2. Diabetic Foot: A Surgical Look
Hosam Roshdy Zaher, MD,
Assistant Professor & Consultant
General & Vascular Surgery of
Mansoura University

3. WHO SHOULD TREAT THE DIABETIC FOOT?

4. Is it a debatable issue? General Surgeon Vascular Surgeon
Orthopedic Surgeon
Plastic Surgeon
Podiatrist
May be others?

5. The Vascular Surgeon Are there pedal pulses? Yes, Sir.
Please refer to General Surgery
No, Sir.
Please check with the doppler sounds
Pedal pulses are audible, Sir
Please refer to the General Surgeon

6. The Vascular Surgeon There are no audible Doppler sounds, Sir.
A~~h, from where you bring me these cases
Please try with general surgery again!
Sir, they wont accept this case
Ok. Ok. Get the patient inn and I’ll see him/her later today or tomorrow

7. The Orthopedic Surgeon
Does the patient has any osteomyelitis?
Yes, Sir
Can you try with General Surgery to take
care of this patient
They wont accept this patient, Sir
Ok. Ok. Get the patient inn and consult I.D.

8. The I.D. Consultant Thank you for referral.
However, I need bone biopsy from the affected parts
Please do this and this and this ………
Antibiotics for at least 6 weeks

9. The Plastic Surgeon Is there any active infection? Yes, Sir
Please refer case to General Surgery, and if they need us again they can call us
No, Sir
Ok. We can see the patient later
Next day: By the way where is that patient that you have called me for yesterday?
He/She is in ward ..and bed..
One week later: Nurse, where is the patient of Dr……..

10. The Podiatrist We have a case for you, Sir.
Ok. Can you call the senior surgical resident to see the patient first and let him call me
Please.
Ok., Sir
Senior resident & Podiatrist: After a very long conversation,

11. The Podiatrist
Ok. Please consult:
Vascular Surgery &
Do MRI

12. May be Others?
WHO CARES!

13. DIFFERENTIATION OF THE FOOT
DIABETIC FOOT
Damaged Nerves  difficult to feel pain, pressure, heat and cold.
Blocked Blood Vessels bring fewer nutrients and oxygen to feet  sores may not be able to heal.
Weakened Bones may slowly shift, causing foot to become deformed and changing the way distributes pressure.
Collapsed Joints, especially a collapsed arch, can no longer absorb pressure or provide stability. The surrounding skin may begin to break down.
HEALTHY FOOT
Nerves let you feel pain, vibration, pressure, heat, and cold
Blood Vessels Carry nutrients and oxygen to your feet to nourish them and help them heal from injuries.
Bones give your foot shape and help distribute the pressure from your body's weight.
Joints are the connections between your bones. They help absorb pressure and allow your foot to move. Your arch is a group of joints that provides stability for you entire foot

14. What is a diabetic foot?
Diabetic foot is a disease complex that can develop in the skin, muscles, or bones of the foot as a result of the nerve damage, poor circulation and/or infection that is associated with diabetes.

15. 15% DIABETIC PATIENTS WILL SUFFER FOOT PROBLEMS
RISK FACTOR : MAJORITY OF PATIENTS WITH TYPE 2 DM AND LONG STANDING TYPE 1 DM
45% OF ALL MAJOR AMPUTATION CAUSED BY DIABETIC FOOT SYNDROME

16. DEATH CAUSED OF FOOT DIABETIC 17-32%
GOOD DIABETIC FOOT CARE WILL DECREASE AMPUTATION IN ½ - ¾ CASES

17. DIABETIC FOOT SYNDROME
FOOT ABNORMALITIES CAUSED BY NEUROPATHY, ANGIOPATHY AND INFECTION IN DIABETES MELLITUS PATIENT’S

18. What is the etiology of diabetic foot?
Multifactorial
Neuropathy
Ischemia
Infection

19. Neuropathy affects more than 50% of diabetics
Sensory loss
Motor loss
Autonomic neuropathy

20. Ischemia (PAD)
More than 50% diabetics get significant atherosclerotic disease
“Large vessel PAD” – often with tibial involvement with relative sparing of proximal and pedal vessels
“Microcirculatory” disease – intimal and basement membrane thickening

21. Peripheral neuropathy Peripheral vascular diseaseDM
Peripheral neuropathy
Peripheral vascular disease
Increase flow regulation
motor
Autonomic
sensory
pain 
proprioception 
Shunting
sweat 
Power imbalance
Reduced capillary blood flow
Fissuring 
Deformity
Defective response to start foot ulcer and infection

22. PATOGENESIS

23. Combination of PAD & Neuropathy
 Risk of injury
Invasive soft tissue infection
Osteomyelitis
Chronic ulceration
Gangrene

24. Clinical presentation
Evidence of PAD
Intermittent Claudication
Critical limb Ischemia / Ulcers
Evidence of Neuropathy
Deformities
Ulcers
Infection
Cellulitis
Invasive soft tissue infection
Osteomylitis

25. How do patients with PAD present?

26. How do patients with neuropathy present?

27. How do patients with infection present?

28. Evaluation & Management
Multi-displinary Approach
Diabetologists
Primary Care Physicians
Specialized Nurses
Social Workers
Diabetes Educators
Foot Care Specialists
Physiotherapists/ Occupational therapists
Radiologists
Vascular Surgeons

29. DIABETIC FOOT LESION GRADING SYSTEM - WAGNER

30. (WAGNER CLASSIFICATION)
GRADING ULCER
(WAGNER CLASSIFICATION)

31. MANAGEMENT GOAL FOR DIABETIC FOOT
ACUTE :
WOUND HEALING
SAFE THE FOOT FROM AMPUTATION
CHRONIC :
TO PREVENT RECURRENCY OF WOUND

32. Evaluation & Management
Clinical Assessment
History
Physical Examination

33. Evaluation & Management
Investigation
Plain films / Nuclear Medicine
Non-invasive (Duplex / Digital pressures/ ABI, CTA, MRA)
Invasive test (Arteriography)

34. Investigations

35. Investigations

36. ABI= Ankle SBP(PT or DP)/ Highest Arm SBP
Ankle Brachial Index
ABI= Ankle SBP(PT or DP)/ Highest Arm SBP

37. Ankle Brachial Index ABI value Indicates <0.9 Abnormal 0.8- 0.9
Mild PAD
Moderate PAD
<0.5
Severe PAD
<0.25
Very Severe PAD
The ABI has limited use in evaluating calcified vessels that are not compressible as in Diabetics

38. Toe pressure
Segmental pressure

39. Arterial duplex

40. Digital Subtraction Angiography

41. Treatment Relief symptoms Improve quality of life Limb salvage
Goals of treating patients with Diabetic Foot
Relief symptoms
Improve quality of life
Limb salvage
Prolong survival

42. Treatment Preventive Measures Treatment Patient Education
Local- footwear, cotton socks, nail care can reduce amputation rate by 40 to 80%
Systemic- Risk factors modification

43. Treatment Patient Education Importance of risk factors control
Avoidance of trauma and minor cuts
Proper foot care
Medical visit with early signs of infection or ulcer development

44. When to Seek Vascular Surgery Consultation?
Evidence of PAD
- Intermittent Claudication
- Critical Limb Ischemia
Rest Pain
Impeding soft tissue compromise
Tissue Loss
Frank ulceration or gangrene.

45. Strategies in treating patients with diabetic foot
Eradication of Infection
Debridment
Drainage
Minor amputations

46. Strategies in treating patients with diabetic foot
Improve Lower Limb Circulation
Conservative (Exercise Program)
Intervention ( Revascularization)
- Angioplasty +/- Stenting
- Surgical Bypass

47. Percutanous Transluminal Angioplpasty PTA

48. Surgical Bypass

49. Strategies in treating patients with diabetic foot
Major amputation
Primary vs Secondary
BKA vs AKA

50. Take home message
Diabetic Foot is a major and an increasing public-health problem
Etiology is Multifactorial
Multi-displinary approach is the key for better outcomes

51. THANK YOU