoot Midfoot deformities Usually associated with a charcot foot and commonly plantar ulcers Usually associated with a charcot foot and commonly plantar ulcers May heal but tend to recur May heal but tend to recur

10. Midfoot - rocker bottom foot If old Charcot then bumpectomy may be valid If old Charcot then bumpectomy may be valid Lateral prominence of 5th MT base is another area that may need trim esp if cavovarus foot (eg CMT) Lateral prominence of 5th MT base is another area that may need trim esp if cavovarus foot (eg CMT)

11. Hindfoot and Ankle deformities Often after trauma especially ankle fractures Often after trauma especially ankle fractures May be chronic pre-existing deformity May be chronic pre-existing deformity

12. Ankle Fractures - to operate or not?? Either way high risk 1 study in Ca showed if diabetic and alcoholic 100% complication rate for ankle fractures Either way high risk 1 study in Ca showed if diabetic and alcoholic 100% complication rate for ankle fractures Latest trend is to more aggressively internally fix with screws across fib to tib and possibly steinman pin up the heel but whichever way it needs to be closely followed and double NWB period and immobilization Latest trend is to more aggressively internally fix with screws across fib to tib and possibly steinman pin up the heel but whichever way it needs to be closely followed and double NWB period and immobilization

13. Heel Ulcers/Osteomyelitis More difficult to unload often poor vascularity.Pressure sores need mainly nursing care different to plantar ulcers.Once down to bone if VAC system doesnt help then may need calcanectomy which is a deforming procedure and tends to mean forever custom shoes. If poor circulation may end up with BK More difficult to unload often poor vascularity.Pressure sores need mainly nursing care different to plantar ulcers.Once down to bone if VAC system doesnt help then may need calcanectomy which is a deforming procedure and tends to mean forever custom shoes. If poor circulation may end up with BK

14. Nails Symes procedure for chronic nail infection deformity Symes procedure for chronic nail infection deformity Other procedures such as Zadiks work but all slow to heal in diabetics Other procedures such as Zadiks work but all slow to heal in diabetics