1. DIABETES  India is the country with many diabetic people.  Diabetes is not a single disease but a group of metabolic disorders sharing common underlying features of hyperglycemia.

2. Diagnostic criteria 1.Random blood glucose > 140mg/dl 2.Fasting blood glucose > 126mg/dl 3.Abnormal glucose tolerance test: Blood glucose >200 mg/dl 2hr after of standard carbohydrate load.  Person with blood glucose greater than 100mg/dl and less than 126mg/dl are known as “pre diabetics” who in progress get diabetes over time.

3. Classification

4. Type 1 Auto immune disease characterized by destruction of beta cells of pancreas. 5 to 10% cases Mostly seen < 20 yrs of age.

5. Type 2 Combination of peripheral resistance to insulin &inadequate secretion response to insulin. 90 to 95% cases Adult onset Although of adult onset now a days seen in obese children at alarming rate.

6. Complications of diabetes

7. Acute metabolic complications: 1>Diabetic ketoacidosis 2>Hyperosmolar nonketotic coma 3>Hypoglysemia(If excess insulin is given) Late systemic complications: 1>Atherosclerosis 2>Diabetic microangiopathy 3>Diabetic nephropathy 4>Diabetic neuropathy 5>Diabetic retinopathy 6>Diabetic ulcers & infections

8. Diabetic foot Introduction: one of the complication of diabetes Incidence: Estimated that 10 to 25% of diabetic patients develop some or other foot problem in their lifetime. 5 to 15% require a lower limb amputation

9. Presentation Of Diabetic Foot Shape: change in shape lead to areas of pressure on prominent metatarsal heads,hammertoes,collapsed mid foot. Callus : Callus is seen with excessive wear &tear of tissue. Skin : Skin is dry and without sweating due to autonomic neuropathy. Crack easily & a route of infection. Sensations : Loss of sensations which are assessed by traditional modalities like ankle jerks, tendon reflex. Pain sensation :reduced & is assessed by biosthesiometer& nylon monofilament.

10. Etiopathology of diabetic foot Truly multi factorial but one may predominate others. Factors are 1.Neuropathy 2.Macrovascular disease 3.Microvascular disease 4.Connective tissue abnormalities 5.Infections 6.Hematological disturbances

11. Neuropathology Glove & stocking type Sensory, motor, autonomic all nerves involved.  Causes: 1]Metabolic factor(Due to hyper glycemia) 2]Microvascular disease  Effects: 1]Extrinsic 2]Intrinsic

12.  Extrinsic: Loss of somatic sensations of plantar aspect cause ulcer by: ill fitting shoe,toe nail, thermal injury,foreign body…. Pain is not perceived,So damage continues, Established ulcer is the end point.  Intrinsic: Causes smooth motor neuropathy Weakness of intrinsic muscles Abnormal movements of small bones &joint subluxation Visceral neuropathy cause loss of proprioception Patient keeps on walking on aching foot (which is not known to him) Stretching of joint capsules & bony changes take place With continuous shear pressure cause callus & ulcer formation.

13. Vascular Macrovascular Diabetics are 4 to 7 times more prone for atherosclerosis than normal. Mostly affect tibial and peroneal arteries. Reduced oxygen partial pressure Vascular calcification seen in x-ray & angiography. Microvascular Structural abnormalities in: 1]Basement membrane 2]Endothelial function Basement membrane: Leads to defect in movement of leucocytes & macromolecules. Endothelial Function :Defect leads to poor tissue perfusion & play important role in ulceration.

14. Infections Skin cracks & fungal infection between toes are route of infection. Gram –ve & +ve aerobes & anaerobes are noted.  Causation of infections increased in diabetes due to: 1.Deficiency of cell mediated immunity 2.Impaired chemotaxis 3.Impaired phagocytosis & opsonization.

15. Connective Tissue Disorders Hyperglycemia affect structure and function of proteins like keratin, collagen Changes in them and structures become weak & inelastic affect bone structure of foot Ulcers.

16. Hematological Disturbances They cause: 1.Ischemia 2.Ulceration 3.Spread of infections 4.Red cell deformities ---Hypercoagulability &increased plasma viscocity. 5.All these increase chances of infections.

17. Prevention Patient education is central aim Daily examination of foot for any ulcer and footwear for foreign body. Creams applied must be non allergic & without perfume. Chiropody is advised. Cushions at pressure points must be used. Never walk barefoot. Special types of shoes are adviced.

18. Management & Treatment Chiropody: Special care of foot, removal of callus with scalpel. Padding for prominent areas. Orthotics: Total contact plaster casts. Tailor made temporary shoes are used. Small Surgeries: If conservations fail small surgeries are done. Small bones are checked. Eradication of infections: Antibiotics used Debridement and regular dressings done.

19. Future In spite of all these measures patients land up in amputations They require rehabilitation with prosthetic limbs. “When there is a will There is surely a way”