Surgical Services
Surgical Services
What Is Surgical Diabetic Foot Treatment?
SAVE FOOT, SAVE LIFE! Aim of surgery is to save foot and avoid major amputations, saving life at the same time. Patient should be able to walk on his own feet without any help. Attempt should be made to save every small part of foot.
Another aim is to avoid separate plastic surgery as much as possible. Natural foot skin is the best skin. Every millimeter of skin should be saved as much as possible.
Most diabetic foot conditions need surgical treatment if not treated early.
All diabetic feet need to be tested for blood flow. Any problem with blood flow needs treatment in its own right
NOTE – Treatment of diabetic foot including surgery is a long chain of multiple small events. Every component of treatment is equally important. Many people make the mistake of valuing the most expensive part like surgery and ignore least expensive part like shoes, plaster or walker. Such approach results in failure because a chain is only as strong as its weakest link.
Following Topics Are Covered Briefly Here
Common Conditions in Diabetic foot.
Common surgeries in diabetic foot.
Blood flow related (vascualar) procedures.
Plastic surgery in diabetic foot .
Anesthesia in Diabetic foot .
Risk of surgery in diabetic foot.
We Are Here To Help When You Need Us
Common Conditions in Diabetic foot
INGROWING TO NAIL
What is it?
Toe nail starts growing into the skin, burying into the soft part. Ingrowing toe nail is a common condition even in non-diabetics. It can happen at younger age and on both feet. Big toe is commonly affected.
Why is it important?
Diabetics are at special risk because the infection can spread to remaining toe and foot as well.This can start simple infection, abscess or cellulitis. . People have lost legs with infection starting in toes.
Treatment – Apart from antibiotics, it may need surgery like drainage of pus, partial removal of nail or complete removal of nail. It’s a delicate surgery because it needs removal of not just toe nail, but its nail bed, without damaging nearby toe joints, which is very close. It’s a small price to avoid any further spread.
2..CORN AND CALLOSITY
What is it?
These are thickened patches of skin usually on the lower part, the insole of foot. They typically occur because of high pressure on certain points where shoes are rubbing on them. Some of these thick callosities are harbouring deep ulcers and infection under them.
Why is it important?
These are precursors of ulcers. They are very hard crushing the soft part of foot inside. Treating them early will prevent their further development into ulcers.
Treatment –>
Non-surgical – In early stage, simple modification of footwear to distribute pressure will help.
Surgical – Sometimes they may need ‘shaving’ of superficial part. It can be done in OPD without anesthesia; because it is the dead skin we are shaving or scraping off.
But beware! So, A simple looking calosity may turn out to be a complex problem like a deep ulcer (See below)
3.WARTS
What s it?
They are thickened areas of skin because of a viral infection. It is a very common condition in general. Wart may look similar to callosity or corn to the layperson. They can happen anywhere in the body but are painful on feet as we walk on it. Also, because of our body’s pressure, most of the wart is buried into the skin of foot.
Why is it important?
They are viral infections and can spread causig multiple warts. Though a relatively minor issue in general population, in diabetics, they can lead to further complIcations and serious infections.Because most of the wart is buried into the skin, some part may be left inside if not cut out deeply and completely. They are known to come back.
Treatment –>
In non-diabetics, most can be treated without surgery. Sooner or later body developes immunity and clears the wart. In diabetics, because of the risk involved, many a time a complete excision of the wart is required.
4.Ulcers
What is it?
Ulcer is a break in the skin. In diabetics, ulcers develop commonly on the lower part, the sole of the feet. This happens because of the pressure of our body falling repeatedly on high pressure areas, like heel or ball of great toe.
Why is it important?
Ulcers can quickly spread infection inside into muscles joints and bones. Infection can also travel in the leg and thigh.
Treatment
Surgical – Depending upon the extent of the ulcer, it will need procedures like simple cleaning and dressing, debridement, fasciotomy, minor or major amputations. Non-surgical – Antibiotics, dressing, customised plaster, VAC treatment, special shoes.
5.Abscess
What is it?
It is pus inside foot in one or many pockets. Pus is nothing but dead tissue and lot of bacteria. It may show just as a swelling below thick skin or yellow areas sometimes in the centre of red areas.
Why is it important?
Pus if not let out, will spread inside the foot destroying it. It can spread up the foot and in the blood endangering foot and making person septic. So, pus anywhere must be let out as soon as possible. Doing so will convert abscess into an ulcer which is relatively less risky.
Treatment–>
Surgical – Incising/cutting open and cleaning the area. Sometimes pus extends into many pockets. One may need to open different pockets. Sometimes, one can’t remove all the dirty area if one wants to save foot and has to take help of other treatments as below.
Non-surgical – Antibiotics, Debridement, VAC therapy, plaster.
6.Cellulitis
What is it?
It is infection in the plane of skin and just below it. It shows as redness, swelling, hot and pain sometimes.
Why is it important?
Though it is an infection just near skin, in diabetics it can spread extremely fast, sometimes even in a day into the whole leg. If treated in early stage, it may settle without surgery. Delay can result in spread, abscess or fasciitis. Many patients come with complications like pus or deeper infection or fasciitis, but are diagnosed wrongly just as cellulitis, getting inadequate treatment, thereby complicating the matter. It becomes more difficult to get rid of infection once it spreads in multiple deep pockets.
Treatment–>
Non-surgical – If confirmed as being in early stage with no other complications, it may not need surgery but rest and antibiotics and other medical treatment. But any delay may need further surgical treatment.
Surgical – Complications like abscess or faciitis will need treatment accordingly as mentioned elsewhere here.
7.GANGRENE
What is it?
Gangrene is part of body like a toe dying and rotting afterwards. It usually happens either because of poor blood flow or infection or both. The toe may change colour to black, bluish or yellow.
There are 3 types of gangrene discussed here – dry, wet and gas gangrene.
Dry gangrene – It is dry with little infection. It is the least dangerous and slow to progress. Many a times, if safe, one can just wait and the dead gangrenous part falls off after few weeks. Sometimes, diabetic may start with a dry gangrene but may soon become wet needing urgent treatment.
Wet gangrene – This is the commonest type in diabetic patients. Infection is a major issue in addition to poor blood flow. It needs urgent treatment like amputating or removing affected area in order to save remaining foot or life.
Gas gangrene – This is the worst of them all. It has gas forming bacteria. It is a serious medical emergency. It needs treatment within hours. Here saving life is the priority.
Why is it important?
Dead part (gangrene) needs removal anyway.
In diabetics the wet gangrene can quickly spread to neighbouring toes, foot and leg, endangering foot and life.
Gas gangrene is the most serious gangrene endangering life and limb.
Treatment->
Depending upon urgency, especially in wet gangrene or gas gangrene, the part needs to be amputated to save life.
Non-surgical treatment – Antibiotcs, dressing, VAC therapy, HBOT.
Blood flow treatment – Circulatory problems may need medical treatment, angioplasty, bypass surgery (Discussed in detail in ‘Special treatment and advances in Diabetic foot’). Not all gangrenes need blood flow treatment. Sometimes the blood flow problem is a result of uncontrolled infection, and getting rid of infection may suffice.
8.FASCIITIS
What is it?
It is an infection of fascia, the tight layer that encircles the whole leg. It also separates different compartments of legs and foot. Fascia though lies just below the skin, it can cause extensive infection, spreading fast into multiple compartments. This is how infection of toe can reach upto knee level in a day through the tunnel of fascia.
Why is it important?
Its importance lies in it being missed out or mistaken as simple infection like cellulitis. Also, infection can increase pressure in the leg compartment compromising blood flow to the foot. The treatment of fasciitis needs urgent surgical approach unlike other superficial infections. If treatment is delayed, infection reaches into many pockets and may become difficult to remove or save limb.
Treatment
Surgical – Fascia is cut open to release pressure. Dead fascia is cut out. Dead areas are cleaned.
Non-surgical – Antibiotics, plaster, rest, VAC therapy.
Common surgeries in diabetic foot.
Debridement
What is It?
It invloves debriding or removing of any infected or dirty part that is dead or unlikely to survive. It involves cutting out any necessary parts like muscles, skin, and fascia. But if bones are removed, the word amputation is used. It can be a small procedure done in OPD or a major procedure needing anesthesia, OT and admission. This is the procedure done most commonly on diabetic foot. Usually, a diabetic foot needs multiple debridements till infection is fully controlled.
Fasciotomy and fasciectomy
Fasciotomy is cutting open of that tough thick layer called fascia below the skin level. It releases presure from inside and also lets infection out. Fasciectomy is excising dirty part of fascia.
Amputations
What is it?
It usually involves removal of many bones, a bone or part of it. In diabetic foot treatment, different combinations of amputations along with other surgeries are used. The aim being to do whatever is necessary to remove the infection completely and at the same time save as much of function of foot or leg as possible. So, one may need to do a ray excision that needs excision of 1st toe with some part of bone behind it, total amputation of 2nd toe, and partial amputation of 3rd toe. For the sake of simplicity and understanding, some types are given below.
Amputation of a toe, total or partial – It involves removing of the whole toe (with its 3 bones, or 2 in case of 1st toe). Removing part of the toe is called partial amputation of the toe.
Note – 1st or greater toe does 50% of job and hence attempt is made to save it as much as possible. Once first three toes are lost, sometimes remaining two are removed as well as they can’t help in walking but may create problems later.
Metatarsal excision – Metatarsal is the long bone behind the toe and usually some part of it needs excision along with the toe. Otherwise the projecting sharp metatarsal can cause further ulcers or leave a gap between toes
Mid foot and similar amputations – This involves removing of all toes and some part behind, leaving behind heel and half of the foot approximately. This operation is helpful in many diabetics in getting rid of infection and still allowing them to walk near normal.
Below knee (BK) amputation – This is done approx 10-12 cm below knee and the length is fixed once it is decided that foot can’t be saved. There are no other levels. It’s a major operation. It is a high risk surgery. Despite all the infection being controlled; many survive only a few years.
Above knee (AK) amputation – When below knee amputation fails or infection has spread up or circulation is very poor, above knee amputation is required.
Note – Major mutilating surgeries like, below knee and above knee amputations not treatments but usually failure of treatment and should be and can be avoided by early and proper treatment.
Blood flow related (vascular) procedures
Most diabetics have some circulation problem, but in 10-15 % diabetics, it is very poor to endanger the foot. Active treatment is required to improve the blood flow. Without adequate blood flow, wounds don’t heal and leg may need to be cut higher and higher.
Angiography of the leg (peripheral angiography)
What is it? – Literally it means visualization of blood flow in vessels. ‘Angio’ stands for blood vessels and ‘graphy’ stands for seeing. Angiography is a highly specialized test done to know the blood flowing into the leg and the foot. It is an invasive test, as an injection of some contrast is required to see blood vessels. It can be done by different methods like Digital subtraction angiography (DSA), CT angiography (CT scan of blood vessels) MR angiography (MRI scan of blood vessels), and CO2 angiography.
What information it provides? – It tells exactly where the blood is flowing and where are the blocks. This helps in the next step of angioplasty or bypass surgery. It also helps in planning nature of foot surgery as in how much part of the foot needs to be removed.
Procedure – A contrast injection is injected in the body so that the blood flowing is ‘seen’ more clearly. It can be done as a daycase. The contrast injection itself can cause serious allergic reaction or damage to kidneys.Because of different methods available, one can just do angiography in the first setting, rather than decide of angioplasty on urgent basis. The decision can be taken later whether to do angioplasty (depending upon urgency of the situation).
Angioplasty – It means actually doing something to increase the blood flow, like widening the blood vessel or putting a stent in the blood vessel. Usually this is preceded by angiography. Angioplasty is expensive. Angioplasty though sounds like a simple procedure, is a serious one; it has its own pitfalls and complications. A lot of thought needs to be put in the decision of doing angioplasty. These are some of the important issues that need to be considered before doing angioplasty.
It doesn’t help all patients – In diabetes, by the time a person gets a foot problem, the diabetes has been there uncontrolled for many years. Hence the damage to the blood vessels has happened not just in one place, but all over the body, in multiple places and in all organs, including heart brain, kidney.
Limitations of results – Even in the leg itself, there may be multiple blocks all the way up to the small blood vessels of the toes. Hence, removing a block at knee level may not always help if there are blocks further down in the foot.
Technical difficulties – Blood vessels are likely to be hardened in diabetes and difficult to open up.
Most doctors can do angioplasty only in the leg and not in the foot, because the blood vessels in foot are small. Hence it may not always work for foot problem.
In a few selected cases, angioplasty/bypass surgery can help to save the foot.
o IMPORTANT – In diabetic patients, owing to uncontrolled diabetes for many years, there are multiple hardened calcified long blocks from head to toe in all blood vessels. Most people may not get benefitted even if circulation is opened in one place. This is because, even if one block is removed, there are likely to be many blocks beyond it. The procedure itself is costly and has complications. It definitely has a place in poor circulation but is useful in very select cases and it should be used wisely.
(a) Bypass surgery – Similar to the bypass in heart, it can be done even in legs and can help in much selected cases. Here again the blocked part of the blood vessel is bypassed. For the same reasons as above, it is done in very select cases. Nowadays it is done rarely
Plastic surgery in diabetic foot
Natural skin of foot is the best option and every effort must be made to save every millimetre of the skin. The reason being, we walk on foot and the skin of sole of foot is thick and specialised to take weight. Any other replacement won’t be as good.
Most complicated plastic surgeries are difficult as skin from other parts doesn’t stick easily because of blood flow problem.
Not suturing wounds after surgery but letting them heal naturally saves a lot of skin.
Common plastic surgeries
->Local flaps – Saving skin of the foot and using it to cover raw areas, is what is done most commonly.
Skin graft – Partial-thickness skin graft can be taken from the patient’s own body, usually the opposite thigh. Skin grows there again. It is a relatively simpler procedure and has high success rate. Most general surgeons can do it without needing a plastic surgeon. But, the skin is thin and gets damaged easily. Hence, saving local skin is very important.
Anesthesia in Diabetic foot
–> Special anesthesia is necessary.
–>Anesthetic fitness – A patient will always need some test to check the status of important organs like heart, kidney, liver, lungs. Usually a physician gives fitness or a ‘green’ signal for the surgery.
–>High risk – All diabetic foot patients had diabetes for many years and that too uncontrolled. This has already damaged important organs especially the heart and kidney whether routine tests show it or not. So, when any chemical anesthetic is used, one has to take care of these important organs.
–> No general anesthesia – It is risky and best avoided.
–> Local blocks – Practically, most surgeries can be done under some local or regional block. Here, only the affected part of leg is anesthetized by selectively locating the nerves and numbing them. Popular blocks are – ring block for toe, ankle block for foot, popliteal or knee level block for major foot surgery, etc.
—> Skilled anesthetist – Just like there are specialized doctors, there are specialized anesthetists. Anesthetists may use ultrasound or other methods to locate the exact nerve.
Risk of surgery in diabetic foot
1–> Uncontrolled diabetes for years – Typically, by the time a patient comes with diabetic foot, he has had diabetes for many years with poor control of sugar
2—>Complications – Most will have complications of important organs like heart, brain, kidney.
3—> High-risk consent – Usually a high-risk consent is taken before the surgery. But, patients and relatives have a right to ask any query and a good doctor will always answer them.
Communicating to the patient – It is best to tell all the facts and risks to the patient directly. Not only, it is the legal requirement, but patients fare better when they are well informed instead of facts being hidden from them.