diabetic foot

1. MINIMALLY INVASIVE
SURGICAL MANAGEMENT
OF DIABETIC FOOT
(The Charcot Foot)
PROF. SALAH EL-NOUR, F.R.C.S.
DEPARTMENT OF ORTHOPEDICS
SECURITY FORCES HOSPITAL PROGRAM
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2. Diabetes Mellitus
EPIDEMIOLOGY
 800,000 new cases / year (USA)
 10,000,000 people currently diagnosed
 5,000,000 Potential
 Leading cause of lower extremity amputations
(LEA) in both the U.S.A. & Europe
 50% of all non-traumatic LEA occur in people with
diabetes = 56,000 cases / year
 20% of all diabetic patients will develop a
significant ulcer = 1,500,000 cases
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3. Diabetes Mellitus
THE COST of CARE - $$$$$$$$
 2005 = $120,000,000,000 (billion!)
 Hospital related care = $44.1 Billion
 Ulcer Care = $4,595 / ulcer
 $28,000 more for next 2 years of care
 1999 – 800,000 prevalent ulcers @ $5,457 /
patient = $5 Billion
 Cost of LEA = $20,00 - $40,000
ECONOMICS:
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4. AETIOLOGY
 ENDOCRINE
 VASCULAR
small & large vessels (Arteriosclerosis, Microangiopathy, V. Nervousa
 NEURAL
Central & Peripheral Nervous System
Segmental Demylination
Degeneration of Sensory Fibers
Neurodystrophic changes
 BONE
Vascular & Neural element
Osteopathic lesion
Charcot Arthropathy
Infection
 MUSCLOSKELETAL
Ulceration, Charcot Arthropathy, Infection
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5. ULCER FORMATION
 Callosity, Dryness
 Breakage
 Cavity Contamination
 Blockage Spread
 Pressure Point
 Trophic Changes
 Perforating Planter Ulcer

6. MIS

7. DEEP
HOSPITALIZE
IV ANTIBIOTICS
SURGICAL CARE
(Local & Causes)
SUPERFICIAL
OUT- PATIENT
ANTIBIOTICS, REST,
CARE
IMPROVED 48 - 72
HRS.
NOT
IMPROVED
DIABETIC FOOT INFECTION
PROTECTION
CONTACT PLASTER,
AFO, DIABETIC SHOES
Aim: Plantigrade stable, shoeable foot
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8. FACTORS CAUSING AND PROMOTING
ULCERATION & INFECTIONS
INFECTION
GOOD
FOOTCARE
ULCERATION
PROMOTE
HEALING
 Mechanical
 Vascular
 Hematological
 Immunological
 Bacteriological
 Chemotaxis & Phagocytosis
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9. LOAD DISTRIBUTION & PRESSURE POINTS
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10. Patterns of Bone &Joint Destruction
(Ulcers & Charcot)
 Forefoot: MTP, IP
 Lisfranc:
 Chopart: TN-, CC- joint
 Ankle joint
 Calcaneus
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11. Surgical Management of Diabetic Foot
 Prophylactic surgery: (MIS)
 Soft tissue release (ETA, G.Recession)
 T. Achillis lengthening ( 80% for foot, 10% hind
foot ulcer healing)
 Osteotomis and fusion
 Limb salvage procedure (Vascular)
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13. Lengthening of Achilles
Tendon
 aim: pressure release
on midfoot
 technic: gastrocnemius
resection
 G. Release, ETA
 Load Mid & Fore foot
 Prerequisite for Ulcer Prevention & HealingMIS

14. Exostosectomy
 remove plantar bony
prominences
 produce a plantigrade
foot - to give the
shoemaker a chance
Internal decubitus
Exostectomy
M/L Incision, Plantigrade surface
Contact Cast, AFO, >> Chance Shoemaker
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15. Diabetic Charcot Arthropathy
THE SEQUENCE OF EVENTS
 Maintain Suspicion Index  Recognize at risk patient
 A Swollen Foot -------- MISDIAGNOSIS
 Deformity of the Foot
 Foot Ulceration(s)
 Infection / Osteomyelitis / Disintegration
 Partial / Complete Amputation
 Dilemma: Progressive, Non Infective Destructive
Process Associated with Neuropathy
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16. Natural History of Charcot Foot
 Stage of acute, destructive period
 Stage of coalescence: destruction, healing
 Stage of reconstruction: further repair and
remodelling of bone, restore stability
Charcot joints 1966 Springfield III
STAGES:
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17. MIS
2007

18. Diabetic Charcot Arthropathy
Case Presentation
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20. Stage 0 Charcot Foot
LONG TERM TREATMENT
 Custom Bracing
 Custom Orthotic Devices
 Custom Shoes
 Periodic Monitoring
 Serial Radiographs
 Prophylactic Bracing of
Contralateral Limb
 Further Patient & Family
Education
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21. The Charcot Joint
 Deformily 
 Instability 
 Pain 
 Prophylactic Surgery?
 Anthrodesis (Regidity)
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30. Diabetic Charcot Arthropathy
RELOCATION ARTHRODESIS
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31. Thank You
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