Minor Amputations andProphylactic Surgeryin Diabetic Feet

Klaus Kirketerp-Møller, Consultant, Ph.d. stud

Copenhagen Wound Healing Center

Bispebjerg University Hospital, Denmark

kkm@dadlnet.dk

Levels of Foot Amputations

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Diabetes

Toe Amputations

• Indications

• Infection in IP joints

• Osteomyelitis

• Non-healing ulcer is NOT an

indication

• Gangrene with restored

perfusion

• Localized gangrene (emboli)

• Deformities in lesser toes

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Exarticulations

•Never in IP joints

•Remove cartilage in MTP

joints

•=Transmetatarsal

amputation

Joint Resection

•MTP Joints

• Infection

• Infection control

•Off-loading

•Plantar approach

•Resect cartilage on proximal

phalanx

Transmetatarsal amputations

•Single rays

• From medial side

- Up to two

• From lateral side

- Up to three

•Forefoot amputation

Chopard amputation

•Short stump

•High pressure

•Rotational forces

Symes Amputation

•Shortening

•High Pressure

•Rotational forces

•Fat pad displacement

Tissue Defects

• Definition of a diabetic foot ulcer:

• ”A defect of the skin on a foot in a person with diabetes”

• The ”beginning”

• The ”end”

How Long to Heal a Diabetic Foot Ulcer?

• ”How long is a reasonable time?”

• 3 weeks!

Tenotomy

•Curative

•Prophylactic

•Local anesthetics

•Out-patient clinic

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Nano Surgery

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One Week Later

Tenotomy Results

Consider Tenotomy

•Ulcer at pulpa

•Ulcer at dorsal PIP

•Nail changes

•Callus formation at tip of

toes

•Be aware of transfer

pressure

Achilles Tendon Lengthening

•High healing rates of

forefoot ulcers (91%)

•Transfer ulcers at heel

(15%)

•This lead to a pause in using

this procedure

• It is re-introduced due to a

change of procedure (from

percutaneous to open

technique)

Further Reading

The Diabetic Foot Triad

• “…with reported recurrence rates between 30% and 40% in the first

year.”

Guidance on footwear and offloading, IWGDF 2015

Prophylaxis

•Primary

• Diabetes Care

• Screening for Neuropathy

• Screening for PAD

• Training

• Regular Podiatry

• Appropriate foot wear

•Secondary

• Appropriate foot wear

• Training

• Regular podiatry

• Diabetes Care

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Wound Closure

• Primary Healing

• Healing by secundary intention

• Conservative

• Augmented

- NPWT

- Growth factors

- Artificial skin

• Tissue Transfer

• Split skin transplant

• Local flap

• Free flap

Titel/beskrivelse (Sidehoved/fod)

Wound Closure

• Primary Healing

• Healing by secundary intention

• Conservative

• Augmented

- NPWT

- Growth factors

- Artificial skin

• Tissue Transfer

• Split skin transplant

• Local flap

• Free flap

Wound Closure

• Primary Healing

• Healing by secundary intention

• Conservative

• Augmented

- NPWT

- Growth factors

- Artificial skin

• Tissue Transfer

• Split skin transplant

• Local flap

• Free flapInvolves a plastic surgeon

Flaps

• Why not flaps?

• Tradition

• Arteriosclerosis

• Patency

• Durability

Thank You for Your Attention

How I work

85 %

Thank you for your attention.

Navn (Sidehoved/fod)