Healing ulcers and preventing their recurrences in the diabetic foot

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1 Prof. Mir Sen (Bnerjee) CME Article Heling ulcers nd preventing their recurrences in the dietic foot S. Rj Spthy, Mdhu Perismy Deprtment of Plstic, Hnd nd Reconstructive Microsurgery nd Burns, Gng Hospitl, Coimtore, Tmil Ndu, Indi Address for correspondence: Dr. S. Rj Spthy, Deprtment of Plstic, Hnd nd Reconstructive Microsurgery nd Burns, Gng Hospitl, 313, Mettuplym Rod, Coimtore , Tmil Ndu, Indi. E mil: rjhnd@gmil.com ABSTRACT Fifteen percent of people with dietes develop n ulcer in the course of their lifetime. Eighty five percent of the mjor mputtions in dietes mellitus re preceded y n ulcer. Mngement of ulcers nd preventing their recurrence is importnt for the qulity of life of the individul nd reducing the cost of cre of tretment. The min custive fctors of ulcertion re neuropthy, vsculopthy nd limited joint moility. Altered io mechnics due to the deformities secondry to neuropthy nd limited joint moility leds to focl points of incresed pressure, which compromises circultion leding to ulcers. Ulcer mngement must not only ddress the heling of ulcers ut lso should correct the ltered io mechnics to reduce the focl pressure points nd prevent recurrence. An nlysis of 700 ptients presenting with foot prolems to the Dietic Clinic of Gng Hospitl led to the strtifiction of these ptients into four clsses of incrementl severity. Clss 1 the foot t risk, Clss 2 superficil ulcers without infection, Clss 3 the crippled foot nd Clss 4 the criticl foot. Almost 77.5% presented in either Clss 3 or 4 with complicted foot ulcers requiring mjor reconstruction or mputtion. Clss 1 foot cn e mnged conservtively with foot cre nd pproprite foot wer. Clss 2 in ddition to mesures for ulcer heling would need surgery to correct the ltered io mechnics to prevent the recurrence. The procedures clled surgicl offloding would depend on the site of the ulcer nd would need n in depth clinicl study of the foot. Clss 3 would need mjor reconstructive procedures nd Clss 4 would need mputtion since it my e life thretening. As clinicins, our min efforts must e focused towrds identifying ptients in Clss 1 nd offer dvice on foot cre nd Clss 2 where pproprite surgicl offloding procedure would help preserve the foot. KEY WORDS Dietic foot; lim slvge; offloding in dietic foot Access this rticle online Quick Response Code: Wesite: This is n open ccess rticle distriuted under the terms of the Cretive Commons Attriution NonCommercil ShreAlike 3.0 License, which llows others to remix, twek, nd uild upon the work non commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com DOI: / How to cite this rticle: Spthy SR, Mdhu P. Heling ulcers nd preventing their recurrences in the dietic foot. Indin J Plst Surg 2016;49: Indin Journl of Plstic Surgery Pulished y Wolters Kluwer Medknow 302

2 INTRODUCTION The prevlence of dietes mellitus is incresing throughout the world. Glolly, out 415 million people hve dietes which ccounts to 1 in 11 people. Indi hs pproximtely 69 million people with dietes mounting to the world s second lrgest dietic popultion. [1] Modern tretment modlities hve incresed the life spn of people with dietes nd this hs in turn led to proportionl increse in the prevlence of long term complictions ssocited with dietes, prticulrly those involving the lower lims. Fifteen percent of people with dietes re ffected y foot ulcer t some time during their lifetime, [2] nd complicted foot ulcer is one of the common cuses of hospitl dmissions in ptients with dietes. A dreded compliction of dietic foot ulcer is mjor lower lim mputtion. The World Helth Orgniztion estimtes tht, every 30 s, leg is lost somewhere in the world ecuse of dietes. [3] The incidence of non trumtic lower extremity mputtion is up to 22 times higher in dietics thn in non dietics [4] nd out 85% of these lower lim mputtions re preceded y foot ulcer. Mjority of these mputtions re preventle if these ulcers re treted t n erly stge. For long, clinicins hve een concentrting on heling of these ulcers y vrious medicl nd plstic surgicl techniques nd hve very frequently een chllenged y their stuorn refusl to hel or erly recurrence in surgiclly heled wounds. Reserch on the pthophysiology of these ulcers hs shown tht derngement of the iomechnics of the foot plys n importnt cusl reltionship in the occurrence of these ulcers. [5,6] Estlishment of the cuse of individul ulcers helps pln the pproprite surgicl procedure to hel the ulcer nd prevent its recurrence. PATHOLOGY OF DIABETIC FOOT ULCERS Three mjor fctors ply dominnt role in the custion of dietic ulcers. They re neuropthy, limited joint moility nd ischemi [Figure 1]. Mjority of ulcers in Indi occur in neuropthic foot, [7,8] nd infection in such ulcers ws found to e responsile in 90% of the mputtions in one series. [7] NEUROPATHY Figure 1: Trid of fctors cusing dietic foot ulcer Neuropthy of dietes ffects the motor, sensory nd utonomic nerves. Motor neuropthy cuses intrinsic muscle trophy which results in deformities, ony prominences due to soft tissue trophy nd disrupts the norml position nd orienttion of the smll joints of the foot nd toes [Figure 2]. These normlities led to focl res of high pressure on the plntr spect of the foot nd norml strin ptterns in ones due to loss of soft tissue support. Sensory neuropthy results in loss of protective senstion cusing the ptient to ignore the wrning signs of tissue dmge till complictions nd systemic symptoms occur. Autonomic neuropthy cuses imlnces in lood flow nd reduction in the moisturiztion of the skin resulting in crcks nd dely in wound heling. LIMITED JOINT MOBILITY Limited joint moility is the stiffness of joints of the hnds nd feet seen with incresed frequency in ptients with dietes mellitus. It results from ltertions to the properties of elstin nd collgen fires of ligments nd tendons s result of non enzymtic glycosyltion nd excessive dvnced glyction end product (AGE) deposition. Limited joint moility plys significnt role in the development of plntr ulcers in people with dietes. People with dietic neuropthy nd ulcertion were found to hve higher incidence of reduction in joint moility compred to non dietic people nd dietics without neuropthy. Limited joint moility is ssocited with normlly high plntr pressures [9] nd when comined with sensory 303

3 loss leds to n increse in the incidence of plntr ulcers. [10] Limited joint moility comined with sher forces results in the formtion of clluses on the sole. These clluses which develop to protect the skin from these high sher forces, eventully turn deleterious s they result in n increse in the focl pressure y out 26%. [11] Persistent high pressures underneth these clluses led to the rekdown of the underlying skin nd soft tissues resulting in sucllus ulcers [Figure 3]. These ulcers which re initilly superficil grdully deepen due to prolonged repetitive trum nd rech tendon, one or joint cusing loclised deep tissue scess or osteomyelitis. Infection cn then rpidly spred proximlly long the loose tissue nd tendon plnes nd cuse life or lim thretening complictions. Pressure redistriution y surgicl restortion of joint pliility leds to lower focl plntr pressures nd susequently reduced recurrence of plntr ulcers. [12] ISCHAEMIA A dysvsculr foot is defined s foot without ny plple pedl pulse or documented nkle rchil pressure index (ABPI) of <0.9 or >1.3. [13] Mcrovsculr vsculr disese of the lower lim in dietes ffects the mjor rteries. Its mngement depends on the loction of the lock nd requires the involvement of vsculr specilist. In generl, suprpoplitel disese responds well to endovsculr therpy while infrpoplitel vsocclusive disese hs improved long term ptency rtes with open surgery. The ypss versus ngioplsty in severe ischemi of the leg (BASIL) study fvoured primry open surgery if the ptient hd life expectncy of >2 yers nd hd good vein for ypss grft. Endovsculr therpy ws the first choice for ptients with limited life expectncy nd those who required prosthetic grfts for ypss. [14] Endovsculr techniques hve, however, evolved t rpid pce since the BASIL study nd drug eluting stents nd lloons hve improved the success rtes of endovsculr therpy for tiil disese. [15] MANAGEMENT OF ULCERS Offloding Offloding of pressures in the foot is the gold stndrd for tretment of trophic ulcers of the foot. Offloding hs een proven to hel ulcers y reducing the pressures t the high pressure foci nd re distriuting them cross the entire weightering surfce of the foot. Conventionlly, offloding the deformed dietic foot hs een done with the help of externl devices such s totl contct csts, prescription footwer, orthoses, rces nd other externl offloding devices. These removle devices, however, require very high degree of complince for them to e effective nd ptients hve een shown to wer them only 22% 28% of the prescried time. [16,17] Surgicl offloding, lso known s internl offloding, ims to dissipte pressure throughout the plntr surfce of the foot y helping to restore moility of the stiff joints, restoring correct posture, correcting deformities nd mximising preservtion of the contct surfce of the foot. Surgery is idelly done in ptients with pre ulcertive chnges who hve filed conservtive mesures or in those with erly uncomplicted ulcers. Clinicl stging of the dietic foot Bsed on our oservtion in 700 cses of ulcers t the specil Dietic Foot Clinic t Gng Hospitl, we hve evolved stging of the dietic foot into the 4 ctegories of incrementl severity [Tle 1]. Stging of the cses is useful in guiding the line of mngement mongst vrious involved specilties nd explining the prognosis to the ptient [Figures 4 7]. Figure 2: () Deformity due to neuropthy () prominences with corresponding clluses Figure 3: () Cllosity () skin rekdown cusing sucllus ulcers 304

4 The surgeon s pproch to the tretment of dietic foot ulcer needs to e different while mnging ech of the following presenttions. A ptient with only pre ulcertive chnges nd other risk fctors such s sensory loss (Gng Clss 1) cn e mnged with pproprite footwer nd other non surgicl supportive mesures. A ptient with chronic uncomplicted non heling ulcer unresponsive to conservtive mesures (Gng Clss 2) is mnged with preventive surgery (surgicl offloding). A ptient with complicted ulcer nd extensive skin nd soft tissue loss (Gng Clss 3) requires reconstructive surgery in the form of Tle 1: Gng Hospitl stging of the dietic foot Stging Foot type Description Gng Clss 1 Foot t risk No ulcer or pre ulcertive chnges only Gng Clss 2 Ulcerted foot Superficil uncomplicted ulcer Gng Clss 3 Crippled foot Deep ulcer extending to tendon, joint or one with Loclized Infection with or without Soft tissue loss requiring reconstruction/criticl lim Ischemi with no ulcer or with minor gngrene Gng Clss 4 Criticl foot Complicted ulcer with thret to lim or life/unslvgele foot/ Frnk Ischemic Gngrene split skin grfts or flps followed y surgicl offloding once the wounds hve heled. Neglected ulcers which hve progressed to lim or life thretening situtions (Gng Clss 4) necessitte urgent mjor mputtion. The ove descried clssifiction ws evolved on the sis of our experience in 700 ptients till Decemer Applying the new clssifiction to continuous series of 188 ptients dmitted s inptients for tretment of foot ulcers during the period of 9 months from Jnury to Septemer 2016, we found tht 22.3% of ptients fell into Gng Clss 2, 57.9% of ptients into Gng Clss 3, nd 19.6% into Gng Clss 4. Clss 1 ptients re treted s outptients with dvice on foot cre nd re not included in this group of 188 ptients. The Gng Clss 2 ptient, if identified nd treted ppropritely y surgicl offloding, cn e prevented from progressing to Gng Clss 3 or Gng Clss 4 sitution nd potentil lim loss. The surgicl methods y which this gol cn e chieved nd recurrences prevented re the focus of this rticle. SURGICAL MANAGEMENT OF GANGA CLASS 2 DIABETIC FOOT (SUPERFICIAL UNCOMPLICATED ULCERS) To simplify the pproch of treting the uncomplicted dietic foot ulcers (Gng Clss 2) nd preventing their Figure 4: Clss 1 Foot t risk. ( nd ) Foot with cllus ut no ulcer Figure 5: Clss 2 Ulcerted foot. ( nd ) Foot with ulcers which do not involve deeper structures nd there is no invsive infection Figure 6: Clss 3 Crippled foot. () A complicted gret toe ulcer with invsive infection evidenced y swelling, erythem nd le formtion proximl to the ulcer. () Sme foot fter deridement which shows the extent of soft tissue loss due to infection Figure 7: Clss 4 Criticl foot. Extensive trnsmurl infection complicting gret toe ulcer cusing soft tissue gngrene oth on the () plntr nd () dorsl spect with systemic sepsis. Ptient underwent elow knee mputtion 305

5 recurrence, this rticle hs divided ulcers ccording to the following loctions: Gret toe ulcers Minor toe ulcers Forefoot ulcers Mid foot ulcers Heel ulcers Dorsl ulcers. Ulcers in ech specific loction hve unique pthomechnics nd require specilised surgicl pproch for lsting cure. Gret toe ulcers Hllux ulcers ccount for out one third of ll ulcers in the dietic foot. [18,19] They re primrily of two types, the plntr hllux inter phlngel joint (IPJ) ulcer nd the plntr hllux suungul ulcer. The pthogenesis of the hllux IPJ ulcer is closely linked to the stiffness of the first mettrsophlngel (MTP) joint. [20] This my mnifest cliniclly s the structurl hllux limitus where there is difficulty in extending the first MTP joint in non weightering foot eyond 60. [20] It my lso e present more sutly s functionl hllux limitus which is defined s the inility of the proximl phlnx (PPX) to extend on the first mettrsl hed during git. [21] Functionl hllux limitus is dignosed cliniclly y the Huscher s mnoeuvre which involves demonstrting the inility to pssively dorsiflex the first MTP joint while the ptient is stnding on his/her feet. Both of the ove conditions re relted to the inelstic plntr common intrinsic tendons pssing from the intrinsic muscles to the se of the PPX of the gret toe through their respective sesmoids ones. These tendons include the fires of the plntr fsci which extends from the clcnel tuerosity to the se of the PPX nd the intrinsic muscles of the gret toe [Figure 8]. The windlss mechnism of the plntr fsci which psses round the first mettrsl hed to e inserted into the se of the PPX nd its ssocited structures help mintin the medil longitudinl rch of the foot during weightering y cusing flexion of the first ry [Figure 9] during dorsiflexion of the gret toe. Conversely, this ntomicl rrngement cuses flexion of the PPX of the gret toe with dorsiflexion of the first ry during weightering which results in n increse in the pressure on its hed t the level of the IPJ. Figure 8: Intrinsic tendons inserting into the proximl phlnx se of the gret toe. The shded prt of the one long with the insertion of the common intrinsic tendons is excised in Keller rthroplsty This comined with the loss of elsticity of the plntr soft tissues, [22 24] genertes very high pressures nd sher forces t the interphlngel (IP) joint of the gret toe. In foot devoid of protective senstion, the ove fctors led to the formtion of cllus under the IP joint of the gret toe which if left untreted results in progressively deepening ulcertion of the toe. Plntr hllux IP joint ulcers re est treted y procedures tht im to restore the moility of the first MTP joint during git. In ptients who present t n erly stge of the disese with only functionl hllux limitus nd with reltively moile MTP joint, selective plntr fsci relese is done. [25] This procedure cn e done through longitudinl incision t the medil edge of the plntr fcil nds t the level of the trsomettrsl joints [Figure 10]. The plntr fscil nds to the gret toe re divided nd excised. A Keller excision rthroplsty of the first MTP joint is done for ptients with hllux rigidus nd reclcitrnt IP ulcers unresponsive to conservtive mesures. [26,27] The proximl third of the se of the PPX of the gret toe long with the insertion of the intrinsic tendons is excised through dorsl or dorsomedil pproch [Figure 11]. The wound is closed primrily over drin nd the ptients put on non weightering moilistion until suture removl. The ulcer is usully left to hel spontneously fter cllus removl nd scooping of its floor. A suset of ptients hve n ulcer of the suungul tip of the gret toe. The pthomechnics of these ulcers is different from the IP joint ulcers nd is ssocited with 306

6 Figure 9: Schemtic digrm representing the Windlss mechnism () reduction of rch height with relxtion of the plntr fsci () the increse in the rch height tht hppens with the tightening of the plntr fsci during toe dorsiflexion Ulcers of the minor toes Ulcers of the minor toes re usully ssocited with clw nd mllet deformities of the toes which occur due to the intrinsic prlysis ssocited with motor neuropthy. These deformities cuse the tip of the toes to hit the floor nd the dorsum to sher ginst footwer resulting in ulcers. These ulcers rpidly penetrte to the one nd result in osteomyelitis which is cliniclly ssocited with rpid swelling of the whole toe nd is termed s susge toe [Figure 13]. [29] Figure 10: Selective plntr fsci relese. () Demonstrting the plntr fscil nd to the gret toe. () After excision d e Figure 11: Keller rthroplsty for plntr hllux interphlngel ulcers. () Plntr hllux interphlngel joint ulcer. () The proximl third of the proximl phlnx of the gret toe is removed through dorsl incision. (c) It results in slightly shortened ut moile nd ulcer free digit. (d) Pre nd (e) Post opertive X rys of the sme ptient showing the extent of one resection of the se of the proximl phlnx of the gret toe dynmic flexion deformity of the IP joint nd flexor hllucis longus (FHL) contrcture. These ulcers cn e heled nd cn e treted y tenotomy of the FHL tendon distl to its connection with the flexor digitorum longus (Henry s knot) t the midfoot, most commonly t the plntr se of the gret toe [Figure 12]. [28] c If the infection reches the long tendon of the toe t the se of the distl phlnx, there is rpidly spreding tenosynovitis which my endnger the lim itself. It is hence very importnt to ddress ulcers of the toes s erly s possile. Deformed toes tht hve pssively correctle joint deformities cn usully e mnged with soft tissue procedures while those toes with fixed deformities require ony ltertions. A mllet deformity with only DIP flexion contrcture cn e mnged with tenotomy of the long flexor tendon [28] done through longitudinl plntr incision t the level of the se of the toe [Figure 14]. A clw toe with MTP hyperextension nd PIP nd DIP flexion will require intrinsic functionl restortion with tendon trnsfers [30,31] such s Girdlestone Tylor trnsfer to correct the deformity. Here, the intrinsic function is reconstructed y trnsferring the long flexor of the toe dorslly to the extensor expnsion nd correcting the MTP hyper extension y lengthening the extensors in Z fshion [Figure 15]. Fixed deformities my e corrected with rthrodesis of the respective joints in neutrl position. Ulcers of the forefoot These ulcers locted under the mettrsl heds re closely linked to multiple fctors such s distl displcement of the ft pds eneth the mettrsl 307

7 Figure 12: () Plntr hllux suungul ulcer () ulcer heling fter tenotomy of the flexor hllucis longus tendon Figure 13: A swollen susge second toe indicting n underlying osteomyelitis with sinus Figure 14: () A mllet toe deformity with tip ulcer () well heled ulcer fter flexor tenotomy heds, flexed mettrsls, n excessively pronted or supinted foot nd most importntly n nkle in equinus due to contrcture of the tendo chilles pprtus.[32 35] A thorough clinicl exmintion helps to decipher the contriutory fctors which re then ddressed ppropritely. Ulcers under the first mettrsl hed need to e viewed seprtely from the minor mettrsls considering its importnce in lod shring. Hence most procedures for first mettrsl hed ulcer re imed t preserving it. An isolted prominent moile flexed first mettrsl with clwing of the gret toe cn e treted y Jones trnsfer which involves trnsferring the extensor hllucis longus to the first mettrsl shft long with fusion of the IP joint of the gret toe [Figure 16]. Prontion of the foot is comintion of three movements duction of the hindfoot, eversion of the forefoot nd dorsiflexion. In n excessively pronted foot, there is proportionlly more lod ering long the medil rch nd first MTP joint. Relese of the tight peroneus longus Figure 15: A Girdlestone Tylor flexor to extensor hood trnsfer with Z lengthening of the extensors for clw toe correction nd its trnsfer to the peroneus revis reduces the pronted posture nd helps offlod the first mettrsl hed. A soft tissue equinus cn e ddressed y either gstrocnemius slide or gstrocsoleus slide [Figure 17] depending on the clinicl finding of n isolted gstrocnemius contrcture or comined gstrocnemiussoleus contrcture which cn e differentited y the Silfverskiold test.[36 38] The test is done y testing the dorsiflexion of the nkle with the knee in extension nd then in flexion. Limittion of pssive dorsiflexion of the nkle to 10 from neutrl signifies the presence of n equinus. The presence of n equinus contrcture with the knee in extension ut not in flexion signifies n isolted gstrocnemius contrcture while restriction of dorsiflexion oth with the knee extended nd flexed signifies the presence of oth the gstrocnemius nd soleus contrcture. 308

8 Ulcers over the minor mettrsl heds re ddressed y the excision of the involved mettrsl hed through dorsl pproch. [39,40] Here too n ssocited equinus deformity, if present, is ddressed y gstrocsoleus recession. However, possiility of susequent development of new trnsfer ulcers over the djcent mettrsl heds must e kept in mind when such n opertion is done. A split tiilis nterior tendon trnsfer (STATT) cn e done to correct n overtly supinted foot (hindfoot dduction, inversion t the forefoot nd plntr flexion) with ulcers long the lterl longitudinl rch nd fifth mettrsl hed. The tiilis nterior is split longitudinlly nd the lterl hlf trnsferred to new insertion on the lterl spect of the foot to correct the supintion deformity. Ptients who hve multiple ulcers or those with new ulcers over previously unffected mettrsl heds (trnsfer ulcers) re cndidtes for pn mettrsl hed resection. [41] This opertion is however reserved for difficult cses s excision of ll mettrsl heds results in the ltertion of the propulsive phse of the git cycle. Midfoot ulcers Ulcers of the midfoot re usully ssocited with structurl disorgnistion of the midfoot secondry to Chrcot neuropthic osteorthropthy which is progressive non infectious destruction of one nd joints. In these ptients, high midfoot stress cused y n equinus contrcture of the tendochilles results in multiple frcture disloctions of the midtrsl nd trsomettrsl joints due to ltered mechnicl strin ptterns of the disesed one. The clcneus is plntrflexed long with the midfoot y the pull of the tendochilles while the forefoot get dorslly displced y the toe dorsiflexors nd the stress of forefoot loding, resulting in rocker ottom deformity with plntr midfoot ony exostosis. This cuses weightering to e concentrted onto the prominent midfoot nd results in ulcers. Tretment of these ulcers depends on the Eichenholtz stge [Tle 2] of the Chrcot s osteorthropthy. If the ony disese is in the cute stge (Eichenholtz 1), the idel solution would e to tret the ulcer with trditionl plstic surgicl techniques nd rest the foot. Once the ulcer hs heled nd the osteorthropthy turns to the sucute, colescence stge, the ptient is tken up for n orthopedic correction of the collpse nd its stilistion with implnts extending from the mettrsls to the tlus nd clcneum. [42,43] In foot with chronic consolidted disese nd fused ony elements, the ulcer recurrence cn e prevented y excising the ony exostosis through medil or lterl pproch [Figure 18] [44] nd using customised footwer postopertively. Hind foot ulcers Hind foot ulcers re relted closely to insufficiency of the gstrocnemius soleus complex just s forefoot ulcers Tle 2: Eichenholtz stging of chrcot osteorthropthy Stge Presenttion Description Stge 1 Acute, developmentfrgmenttion Mrked redness, swelling, wrmth; erly rdiogrphs show soft tissue swelling, nd ony frgmenttion nd joint disloction my e noted severl weeks fter onset Stge 2 Sucute, colescence Decresed redness, swelling nd wrmth; rdiogrphs show erly ony heling Stge 3 Chronic, reconstructionconsolidtion Redness, swelling, wrmth resolved; ony heling or nonunion nd residul deformity re frequently present Figure 16: () Plntr ulcer eneth the first mettrsl hed. () Extensor hllucis longus trnsferred to the first mettrsl. (c) Well heled ulcer c Figure 17: Gstrocsoleus recession done to correct comined gstrocnemius nd soleus contrcture. In cse of n isolted gstrocnemius contrcture, the relese is done t just elow the gstrocnemius insertion leving the soleus tendon fires intct 309

9 re relted to its contrcture. Inefficient function of the gstrocsoleus cuses clcnel git with overloding of the hind foot. [45] When this iomechnicl normlity occurs in the insenste foot, it cuses the development of n intrctle heel ulcer which is resistnt to ny form of wound cover. A pedorogrm clssiclly shows little or no forefoot loding in such ptients [Figure 19]. The cuse of the tendo chilles deficiency must lso e scertined s its correction is impertive for the mintennce of well heled hind foot. Some of the most common cuses include n unrecognised closed tendochilles rupture nd Chrcot s frcture of the clcneum where the frctured posterior tuerosity long with the tendochilles insertion is discontinuous from the rest of the clcneum. Discontinuity of the tendochilles insertion cuses loss of forefoot lod trnsmission nd concentrtion of the entire lod onto the hindfoot. This norml clcnel git cuses reclcitrnt ulcer resistnt to ny form of wound heling therpy. These heel ulcers cn only e stly heled y reconstruction of the tendochilles clcnel forefoot xis. Options for tendochilles reconstruction include direct repir with or without lengthening nd interposition fsci lt grft if distl stump is ville. Tendo chilles sustitution y flexor hllucis or peronel tendon trnsfers my e used if the distl stump is not ville [Figure 20]. [46 50] Figure 18: () Midfoot ony prominence in foot with Stge 3 consolidted Chrcot s thropthy with collpsed mlunited Midfoot () fter excision of the prominence Figure 19: Pedorogrms of ptient with right sided heel ulcer. () the pedorogrm of the norml left foot showing oth forefoot nd hindfoot loding. () the pedorogrm of the ffected foot of the sme ptient showing norml hindfoot loding only with little or no forefoot loding In ptients who re unsuitle for soft tissue trnsfers, nkle fusion in neutrl position cn e considered to stilise the foot nd llow heel offloding y lod trnsfer to the stle forefoot. Dorsl ulcers Dorsl wounds of the toes re usully cused y friction ginst n ill fitting footwer. This cn e voided y tking cre to prescrie customised footwer with spcious toe oxes to ccommodte deformities nd mking sure tht the foot does not move within the footwer. Surgicl procedures for deformity correction will reduce the chnce of such ulcers. Wounds on the dorsum of the foot re invrily secondry to n infective etiology. The cuse of infection is usully rek in the skin integrity due to utonomic neuropthy which cuses dry, itchy skin due to reduced sweting, [51] intertrigo or pronychi. The infection then spreds esily long the loose dorsl tissue plnes. These ulcers cn usully e mnged y good deridement nd conventionl Figure 20: Tendochilles repir y suture nchor with flexor hllucis longus ugmenttion. () Divided tendochilles with gp nd no distl stump () flexor hllucis longus trnsferred through the clcneum to provide new insertion. (c) Repir completed with flexor hllucis longus weved into the lengthened proximl tendochilles stump plstic surgicl techniques. Recurrences cn e voided y tking good skin nd nil cre nd correction of nil deformities. c 310

10 RECONSTRUCTIVE SURGERY FOR GANGA CLASS 3 ULCERS (COMPLICATED DEEP ULCERS WITH SKIN AND SOFT TISSUE LOSS) This clss of ptients usully present with systemic signs of complicted ulcer such s fever. They give history of recent onset of foul smelling dischrge from the ulcer long with swelling, redness nd wrmth in the involved foot nd n inility to wlk on the ffected foot. The importnt initil step in the tretment of such ptients is rdicl deridement of the ffected re. Knowledge of the potentil routes of spred of the infection long different plnes is essentil to ensure good result. In our experience, single exhustive deridement is usully enough for infection control in 89% of ptients, nd multiple deridements re exceptions rther thn the rule. Once infection control nd clen ed hve een chieved nd lood sugr hs een stilised, the ptient is tken up for wound cover s soon s possile. The type of wound cover depends on the ed rther thn their ility to provide cushion for weightering. As long s the underlying iomechnicl defect stnds uncorrected, the type of wound cover would mke little difference to the recurrence of the ulcer. The reconstructive ldder is usully followed with regrd to covering of the wound in the dietic foot, nd plenty of literture is ville for the interested reder on the topic. [52 54] We present few situtions in which we find the use of free flp is gretly helpful in the slvge of complicted dietic foot ulcers [Figures 21 nd 22]. Once the wounds hve heled, it is importnt tht these ptients re offered pproprite surgery for internl offloding to correct the pthomechnics which ws responsile for the initil ulcer. In the series of 188 consecutive ptients with foot ulcers dmitted for surgery during the period from Jnury to Septemer 2016, out 19.6% presented with lim tht hs een ffected eyond meningful functionl slvge or one tht poses n imminent thret to life due to spreding sepsis (Gng Clss 4). A mjor lim mputtion my e required in such ptients either s life sving mesure or to improve their qulity of life. We try to preserve the knee joint s much s possile in these fril ptients so s to reduce their energy expenditure during moilistion. After recovery it is essentil to provide these ptients with ccess to good qulity prostheses fitment nd to encourge nd provide them with supervised trining on their use. ROLE OF MULTIDISCIPLINARY APPROACH Surgery forms only prt of the mngement of the ptients with dietic foot ulcer. These ptients need holistic pproch of dedicted tem which includes physicins, plstic surgeons, orthopedic surgeons, nesthesiologists, vsculr surgeons nd poditrists. Ptients with crdic nd renl prolems will need specilised help to optimise their condition oth efore nd fter the surgery. Anesthesiologists skilled in regionl locks gretly contriute towrds ptient sfety during surgery. Their verstility in vrious peripherl nerve locks helps us undertke surgicl procedures on moriund ptients who pose high risk for generl or spinl nesthesi. Ptients need to e offered supportive services such s customised footwer, skin nd nil cre for the prevention of recurrence of ulcers. Digitl pedorogrphy plys n importnt role in oth ojective documenttion of high pressure res nd for designing of customised footwer for the post surgicl foot. An in house footwer unit providing sleek nd Figure 21: () Post infective defect with loss of two centrl rys fter deridement () with grcilis free flp efore inset (c) post free flp cover Figure 22: () Heel defect with extensive soft tissue loss fter deridement () with grcilis flp (c) well settled free grcilis flp c 311

11 well designed footwer improves ptient confidence in footwer, ensures complince nd mximises ptient stisfction, fctors, which re very importnt in reducing the recurrence rte of ulcers. CONCLUSION Ech time when we look t n ulcer we need to think s to wht is the cuse of the ulcer rther thn just thinking of techniques to provide wound cover. Correcting the cuse of the ulcer s erly s possile will not only hel the ulcer nd prevent its recurrence ut will lso go long wy in voiding mny needless mputtions. Perhps tht ojective would need the ptient with dietes to seek surgeon s opinion the moment they form cllus. Finncil support nd sponsorship Nil. Conflicts of interest There re no conflicts of interest. REFERENCES 1. Interntionl Dietes Federtion. IDF Dietes. 7ed. Brussels, Belgium: Interntionl Dietes Federtion; Aville from: [Lst cited on 2016 Apr 14]. 2. Americn Dietes Assocition. Consensus Development Conference on Dietic Foot Wound Cre: 7 8 April 1999, Boston, Msschusetts. 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