Amputation commonly refers to the removal of any extremity or external part of the body.

Amputation of the lower limb is a life-saving procedure. It is done in patients in whom the lower limb has become dead due to infection or loss of blood supply. The dead tissues release toxic substances into the circulation, which can cause the failure of the critical organs like heart, liver and kidney in diabetic patients. Prolonged exposure to these toxins can cause irreversible damage to these organs resulting in multi-organ failure and death. It is also done in some cases with soft tissue defects or bony defects which prevent ambulation and reconstruction is complicated or not possible

The most commonly done amputations in diabetes are removal of the toes, part of the foot (Transmetatarsal amputation) or the entire foot at a level just below the knee (Below knee amputation) and rarely removal of the leg at the mid or lower thigh (Above knee amputation). Of these amputations only, the Below knee and Above knee amputations need fitting of artificial limbs for further walking. Toe amputations or partial foot amputations do not need any sort of artificial limb for walking.

No. Modern prosthesis technology has made it possible for even the frailest of persons to walk independently using artificial lower limbs. It is necessary to wear a good quality prosthesis, and this must be fit at a dedicated prosthetic centre with full-time prosthetists available for proper scientific training and support. It is essential that the patient has a good experience with the prosthesis from day one so that they feel confident and motivated to continue using the prosthesis. In our experience, we have many older adults who now lead a good quality of life after a major amputation and fitting of good artificial limbs.

On an average, it takes about 2 weeks for a stump to heal after surgery. However, the stump needs some time for maturation before it becomes ready to fit an artificial limb. During this waiting period, the amputee is taught muscle strengthening exercises and undergoes compression therapy to reduce the swelling in the stump.

Artificial limbs in diabetic patients are usually fit at about four weeks after the stump wounds heal or about 6 weeks after the operation. However, a few patients who are very weak and have poor heart and lung function may require some more time before they are strong enough to walk with artificial limbs

All patients who have been amputation and fitted with artificial limbs have the potential to achieve their pre-amputation activity levels. All that they require is a proper professional training, support and motivation from family members. Those patients who have a will and desire to walk, jog or run will not be hindered from achieving their wish due to an amputation. This has been made possible due to technologically advanced, lightweight and robust materials used in the manufacture of the modern prosthesis. Hence it is essential to choose a good prosthesis with good pre and post fitting support and service.

A Callus is a thickened area of the outermost layer of skin (Epidermis) that if formed as a response of that part of the body to repetitive mechanical trauma such as pressure, shear and friction

Calluses develop as a protective mechanism. When a part of the skin (commonly foot and hands) is subjected to repetitive forces the epidermis thickens due to accumulation of keratotic cells. This helps that part of the skin to withstand these forces better

Though calluses develop as a protective response of the skin to mechanical trauma they turn deleterious in a few people, especially, in those without adequate sensation in their feet. As dead cells accumulate in the callus it becomes harder in nature. Slowly it becomes so hard that this callus starts to act like a stone under the foot. When it reaches this stage, it increases the pressure on the skin under the callus by about 30% which hastening its breakdown resulting in an ulcer[1]. In effect the callus which was formed to protect the underlying skin ends up hastening its damage. Hence it is advisable for people with insensate feet to get their feet checked for calluses and get them removed at regular intervals.

As Soon as possible. Studies have shown that for a diabetic person the risk of getting an ulcer is 11 times higher when they have an untreated callus[2]. A callus is a pre-ulcerative change and hence it is advisable to get professional help at a dedicated centre once you develop a callus. In people with diabetic foot disease it is said that TIME = TISSUE. Hence the earlier you get medical attention, greater is the chance of preventive tissue loss.

A callus is usually managed by application of keratolytic creams or mechanically by shaving of the callus till normal skin. However, the advantages of getting your callus checked at a dedicated foot care centre is that doctors will be able to identify the specific reason for callus formation and treat the underlying cause (deformity or stiffness of joints) earlier in the course of the problem. A pedicure at a beauty care centre, done improperly with unsterile instruments and self-taught technicians who do not understand the vulnerable and tender nature of the diabetic foot is an assault on the foot which may lead to undesirable consequences.

No. Callus removal is an out-patient (OP) procedure which can be done in the surgeon’s office. It does not require any anesthesia or admission as an inpatient as it is a painless procedure which involves removal of dead cells only.

Most patients are allowed to walk immediately after a callus removal but a small subset of patients who have had a removal of a black coloured callus (due to bleeding under the callus which indicates the formation of a sub-callus ulcer) may require to rest the foot to allow the wound to heal before they are given customized footwear and allowed to walk.

Yes. You can go back to work as soon as you are allowed to walk.

Yes. As no anesthesia is required you can drive back home. Those with a black callus are advised to rest the foot for a few days to allow it to recuperate before they resume their normal activities. However, it must be noted that all diabetics with callus must wear customized prescription footwear at all times when they are one their feet (both within and outside of their homes).

Cellulitis means the inflammation of the subcutaneous cellulite (fatty) tissues. The most common reason is a bacterial infection of the fatty tissues below the skin.

Cellulitis presents with pain, swelling and redness of the affected area. The patient may or may not have an associated fever. The patient usually mistakes the pain for a sprain or muscle pull and massages the area with oil or a pain balm which may worsen the problem by causing the infection to spread to newer areas.

Cellulitis mostly develops in immunocompromised patients like those with Diabetes or other causes of low immunity. Many patients are actually found to be diabetic for the first time during the course of treatment for a cellulitis episode. In these susceptible patients a small inoculum of bacteria in the skin and subcutaneous fatty tissues due to a trivial trauma or other factors like a nail infection or cracks in the skin of the feet can cause these bacteria to rapidly spread within the cellulite tissues both by direct invasion and spread by lymphatic tissues.

It is advisable to get admitted into the hospital in the event of being diagnosed with cellulitis of the limbs. The first and foremost requirement of management is complete rest and elevation of the affected limb. Antibiotics preferably as injection through the veins are more effective than if taken by mouth. The affected limb needs to be reviewed often by a doctor to check for progression (in which case treatment needs to be escalated) or resolution. Management of associated contributory factors like Diabetes and skin diseases are best addressed as an inpatient.

On diagnosis the problem is managed with broad spectrum antibiotics preferably through the intravenous (veins) route. Strict bed rest with limb elevation helps resolution of the problem. Despite adequate measures a minority of patients who do not respond adequately may reqire surgical decompression and drainage of the involved area. This pre-emptive surgery prevents the progression of the problem into a Necrotising Soft Tissue Infection (NSTI) which can lead to extensive skin and soft tissue gangrene necessitating extensive plastic surgery for wound healing

In the presence of a predisposing condition like diabetes the risk of recurrence of cellulitis always exists. However, if the patient strictly follows medical advice then the chances of a recurrence can be minimized. Keeping a low threshold for seeking medical help can help the patient to be identified at an early stage of the problem and this increases the chances of avoiding unnecessary surgery. The patient needs to keep their feet protected, moisturized and free from edema by wearing appropriate footwear at all times, strictly using moisturizing creams and by the regular use of elastic compression garments which are provided to them after the resolution of the first episode of cellulitis.

The time to be off work depends on the severity of the disease with which the patient presents to the hospital. Early cellulitis without systemic symptoms can usually be contained within a week but those patients presenting with severe Necrotising Soft Tissue Infection (NSTI) may require about 3 to 6 months to regain their previous levels of activity. Hence it is always better to catch the problem early.

Corn Foot (Heloma / Clavus) is a painful condition of the foot that results from the formation of hardened areas of skin usually on the sole of the foot.

Corns are formed due to the increased thickness of the outermost layer of the skin, the epidermis in response to repetitive mechanical trauma such as friction, pressure or shear forces

Early corns and calluses (corn like lesions without the central keratotic core or plug) can be treated with creams containing keratolytic agents such as Salicylic acid in varying concentrations. They are available both as prescription drugs and over the counter preparations. Their effectiveness however varies from patient to patient.

Corns usually arise from focal mechanical trauma , in response to which the outer layer of the skin, the epidermis, becomes thicker nad ultimately turns into a corn. Good footwear helps reduce the trauma to the foot and thereby helps to reduce the formation of new corns.

Custom made footwear is the best that todays technology has for the deformed and insensate foot such as the feet of diabetic patients. Offloading of pressure does not only mean taking off pressure from the affected area but it also means that the redistribution of that pressure evenly over other areas of the foot. Wearing customized footwear is the best way to achieve such equal redistribution of pressure

Surgery is advised intractable and painful corns unresponsive to conservative measures like Ointments and footwear change.

Surgery is usually done under local anesthesia in the operation theatre with good facilities. No surgery is minor enough to be undertaken without the best of precautions. In our hospital as a policy we perform even the simplest of procedures in the operation theatre with an experienced anaesthetist present.

Local anesthesia is usually given if it is a single corn. However, for people with multiple corns a regional anesthesia is preferred where only the involved foot and leg below the level of the knee is made to go numb by the help of a small injection in the leg itself and then operation is done.

Surgery will take about 15 minutes for a single corn to about half an hour for multiple corns. This includes the time to give anesthesia and prepare the patient.

If surgery is done under local anesthesia you can go home in a couple of hours but if regional anesthesia is used then an overnight stay is preferable as the leg take about 8 to 12 hours to recover sensation and movement.

If a simple corn excision is done then you can start walking on the affected leg in a couple of days. However, in patients in whom a flap surgery (plastic surgery) is done, walking is prohibited on the affected leg for about 2 weeks till the suture lines heal and suture removal is done. Hence working people can plan their schedule accordingly.

Pain will be present after the operation for about a day or two. During this period, you will be given pain killers to manage the pain. Rest and elevation of the operated part are simple measures that have a profound effect on reduction of pain.

People with diabetes mellitus usually have reduced pain sensation after the operation and hence tend think that there isn’t any risk by walking. However early walking can increase the chance of wound infection and reduce the speed of healing. Other than these factors diabetics do not have any increased risk or need to worry.

Corns have a moderately high risk of recurrence if the original cause of mechanical trauma is not addressed by using good footwear and keratolytic creams.

After surgery patients in whom only an excision is done and the wound left to contract and heal will have to wash the wound with a mild soap and clean water. They can then pat it dry with a clean towel and apply dressings with the provided ointment and dressing material that will be prescribed at the time of discharge.

Complicated (Stage 3) ulcers are those ulcers that have become complicated by invasive bacterial infection of the soft tissues or bone underlying the ulcer. It is a consequence of progressive deepening of the ulcer and once the underlying loose tissue planes such as tendon, bone or joint become exposed the bacteria gain access to these planes of loose tissue resistance and cause a rapidly spreading infection which if left unchecked may result in loss of the leg

Once they gain entry the bacterial multiplication is exponential. For example if bacterial cell divides into two every one hour then the total number of bacteria after the first 10 hours would be 210 (1024), after 20 hours would be 220 (1048576) and after 30 hours would be 230 (1073741824). Once this exponential growth reaches a critical number it soon overwhelms the already weak immune system of a diabetic patient resulting in a rapidly spreading infection that causes extensive gangrene of skin and soft tissue (Flesh eating disease). Hence early intervention is required to limit the spread of tissue infection often best achieved by a multipronged strategy of antibiotic usage along with surgical excision and drainage of the dead and infected tissues. It would be most apt to use the phrase Time = Tissue in this situation.

Debridement is the surgical removal of all infected and dead tissues which harbour bacteria. It also includes the drainage of pus collection. This procedure is best done in the operation theatre with appropriate and adequate anesthesia and tourniquet control to prevent blood loss. Debridement done in the bedside or out patient settings is usually inadequate and increase the risk of losing the limb by providing the patient and surgeon with a false sense of security leading to delay and loss of valuable time and tissue.

Once debridement is over the surgeon reassesses the wound bed. Depending on the exposure of critical structures such as bone, joint and tendons the type of cover is determined. If the bed exposes critical structures a flap (a piece of tissue transferred from one place to another having its own blood supply and which does not depend on the bed for its survival) is used for cover and wound healing. If no critical structures are exposed then a split skin graft usually suffices.

Resting of the affected part followed by isometric and isotonic exercises till the wound completely heals is the usual post-operative course. Once healing has taken place the patient is given appropriate footwear and allowed walk bearing weight on the affected part. Some patients may be advised to undergo a second surgery to prevent recurrence of the ulcer which caused the original problem

Patient can be made to walk without bearing weight on the affected leg with a help of a walker device (photo) as soon as two weeks following the definitive procedure. However, those who require further corrective surgery are advised to rest until the wound heals. A few patients are allowed to walk with weight bearing on the affected leg after the application of a protective plaster of Paris cast.

Amputation is usually kept as a last resort. It is done in patients with extensive gangrene, life threatening infection or in complicated ulcers with structural soft tissue and bone loss which precludes a meaningful limb reconstruction.

Diabetic Foot Ulcers are wounds that occur in the feet of persons with diabetes mellitus. About 15% of all diabetics develop a foot ulcer. Foot ulcers are treatable and curable the earlier they are brought to appropriate medical attention. Treating a foot ulcer is all about healing an ulcer without recurrence. At Ganga Hospital we have created an entire ecosystem to treat the entire spectrum of Diabetic Foot ulcers right from the simplest to the most complicated wound requiring microsurgical reconstruction. Our philosophy at Ganga Hospital is to address the wound at an early stage by suitable therapy to ensure that there is recurrence free healing. Such a philosophy helps us to prevent wound complications like infection which may lead to loss of the limb. For the unfortunate few who require a major amputation, we have established in collaboration with Otto Bock (one of the largest prosthesis makers in the world) a centre that provides prosthetic limbs made with cutting edge technology. At Ganga Hospital all medical professionals involved in the care of diabetic foot patients, the Diabetologist, Plastic Surgeon, Orthopedic Surgeon, Vascular Surgeon, Intensive care specialist, Anesthesiologist, Physiotherapist and Footwear specialist collaborate under one roof to provide wholesome care.

Diabetic Foot ulcers develop due to damage to the nerves and blood vessels of the leg and foot in patients with long standing Diabetes or Pre-Diabetes. Majority (85%) of Diabetic Foot ulcers develop in patients with good blood supply to the feet. That means that most of these cases are easily curable with proper focussed treatment at an early stage. Such ulcers are called Neuropathic Ulcers. The loss of nerve function causes these feet to develop abnormalities and deformities that cause excessive pressure on the sole of the foot. These areas of excessive pressure then develop areas of skin thickening called calluses. The callus which starts off to protect the skin gradually increases in size and thickness over time in response to the increased pressure. Soon it turns big enough to act like a hard stone and by itself increases the pressure on the underlying skin (by about 30%) thereby hastening skin breakdown resulting in ulceration. Once an ulcer forms the continuing excessive pressure on the area prevents the ulcer from healing and it becomes a non-healing ulcer resistant to any form of conservative management like dressings and ointment application. The only treatment that can give consistent, predictable and recurrence free healing is appropriate offloading surgery.

Preventive podiatry is the method of choice to treat the pre-ulcer foot (Callosity stage). It consists of shaving of the callus, application of emollient creams, proper cutting of nails, wearing appropriate custom-made prescription footwear (available in-house) and compression garments. These methods need to be followed even after the ulcer is healed to keep the feet soft and supple and prevent any future ulcers

Footwear for Diabetes patients is used to redistribute the pressure from areas of excessive force to the entire foot. This results in lowering of peak pressure in the prominent ares and helps to prevent ulcer formation. Diabetic footwear widely available and of varying quality and technology. However, people with “at risk” pre – ulcer foot the best that today’s technology has to offer is a custom-made prescription footwear. At Ganga Hospital we have tied up with “Diastride” to provide the best quality diabetic footwear at competitive rates to ensure the best for our patients. We have the entire range of footwear to to suit all pockets and ensure that the patient gets the best for what he pays.

Pedobarography, otherwise known as force plate testing is a device used to measure the ground reaction forces produced by the foot on walking. This is achieved by using the latest force plate equipment which is connected to a computer which analyses the data and presents it in a visual form. This test requires the patient to walk bare-footed on a track in which the force plate is embedded.
The data is used by the surgeon to understand the pattern of the patient’s gait and the way different forces are transmitted during walking. It helps plan the appropriate surgical correction.
The data from force plate testing is also used to design and manufacture appropriate customized prescription footwear. It helps to design the shape of the footwear insole and to provide the foam of appropriate density asper the pressures transmitted by the patient’s foot.

Proper treatment of an ulcer requires for the ulcer to be staged properly and then treated as per the stage. All previous staging systems have relied upon main three factors to stage the wound

The main purpose of most of the staging systems have been to take into account the above three factors and use them to communicate risk of amputation or to predict outcome

The most common staging systems are the Meggitt and Wagner staging and University of Texas staging systems. Both of the above use the above variables in different combinations to stage a wound into up to 16 possible stages and both of the above systems do not incorporate Charcot’s neuro-osteoarthropathy as a risk factor and do not serve as a guide to the type of therapy needed for a particular ulcer amongst the gamut of presentations.

The type and complexity of therapy needs to be escalated as the complexity and complications of an ulcerated foot. Early problems can be managed with conservative methods that like Callus debridement, moisturizers and good footwear. Once the ulcer develops and is not responsive to any conservative method the patient must undergo preventive surgery to correct the responsible pathomechanics and allow the ulcer to heal. Some patients may present with signs of localized invasive infection such as cellulitis, abscess formation of osteomyelitis. These patients require debridement (preferably under tourniquet) and if there is a resultant skin of soft tissue loss; they need to undergo reconstructive surgery in the form of Grafts or Flaps. Rarely the patient may present with a neglected foot with rapidly spreading infection and gangrene and sepsis which poses a threat to life. Such patients require a major amputation without wasting further time.

Some patients present with early signs of Ischemia or Charcot Osteoarthropathy are grouped with stage 3 patients. Such feet can usually be saved by directing the patient to the appropriate tertiary care centre. Patients with gross ischemic gangrene or advanced Charcot neuro-osteoarthropathy with extensive loss of bone are candidates for early amputation and are classified together with the previous stage 4 patients

The Ganga Hospital Staging system of Diabetic Foot ulcers[2] is a simple staging system which develops up on the older classification systems, is treatment oriented and is highly suitable for day to day practice at the General physician level onwards. It clearly specifies which patients require surgery and also recommends the type of surgery that may be required and the specialist who would best suit the situation. It also indicates the need for involvement of other specialities when needed.