Diabetic Foot: Surgical Principles and Practices G Sivakumar
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IntroductionCHAPTER 1

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‘No head injury is so slight that it should be neglected or so severe that life should be despaired of’, Hippocrates 460-370 BC.
This famous aphorism aptly applies to diabetic foot. Foot can always be salvaged even in fulminant sepsis while even a trivial, ignored impalement can be life threatening.
The diabetic foot may be defined as a group of syndromes in which neuropathy, ischaemia, and infection lead to tissue breakdown resulting in morbidity and possible amputation’1
Diabetes is no longer a disease of the affluent west. Global prevalence of diabetes in 2003 was estimated to be 194 million. By 2030, this figure is predicted to rise to 366 million due to longer life expectancy and changing dietary habits. In fact the prevalence is soaring in southern India it may reach an astronomical figure of 13% to 18%.
In such a scenario knowing about the disease is important. Foot complications in diabetics are on the rise and this is attributable to many reasons. India with the oncoming diabetic epidemic and the increased geriatric population is bound to have a good percentage of its population with foot ulcers. Amputations and the ulcers that precede limb loss are largely preventable. Health education and organised foot care programmes are required to check this public health problem.
Diabetes mellitus affects every system in the body and it can be well said ‘knowing diabetes, is like knowing entire medicine’.
Every diabetic needs to know in detail about the changes in the foot. Changes are apparent and what the mind does not know the eyes do not see. Elderly diabetics with compromised vision due to retinopathy and arthritic stiff spine do not inspect their feet at all.
The metabolic complications namely raised blood sugar, etc, are now easily controlled while the foot, kidney, eye and heart are targets of long-term complications. Blood sugar values just tell you the state of diabetes but every cell in the body relentlessly undergoes changes which are reflected in long-term complications. Among all the long-term complications foot involvement is the foremost complication. The other organs affected are the heart, brain, eyes and the kidneys. Diabetic patients with foot ulcers constitute the majority of hospital admissions (Fig. 1.1). The number of admissions to hospitals for foot related complications is increasing and the limbs amputated are more than those lost in both world wars. This is of great socioeconomic importance as majority of them are in the prime earning age group and are poor (Fig. 1.2).
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Figure 1.1: Foot ulcers constitute the majority of hospital admissions
The treatment of foot ulcers needs frequent surgical consultations, use of costly antibiotics, repeated investigations, dressings and minor surgical procedures. The patients with compromised mobility find commuting to the hospital difficult.
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Figure 1.2: Majority of the foot ulcers affect the patients in their prime earning age group
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Table 1.1   Multidisciplinary team
Surgeon
Diabetologist
Podiatrist
Orthotist
Vascular surgeons
Orthopaedic surgeon
Neurologist
Social worker
Hospital admissions are expensive. These eventual foot loss are largely preventable and adequate foot care prevents foot loss.
Treatment of diabetes transgresses speciality and hence the need of the hour is ‘multidisciplinary approach’. This is well exemplified in the management of foot complications. This requires the expertise of diabetic physician, vascular surgeon, orthopaedician, neurologist, orthotist and social workers (Table 1.1).
With voluminous literature available there is a need for a comprehensive book on all aspects diabetic foot disease. This book is useful for all health care professionals involved in the management of diabetic foot disease.
Our country has a large rural population of bare foot walkers. The importance of wearing footwear must be impressed to them. This will witness a reduction of foot ulcer and eventual amputations. Footwear industry can sponsor patient education programmes and wearing footwear inside the house also need to be encouraged.
Various research papers published world over have shown that “reaching out the patient” approach has helped in reducing the amputation rate dramatically. This is more important than tertiary care. The economic impact of diabetic foot problems is very significant, as patients with foot ulcers need long, expensive hospital stay away from work. Loss of the limb is a disaster. “The most common cause of amputation of the lower limb is diabetes mellitus”.
Early detection and attention to warning signals in the foot definitely can prevent amputations. The patient once a diabetic is always a diabetic because the genetic cause persists. Patients need to have a complete knowledge of the chronological changes that takes place in the leg and foot.
The elderly diabetic with a bad spine and failing vision due to diabetic retinopathy is ‘divorced from the feet’, as they have all the difficulty of seeing the changes in the feet. The high-risk group should be identified and intense health education alone will avert amputation.
REFERENCE
  1. Krans HMJ, et al. World Health Organisation. Diabetes care and research in Europe: the St Vincent Declaration Action Programme Implementation Document (2nd edition) World Health Organisation,  Copenhagen:  1995.