Retrospective analysis of 73 cases of Diabetic foot diseases in various stages, from May 2007 to April 2009, was undertaken. Patients were catagorised as follows: Day Case debridement: 41; Disarticulations and minor amputations: 10; Secondary Suturing: 10; Skin grafting: 6, Indoor patients: 30; Limb amputation: 1. Some of the patients have undergone more than one procedure over a period of time.

The intent of this article is to showcase the possibilities of One Day Surgery in select Diabetic foot afflictions. The degree of damage and the extensiveness of surgery, including the toxaemia, were used as criteria for keeping the patient indoors or treating as a Day Case. However, the Protocols set for selection, preparation and discharge were strictly followed. (1)

Presenting a retrospective analysis of 73 Diabetic foot cases. Diabetic foot is a disease which invariably lands up in a limb amputation. To save a limb, it requires time, money and patience. It is the passion of a surgeon that enables him to save a diabetic gangrenous limb.

A late complication of long standing diabetes mellitus is a diabetic foot. The sequel of neuropathy and vascular compromise, ultimately leads to infection and gangrene, in a susceptible patient. A good glycaemic control, regular exercises, definitely prevents such changes.

Material & Method:

Data collected from May 2007 to April 2009, were analysed retrospectively, out of the 73 patients of diabetic gangrene of different stages and patients requiring secondary suturing and skin grafting, there were 30 patients hospitalised and 43 treated as Day Case. Out of which, 10 patients required secondary suturing and 6 patients underwent skin grafting.

  Before Surgery

  After Surgery

Case 2

Case 3: Mr. SM, aged 58 years, male patient, presented with a non healing ulcer of size 4 cm X 4 cm, on the dorsal surface of the right foot. FBS was 200 mg%. Debridement was performed under local anaesthesia and regular follow up dressings were done. Patient refused skin grafting, the wound healed by primary closure over a period of 6 months. Again, glyceamic control and antibiotics were given on OPD basis.

Before Surgery

After Surgery

Case 3

Patients were selected and prepared by the protocols. Apart from the 30 indoor patients, where, the average hospital stay ranged from 1 week to 8 weeks. The One Day Surgery cases were discharged after fulfilling the discharge criteria laid down in the protocols. There were no readmissions seen in the One Day Cases.

Most surgeries are performed under minimal local blocks, due to neuropathies, there is a lack of sensations, therefore in most of the cases, do not require extensive blocks. On the other hand, hyperesthesia is seen in some cases, making the infiltration of local difficult and has patchy results. This usually is overcome by sedating the patient with low dose of medazolam. Most commonly used anaesthetic agents at our centre was a combination of Lignocain HCl 2%, without adrenaline and 0.5% Bupivacain, mixed in equal amounts and injected through a 27G needle for even distribution. Commonly used blocks were ankle block, ring block and infiltration around the wounds and skin graft sites before harvesting.

During the follow up dressings, basic method of dressing was to clean the wound with Povidon-iodine solution, and minimal hydrogen peroxide, only P-iodine solution at graft sites.

Complications were explained, pain, especially from the donor site, in cases of skin grafting, were prescribed mild non NSAID pain killers. Oral antibiotic cover was usually a broad spectrum type. Other supportive treatment in the form of multivitamins, haematenics were prescribed, usually by the physicians.

Dressing for diabetic ulcers and wounds are a procedure in itself. Debridement is to be done with a fine scissor and forceps, on a daily basis. It is understood that the patients presenting with diabetic foot have long standing medical ailments other than Diabetes mellitus, like hypertension and IHD. Associated sequel to DM, such as severe paraesthesia and compromised vascularity, works to our advantage in these patients. Due to the chronicity of the disease, vascular blocks and occlusions develop over a period of time and also develop collaterals. Sometimes, these are not sufficient, or the fine balance between the supply and demand gets tipped by certain factors like injury or raised sugar levels, making the tissues prone to infection. The neurological deficit prevents the patient from reporting the injury in time, as a result, by the time there is a visible change in the tissues, and it is already late.

In this series, we have not seen any reaction to local anaesthesia. Most cases were successfully performed with a substitution of midazolam and pentazocine intravenous injections given by our anaesthetist.

For example, Case 1, patient did not have pain after injury at home. A politician; did not have time to consult a doctors and felt obliged to take home remedies offered by his patrons. Resulting in setting in of gangrene before he consulted a physician. By the time surgical opinion was taken, a well demarcated gangrene was evident.

Case 2, after the initial fear of surgery, care was taken for almost a year and half, but, later, barefoot walking in and out of the house was the norm. Lack of sensation compounded by injury, which continued to grow into a non healing granuloma. On and off bleeding noticed by family members lead to a visit to the doctors and surgical correction.

Complications were few and mostly related to surgical wound bleeding. These were explained to the patient along with post procedure instructions as to how to care for them. Regular follow up was recommended. Patients were managed by physician-diabetologist, and among other parameters, blood sugar levels were kept under control. Regular dressings were demonstrated and taught to the patient or to an able relative if a visit to a doctor was not possible on a daily basis.

Most patients were comfortable with the fact that they would get immediate attention and admission, if required, irrespective of the time of the day or night.

There are several adjuant therapies available for diabetic patients, espicially with wounds. Hyperbaric Oxygen therapy, is and when available, is very good for wound healing. Hypersaturated Oxygen solutions, debriding powers and gels, enzymatic creams and lotoins, used selectively and judiciously, help in wound care. evry available therapy which will help in fasted wound healing, can be tried, provided these are easily available and affordable to the patient. Due consideration should be given to the side effects and drawbacks of these therapies and pros & cons weighed properly.

As is well known, prevention is better than cure, foot care becomes an important part of every diabetic’s lifestyle. A few minutes spent on pampering your feet will go a long way in keeping them healthy. While prescribing medication, please spend 5 more minutes to explain foot care to your patients.

What can go wrong? Remember, diabetics are prone to Neuropathy and Vascular occlusion/damage of the limbs. Therefore, not only is it mandatory to keep the blood sugars in control, but also, regular exercise to keep the circulation in good order.

Reduced sensation makes you vulnerable to injuries. As the lack of pain usually does not mandate attention, till it is too late. Damaged circulation allows the tissues to die and retards healing.

Foot wear: always wear a foot wear, even at home, as you can injure yourself if not careful. While choosing a foot wear, care is to be taken to see that it is soft inside and firm outside. Fits comfortably, not loose nor tight. It is important to keep these in mind, as a shoe bite or a corn, can be the precursor to full blown gangrene. Broad based open sandals with adjustable straps or sports shoes are the best. Remember, money spent on a good foot wear, will protect your patient from bigger medical expense later.

Foot wash: regular foot cleaning is to be advised, especially whenever the patient has been outside the house for a long time. The sweat and dirt need to be cleaned with soft soap. The sides of the foot and sole should be scrubbed with a foot scrubber or a Pumice stone. Very gently, so as to just remove the dead skin and not the skin it self. Remember, neuropathy reduces the sensation and this can damage the skin causing abrasions. The web spaces need special attention, as sweat and dirt make these spaces prone to fungal infection and damage. Gentle cleaning with soap and water using your fingers is sufficient. Followed by drying of the feet and the web spaces is mandatory. Application of petroleum jelly or aloe era, very small amount to keep the skin soft and supple, is helpful.

Excessive sweating: in the shoes can harm the skin by making it soggy and prone to skin infection and intertrigo. Use of thick cotton socks, washing them daily, with use of a very small amount of talcum powder, usually helps. Mind you, too much of powder is also not good. Take talcum powder on your palm and just touch it with the tips of your fingers, and then pass your fingers in between the web spaces of your toes.

Diabetic foot is a chronic disease. Here, not only the patient, even his relatives are tired of hospital/doctor visits and the involvement of time and money.

Prevention is the main stay of diabetic foot care. Protective foot wears at home and outside home. Nail care, immediate attention to callosities, look for and attend to neuropathic fractures, sugar control and regular exercises, are all a part of the multipronged approach to diabetic foot care.

These patients are more than willing to avoid hospitalization for lack of time and money. Day surgery is a concept, a mind-set, which can easily be changed, from an indoor patient to an outdoor patient. This aversion to hospitals gives a boost to the overall success of Day Surgery, which, in select cases has shown tremendous benefit to the patients.