SURGICAL SURGICAL ANATOMY OF ANATOMY OF

DIABETIC FOOTDIABETIC FOOT

DR.ARUN BALDR.ARUN BALMUMBAIMUMBAI

Leonardo da Vinci described the foot as

“A masterpiece of engineering and a work of art”

Dr.bal

HUMAN FOOT IN HUMAN FOOT IN EVOLUTIONEVOLUTION

HUMAN FOOT HAS CULTURAL HUMAN FOOT HAS CULTURAL VARIATIONSVARIATIONS

INDIAN FEET HAVE SHALLOW INDIAN FEET HAVE SHALLOW MEDIAL ARCHMEDIAL ARCH

SHALLOW MEDIAL ARCH SHALLOW MEDIAL ARCH INCREASES MEDIAL MOBILITY AT INCREASES MEDIAL MOBILITY AT MIDTARSAL JOINTSMIDTARSAL JOINTS

HUMAN FOOT IN EVOLUTION

QUADRUPEDAL REQUIRES FOR GRIPPING ABILITY ORTHOGRADE/BIPEDAL REQUIRES FOR ABILITY TO SUPPORT

Dr.bal

SURGICAL ANATOMY OF SURGICAL ANATOMY OF THE DIABETIC FOOT THE DIABETIC FOOT

FOOTFOOTTHE FOOT CONSISTS OF:THE FOOT CONSISTS OF:29 JOINTS (8 MAJOR & 29 JOINTS (8 MAJOR & 21 MINOR)21 MINOR)

26 BONES26 BONES42 MUSCLES42 MUSCLES

PLANTAR PLANTAR ARCHESARCHES

ARCHES OF FOOTARCHES OF FOOTLONGITUDINALLONGITUDINALTRANSVERSETRANSVERSE

LONGITUDINAL ARCHESLONGITUDINAL ARCHESMEDIAL: MEDIAL: HIGHERHIGHER MORE MOBILEMORE MOBILE RESILIENTRESILIENTLATERAL:LATERAL:LOWLOW LIMITED MOBILITYLIMITED MOBILITY BUILT TO BEAR WT.BUILT TO BEAR WT.

MEDIAL LONGITUDINAL MEDIAL LONGITUDINAL ARCHARCH

CAL-TAL-NAV-CUN-THREE MED MTCAL-TAL-NAV-CUN-THREE MED MT ENDEND:HEADS OF MEDIAL THREE MT:HEADS OF MEDIAL THREE MT SUMMITSUMMIT:SUP.ART.SURFACE - TALUS:SUP.ART.SURFACE - TALUS ANT.PILLAR:ANT.PILLAR:TALUS-NAV-THREE MTTALUS-NAV-THREE MT POST PILLAR:POST PILLAR:MEDIAL HALF OF CALMEDIAL HALF OF CAL

LATERAL LONGITUDINAL LATERAL LONGITUDINAL ARCHARCH

CALCANEUM-CUBOID-TWO LAT MTCALCANEUM-CUBOID-TWO LAT MT ENDEND:HEADS OF 4TH&5TH MT:HEADS OF 4TH&5TH MT SUMMIT:SUMMIT:SUP.SURFACE OF CALSUP.SURFACE OF CAL ANT.PILLAR:ANT.PILLAR:CUBOID-TWO LAT MTCUBOID-TWO LAT MT POST.PILLAR:POST.PILLAR:LAT.HALF OF CALLAT.HALF OF CAL

TRANSVERSE ARCHES

MEDIAL:MEDIAL: PLANTAR APONEUROSISPLANTAR APONEUROSIS FLEX.DIG.BREVISFLEX.DIG.BREVIS ABDUCTOR HALLUSISABDUCTOR HALLUSIS TIBIALIS ANTERIORTIBIALIS ANTERIOR TIBIALIS POSTERIORTIBIALIS POSTERIOR FLEX.HAL.LONGUS FLEX.HAL.LONGUS

MAINTENANCE OF FOOT MAINTENANCE OF FOOT ARCHESARCHES

MAINTENANCE OF FOOT MAINTENANCE OF FOOT ARCHESARCHES

LATERALLATERAL:: LATERAL PLANTAR LATERAL PLANTAR APONEUROSOS .APONEUROSOS . ABD.DIG.MINIMIABD.DIG.MINIMI PERONEUS LONGUSPERONEUS LONGUS PERONEUS BREVIS PERONEUS BREVIS

FUNCTIONS OF FOOT FUNCTIONS OF FOOT ARCHESARCHES

DISTRIBUTION OF BODY WEIGHTDISTRIBUTION OF BODY WEIGHT ELASTICITY HELPS IN WALKINGELASTICITY HELPS IN WALKING SHOCK ABSORBERSHOCK ABSORBER CONCAVITY PROTECTS SOFT CONCAVITY PROTECTS SOFT

TISSUES AND BLOOD VESSELSTISSUES AND BLOOD VESSELS

LIGAMENTS OF LIGAMENTS OF FOOTFOOT

LIGAMENTS OF FOOTLIGAMENTS OF FOOTDELTOID LIGAMENTDELTOID LIGAMENTLATERAL LIGAMENTLATERAL LIGAMENTSPRING LIGAMENTSPRING LIGAMENTLONG PLANTAR LIGAMENTLONG PLANTAR LIGAMENTSHORT PLANTAR LIGAMENTSHORT PLANTAR LIGAMENT

LATERAL LIGAMENT

DELTOID LIGAMENT

PLANTAR(FASCIALPLANTAR(FASCIAL) SPACES) SPACES

MEDIAL PLANTAR SPACEMEDIAL PLANTAR SPACE DORSAL:DORSAL:INF SURFACE OF 1STMTINF SURFACE OF 1STMT MEDIAL:MEDIAL:PLANTAR FASCIA EXTENSIONPLANTAR FASCIA EXTENSION LATERALLATERAL::INTERMUSCULAR SEPTUMINTERMUSCULAR SEPTUM

CONTENTS:CONTENTS: ADD.HALLUSISADD.HALLUSIS FLEXOR H.LONGUSFLEXOR H.LONGUS TIB.POSTERIORTIB.POSTERIOR FLEXOR H.BREVIS FLEXOR H.BREVIS PERONEAL LONGUS PERONEAL LONGUS

CENTRAL PLANTAR CENTRAL PLANTAR SPACESPACE

INFERIOR:INFERIOR:PLANTAR FASCIAPLANTAR FASCIA LATERAL:LATERAL:INTERMUSCULAR SEPTUMINTERMUSCULAR SEPTUM DORSAL:DORSAL:TARSOMETATARSAL JTSTARSOMETATARSAL JTS

CONTENTS: CONTENTS: FLEXOR DIG LONGUSFLEXOR DIG LONGUS FLEXOR DIG BREVISFLEXOR DIG BREVIS LUMBRICALSLUMBRICALS PERONEAL&POST TIB.PERONEAL&POST TIB. ADD.HAL.MUSCLEADD.HAL.MUSCLE

LATERAL PLANTAR LATERAL PLANTAR SPACESPACE

DORSAL:DORSAL: 5TH METATARSAL5TH METATARSAL MEDIAL:MEDIAL:INTERMUSCUALR SEPTUMINTERMUSCUALR SEPTUM LATERAL:LATERAL:PLANTAR FASCIAPLANTAR FASCIA

CONTANTSCONTANTS::ABDUCTOR DIG.ABDUCTOR DIG. FLEXOR DIG QUINTIFLEXOR DIG QUINTI SMALL MUSCLES OF SMALL MUSCLES OF 5TH TOE5TH TOE

CONCEPT OF PLANTAR SPACES

PLANTAR SPACES

SURGICAL TREATMENT SURGICAL TREATMENT OF DIABETIC FOOTOF DIABETIC FOOT

MID FOOT MID FOOT ABCESS WITH ABCESS WITH TOE GANGRENETOE GANGRENE

Dr.bal

SURGICAL TREATMENT SURGICAL TREATMENT OF DIABETIC FOOTOF DIABETIC FOOT

DRAINAGE DRAINAGE OF MID FOOT OF MID FOOT ABCESS-ABCESS-POST POST OPERATIVEOPERATIVE

Dr.bal

PLANTAR PLANTAR FASCIAFASCIA

SUP.TRAN.MT.

LIGAMENTS

TRANS.

FASCIC.

ROLE OF PLANTAR FASCIA IN LJM

ROLE OF PLANTAR ROLE OF PLANTAR FASCIA IN FOOT FASCIA IN FOOT

ULCERATIONULCERATION RUPTURE OF PLANTAR FASCIARUPTURE OF PLANTAR FASCIA ATTACHMENT OF PLANTAR FASCIA ATTACHMENT OF PLANTAR FASCIA

TO SKIN UNDER 1ST MT TO SKIN UNDER 1ST MT GLYCATION OF FASCIA CHANGES THE GLYCATION OF FASCIA CHANGES THE

LOADING PATTERN OF THE FOOTLOADING PATTERN OF THE FOOT

ARTERIES OF THE ARTERIES OF THE FOOTFOOT

ARTERIES OF THE ARTERIES OF THE FOOTFOOT

POST.TIBIAL IS DOMINANT VESSELPOST.TIBIAL IS DOMINANT VESSEL POST.TIBIAL IS CLOSELY RELATED TO POST.TIBIAL IS CLOSELY RELATED TO

THE TENDON OF F.H.L.THE TENDON OF F.H.L. LAT.PLANTAR ARTERY IS MAJOR LAT.PLANTAR ARTERY IS MAJOR

BRANCH OF POST.TIBIALBRANCH OF POST.TIBIAL ANT.TIBIAL CONTRIBUTES TO THE ANT.TIBIAL CONTRIBUTES TO THE

BLOOD SUPPLY TO 1,2 DIGITSBLOOD SUPPLY TO 1,2 DIGITS

POPLITEAL

ARTERY

TIBIOPERONEAL

TRUNK

POST TIBIAL

PERONEAL

ANT.TIBIAL

SURGICAL ANATOMY OF SURGICAL ANATOMY OF THE FOOTTHE FOOT

ARTERIES OF ARTERIES OF THE FOOTTHE FOOT

CAUSE OF NEUROPATHIC ODEMA

CROWDING OF TOES CAUSING ARTERIAL THROMBOSIS

ANATOMY OF THE HEEL

NERVES OF THE FOOTNERVES OF THE FOOT

PERONEAL N.TIBIAL NERVE

TIBIAL N

LATERALPLANTARNERVE

MEDIAL

PLANTAR

NERVE

FOOT FOOT MOVEMENTSMOVEMENTS

AXIS OF ANKLE MOVEMENT

FOOT FOOT BIOMECHANICSBIOMECHANICS

NORMAL WALKING CYCLENORMAL WALKING CYCLE

Initial contact Forefoot contact

Heel lift Toe-off

Dr.bal

HEEL STRIKEHEEL STRIKE

Initial contact Start midstace Start foot flat

Dr.bal

MIDSTANCE PHASEMIDSTANCE PHASE

Start mischance Start foot flat Heel lift

Dr.bal

PROPULSION PHASEPROPULSION PHASE

Heel lift Toe-off

Dr.bal

Neutral Neutral PositionPosition

DYNAMIC 3 DIMENSIONAL ORTHOSIS

Alpha: Rear-foot Position

Dr.bal

Rear-Rear-foot foot

pronatiopronationn

(Valgus)(Valgus)

DYNAMIC 3 DIMENSIONAL ORTHOSIS

Alpha: Rear-foot Position

Dr.bal

Rear-foot supinatio

n(varus)

DYNAMIC 3 DIMENSIONAL ORTHOSIS

Alpha: Rear-foot Position

Dr.bal

IMPULSE LOADING IMPULSE LOADING IS MORE IS MORE

RELEVENT THAN RELEVENT THAN ONLY HIGH ONLY HIGH PRESSUREPRESSURE

IMPULSE LOADING IMPULSE LOADING IS PRODUCT OF IS PRODUCT OF PRESSURE AND PRESSURE AND

GROUND CONTACT GROUND CONTACT TIMETIME

Excessive pronation (cont.)

DISORDERS OF THE FOOT

Dr.bal

MAJORITY OF DIABETIC FOOT ULCERS ARE IN THE REGION OF 1ST MTP JOINT

FOOT FOOT PATHOBIOMECHANIPATHOBIOMECHANI

CSCS

HALLAUX RIGIDUS

HALLAUX RIGIDUS

MECHANISM OF DIABETIC MECHANISM OF DIABETIC FOOT ULCERFOOT ULCER

ROLE OF ROLE OF HALLAUX HALLAUX RIGIDUS AND RIGIDUS AND SUBCUT.PAD SUBCUT.PAD OF FATOF FAT

PATHO BIOMECHANICS PATHO BIOMECHANICS OF DIABETIC FOOT OF DIABETIC FOOT

ULCERULCER

MECHANISM MECHANISM OF DIABETIC OF DIABETIC FOOT ULCERFOOT ULCER

Dr.bal

HAMMER TOE

MALLET TOE

CLAW TOE

HAWAI(WEB & HAWAI(WEB & TOE STRAP) TOE STRAP) SLIPPERS SLIPPERS

ACCENTUATE TOE ACCENTUATE TOE DEFORMITIESDEFORMITIES

HAWAI SLIPPERS /STANDING

HAWAI SLIPPERS /WALKING

TOE PRESSURE

PATHO- BIOMECHANICS PATHO- BIOMECHANICS OF DIABETIC FOOT OF DIABETIC FOOT

ULCCEERULCCEER

BIOMECHANICBIOMECHANICS OF FORE S OF FORE FOOT FOOT AMPUTATIONAMPUTATION

Dr.bal

PATH -BIOMECHANICS OF PATH -BIOMECHANICS OF DIABETIC FOOT ULCERDIABETIC FOOT ULCER

BIOMECHANICBIOMECHANICS OF S OF FOREFOOT FOREFOOT AMPUTATIONAMPUTATION

Dr.bal

NORMAL AXIS OF MTP JTS

CAUSE OF 2ND MT ULCER

SEPARATION 1ST AND 2ND CUNEIFORM IN CHARCOT`S FOOT

SEPARATION OF 1ST AND 2ND CUNEIFORM IN CHARCOT`S FOOT

ANGLE OF ADDUCTUSPRIMUS

LISFRANC`S JOINT

CHARCOT`S FOOTCHARCOT`S FOOT

EARLIEST EARLIEST RADIOLOGICAL RADIOLOGICAL SIGNSIGN

Dr.bal

LISFRANC`S JOINT

LOAD TRAINGLE

AXISOF

WEIGHTTRANSMISSION

BILATERAL CHARCOT FOOT

SURGICAL ANATOMY OF SURGICAL ANATOMY OF THE DIABETIC FOOTTHE DIABETIC FOOT

NEURO ARTHROPATHY NEURO ARTHROPATHY OCCURS:OCCURS:

60% IN TARSAL &TARSO MT 60% IN TARSAL &TARSO MT JOINTSJOINTS

30% META TARSO 30% META TARSO PHALANGEAL JOINTSPHALANGEAL JOINTS

10% ANKLE JOINTS10% ANKLE JOINTS

SURGICAL ANATOMY OF SURGICAL ANATOMY OF THE FOOTTHE FOOT

FOOT SIZE FOOT SIZE

DOES NOT DOES NOT CHANGE WITH CHANGE WITH AGE BUT AGE BUT SHAPE SHAPE CHANGESCHANGES

MECHANISM OF PES CAVUS

ANATOMICAL BASIS OF ANATOMICAL BASIS OF SPREADING FOOT SPREADING FOOT

INFECTIONINFECTION

FOOT IS MOST FOOT IS MOST ENERGY EFFICIENT ENERGY EFFICIENT

MACINE.THIS MACINE.THIS ENERGY EFFECIENCY ENERGY EFFECIENCY

IS LOST IN IS LOST IN DIABETES DUE TO DIABETES DUE TO

NEUROPATHYNEUROPATHYDr.bal

HUMAN FOOT CAN NOT HUMAN FOOT CAN NOT BE STUDIED IN BE STUDIED IN

EXPERIMENTAL ANIMAL EXPERIMENTAL ANIMAL MODELSMODELS

FUNDAMENTAL PRINCIPLE FUNDAMENTAL PRINCIPLE OF DIABETIC FOOTWEAROF DIABETIC FOOTWEAR

FOOTWEAR FOOTWEAR SHOULD DO WHAT SHOULD DO WHAT FOOT CAN NOT DOFOOT CAN NOT DO

TAKE HOME MESSAGETAKE HOME MESSAGE

KNOWLEDGE OF FOOT KNOWLEDGE OF FOOT ANATOMY & BIOMECHANICS ANATOMY & BIOMECHANICS IS ESSENTIAL FOR IS ESSENTIAL FOR PREVENTION OF HIGHER PREVENTION OF HIGHER LEVEL AMPUTATION IN LEVEL AMPUTATION IN DIABETESDIABETES

An ancient Sanskrit saying.“The one who walks, his good fortune also

marches ahead.”

PRESERVE & PROTECT THEM

THANK THANK YOUYOU