surgical anatomy of diabetic foot

1. SURGICALSURGICAL
ANATOMY OFANATOMY OF
DIABETIC FOOTDIABETIC FOOT
DR.ARUN BALDR.ARUN BAL
MUMBAIMUMBAI

2. Leonardo da Vinci described the
foot as
“A masterpiece of engineering and a
work of art”
Dr.bal

4. HUMAN FOOT INHUMAN FOOT IN
EVOLUTIONEVOLUTION
 HUMAN FOOT HAS CULTURALHUMAN FOOT HAS CULTURAL
VARIATIONSVARIATIONS
 INDIAN FEET HAVE SHALLOWINDIAN FEET HAVE SHALLOW
MEDIAL ARCHMEDIAL ARCH
 SHALLOW MEDIAL ARCHSHALLOW MEDIAL ARCH
INCREASES MEDIAL MOBILITYINCREASES MEDIAL MOBILITY
AT MIDTARSAL JOINTSAT MIDTARSAL JOINTS

5. HUMAN FOOT IN
EVOLUTION
QUADRUPEDAL
REQUIRES FOR
GRIPPING ABILITY
ORTHOGRADE/BIPEDAL
REQUIRES FOR
ABILITY TO SUPPORT
Dr.bal

6. SURGICAL ANATOMY OFSURGICAL ANATOMY OF
THE DIABETIC FOOTTHE DIABETIC FOOT
FOOTFOOT
THE FOOT CONSISTSTHE FOOT CONSISTS
OF:OF:
29 JOINTS (8 MAJOR29 JOINTS (8 MAJOR
& 21 MINOR)& 21 MINOR)
26 BONES26 BONES
42 MUSCLES42 MUSCLES

8. PLANTARPLANTAR
ARCHESARCHES

9. ARCHES OF FOOTARCHES OF FOOT
LONGITUDINALLONGITUDINAL
TRANSVERSETRANSVERSE

10. LONGITUDINAL ARCHESLONGITUDINAL ARCHES
MEDIAL:MEDIAL: HIGHERHIGHER
MORE MOBILEMORE MOBILE
RESILIENTRESILIENT
LATERAL:LATERAL:LOWLOW
LIMITED MOBILITYLIMITED MOBILITY
BUILT TO BEAR WT.BUILT TO BEAR WT.

12. MEDIAL LONGITUDINALMEDIAL 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

14. LATERAL LONGITUDINALLATERAL 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

15. TRANSVERSE
ARCHES

16.  MEDIAL:MEDIAL:
 PLANTAR APONEUROSISPLANTAR APONEUROSIS
 FLEX.DIG.BREVISFLEX.DIG.BREVIS
 ABDUCTOR HALLUSISABDUCTOR HALLUSIS
 TIBIALIS ANTERIORTIBIALIS ANTERIOR
 TIBIALIS POSTERIORTIBIALIS POSTERIOR
 FLEX.HAL.LONGUSFLEX.HAL.LONGUS
MAINTENANCE OF FOOTMAINTENANCE OF FOOT
ARCHESARCHES

17. MAINTENANCE OF FOOTMAINTENANCE OF FOOT
ARCHESARCHES
LATERALLATERAL::
 LATERAL PLANTARLATERAL PLANTAR
APONEUROSOS .APONEUROSOS .
 ABD.DIG.MINIMIABD.DIG.MINIMI
 PERONEUS LONGUSPERONEUS LONGUS
 PERONEUS BREVISPERONEUS BREVIS

18. FUNCTIONS OF FOOTFUNCTIONS OF FOOT
ARCHESARCHES
 DISTRIBUTION OF BODY WEIGHTDISTRIBUTION OF BODY WEIGHT
 ELASTICITY HELPS IN WALKINGELASTICITY HELPS IN WALKING
 SHOCK ABSORBERSHOCK ABSORBER
 CONCAVITY PROTECTS SOFTCONCAVITY PROTECTS SOFT
TISSUES AND BLOOD VESSELSTISSUES AND BLOOD VESSELS

19. LIGAMENTS OFLIGAMENTS OF
FOOTFOOT

20. LIGAMENTS OF FOOTLIGAMENTS OF FOOT
 DELTOID LIGAMENTDELTOID LIGAMENT
 LATERAL LIGAMENTLATERAL LIGAMENT
 SPRING LIGAMENTSPRING LIGAMENT
 LONG PLANTAR LIGAMENTLONG PLANTAR LIGAMENT
 SHORT PLANTAR LIGAMENTSHORT PLANTAR LIGAMENT

22. LATERAL
LIGAMENT

23. DELTOID LIGAMENT

24. PLANTAR(FASCIALPLANTAR(FASCIAL
) SPACES) SPACES

25. 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.BREVISFLEXOR H.BREVIS
 PERONEAL LONGUSPERONEAL LONGUS

26. CENTRAL PLANTARCENTRAL 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

27. LATERAL PLANTARLATERAL PLANTAR
SPACESPACE
 DORSAL:DORSAL: 5TH METATARSAL5TH METATARSAL
 MEDIAL:MEDIAL:INTERMUSCUALRINTERMUSCUALR
SEPTUMSEPTUM
 LATERAL:LATERAL:PLANTAR FASCIAPLANTAR FASCIA
CONTANTSCONTANTS::ABDUCTOR DIG.ABDUCTOR DIG.
 FLEXOR DIG QUINTIFLEXOR DIG QUINTI
 SMALL MUSCLES OFSMALL MUSCLES OF
 5TH TOE5TH TOE

28. CONCEPT OF PLANTAR
SPACES

29. PLANTAR SPACES

31. SURGICAL TREATMENTSURGICAL TREATMENT
OF DIABETIC FOOTOF DIABETIC FOOT
MID FOOTMID FOOT
ABCESS WITHABCESS WITH
TOE GANGRENETOE GANGRENE
Dr.bal

32. SURGICAL TREATMENTSURGICAL TREATMENT
OF DIABETIC FOOTOF DIABETIC FOOT
DRAINAGEDRAINAGE
OF MID FOOTOF MID FOOT
ABCESS-ABCESS-
POSTPOST
OPERATIVEOPERATIVE
Dr.bal

33. PLANTARPLANTAR
FASCIAFASCIA

35. SUP.TRAN.MT.
LIGAMENTS
TRANS.
FASCIC.

36. ROLE OF PLANTAR FASCIA IN
LJM

37. ROLE OF PLANTARROLE OF PLANTAR
FASCIA IN FOOTFASCIA IN FOOT
ULCERATIONULCERATION RUPTURE OF PLANTAR FASCIARUPTURE OF PLANTAR FASCIA
 ATTACHMENT OF PLANTAR FASCIAATTACHMENT OF PLANTAR FASCIA
TO SKIN UNDER 1ST MTTO SKIN UNDER 1ST MT
 GLYCATION OF FASCIA CHANGES THEGLYCATION OF FASCIA CHANGES THE
LOADING PATTERN OF THE FOOTLOADING PATTERN OF THE FOOT

38. ARTERIES OF THEARTERIES OF THE
FOOTFOOT

39. ARTERIES OF THEARTERIES OF THE
FOOTFOOT
 POST.TIBIAL IS DOMINANT VESSELPOST.TIBIAL IS DOMINANT VESSEL
 POST.TIBIAL IS CLOSELY RELATED TOPOST.TIBIAL IS CLOSELY RELATED TO
THE TENDON OF F.H.L.THE TENDON OF F.H.L.
 LAT.PLANTAR ARTERY IS MAJORLAT.PLANTAR ARTERY IS MAJOR
BRANCH OF POST.TIBIALBRANCH OF POST.TIBIAL
 ANT.TIBIAL CONTRIBUTES TO THEANT.TIBIAL CONTRIBUTES TO THE
BLOOD SUPPLY TO 1,2 DIGITSBLOOD SUPPLY TO 1,2 DIGITS

40. POPLITEAL
ARTERY
TIBIOPERONEAL
TRUNK
POST TIBIAL
PERONEAL
ANT.TIBIAL

41. SURGICAL ANATOMY OFSURGICAL ANATOMY OF
THE FOOTTHE FOOT
ARTERIES OFARTERIES OF
THE FOOTTHE FOOT

43. CAUSE OF NEUROPATHIC ODEMA

44. CROWDING OF TOES CAUSING
ARTERIAL THROMBOSIS

45. ANATOMY OF THE HEEL

46. NERVES OF THE FOOTNERVES OF THE FOOT

47. PERONEAL N.
TIBIAL NERVE

48. TIBIAL N
LATERAL
PLANTAR
NERVE
MEDIAL
PLANTAR
NERVE

51. FOOTFOOT
MOVEMENTSMOVEMENTS

55. AXIS OF ANKLE MOVEMENT

57. FOOTFOOT
BIOMECHANICSBIOMECHANICS

58. NORMAL WALKING CYCLENORMAL WALKING CYCLE
Initial contact Forefoot contact
Heel lift Toe-off
Dr.bal

59. HEEL STRIKEHEEL STRIKE
Initial contact Start midstace Start foot flat
Dr.bal

60. MIDSTANCE PHASEMIDSTANCE PHASE
Start mischance Start foot flat Heel lift
Dr.bal

61. PROPULSION PHASEPROPULSION PHASE
Heel lift Toe-off
Dr.bal

62. NeutralNeutral
PositionPosition
DYNAMIC 3 DIMENSIONAL ORTHOSIS
Alpha: Rear-foot Position
Dr.bal

63. Rear-footRear-foot
pronationpronation
(Valgus)(Valgus)
DYNAMIC 3 DIMENSIONAL ORTHOSIS
Alpha: Rear-foot Position
Dr.bal

64. Rear-foot
supination
(varus)
DYNAMIC 3 DIMENSIONAL ORTHOSIS
Alpha: Rear-foot Position
Dr.bal

66. IMPULSE LOADINGIMPULSE LOADING
IS MOREIS MORE
RELEVENT THANRELEVENT THAN
ONLY HIGHONLY HIGH
PRESSUREPRESSURE

67. IMPULSE LOADINGIMPULSE LOADING
IS PRODUCT OFIS PRODUCT OF
PRESSURE ANDPRESSURE AND
GROUNDGROUND
CONTACT TIMECONTACT TIME

68. Excessive pronation (cont.)
DISORDERS OF THE FOOT
Dr.bal

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

71. FOOTFOOT
PATHOBIOMECHANIPATHOBIOMECHANI
CSCS

73. HALLAUX RIGIDUS

74. HALLAUX RIGIDUS

75. MECHANISM OFMECHANISM OF
DIABETIC FOOT ULCERDIABETIC FOOT ULCER
ROLE OFROLE OF
HALLAUXHALLAUX
RIGIDUS ANDRIGIDUS AND
SUBCUT.PADSUBCUT.PAD
OF FATOF FAT

76. PATHO BIOMECHANICSPATHO BIOMECHANICS
OF DIABETIC FOOTOF DIABETIC FOOT
ULCERULCER
 MECHANISMMECHANISM
OF DIABETICOF DIABETIC
FOOT ULCERFOOT ULCER
Dr.bal

77. HAMMER TOE
MALLET TOE
CLAW TOE

79. HAWAI(WEB & TOEHAWAI(WEB & TOE
STRAP) SLIPPERSSTRAP) SLIPPERS
ACCENTUATE TOEACCENTUATE TOE
DEFORMITIESDEFORMITIES

80. HAWAI
SLIPPERS
/STANDING

81. HAWAI
SLIPPERS
/WALKING
TOE
PRESSUR
E

82. PATHO- BIOMECHANICSPATHO- BIOMECHANICS
OF DIABETIC FOOTOF DIABETIC FOOT
ULCCEERULCCEER
BIOMECHANICBIOMECHANIC
S OF FORES OF FORE
FOOTFOOT
AMPUTATIONAMPUTATION
Dr.bal

83. PATH -BIOMECHANICSPATH -BIOMECHANICS
OF DIABETIC FOOTOF DIABETIC FOOT
ULCERULCER
BIOMECHANICBIOMECHANIC
S OFS OF
FOREFOOTFOREFOOT
AMPUTATIONAMPUTATION
Dr.bal

84. NORMAL
AXIS OF MTP
JTS

85. CAUSE OF 2ND MT
ULCER

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

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

88. ANGLE OF
ADDUCTUS
PRIMUS

89. LISFRANC`S
JOINT

90. CHARCOT`S FOOTCHARCOT`S FOOT
EARLIESTEARLIEST
RADIOLOGICALRADIOLOGICAL
SIGNSIGN
Dr.bal
LISFRANC`S
JOINT

91. LOAD
TRAINGLE

93. AXIS
OF
WEIGHT
TRANSMISSION

95. BILATERAL CHARCOT

96. SURGICAL ANATOMY OFSURGICAL ANATOMY OF
THE DIABETIC FOOTTHE DIABETIC FOOT
 NEURO ARTHROPATHYNEURO ARTHROPATHY
OCCURS:OCCURS:
 60% IN TARSAL &TARSO60% IN TARSAL &TARSO
MT JOINTSMT JOINTS
 30% META TARSO30% META TARSO
PHALANGEAL JOINTSPHALANGEAL JOINTS
 10% ANKLE JOINTS10% ANKLE JOINTS

97. SURGICAL ANATOMY OFSURGICAL ANATOMY OF
THE FOOTTHE FOOT
FOOT SIZEFOOT SIZE
DOES NOTDOES NOT
CHANGE WITHCHANGE WITH
AGE BUTAGE BUT
SHAPESHAPE
CHANGESCHANGES

98. MECHANISM OF PES CAVUS

99. ANATOMICAL BASIS OFANATOMICAL BASIS OF
SPREADING FOOTSPREADING FOOT
INFECTIONINFECTION

105. FOOT IS MOSTFOOT IS MOST
ENERGY EFFICIENTENERGY EFFICIENT
MACINE.THISMACINE.THIS
ENERGYENERGY
EFFECIENCY ISEFFECIENCY IS
LOST IN DIABETESLOST IN DIABETES
DUE TODUE TO
NEUROPATHYNEUROPATHY
Dr.bal

106. HUMAN FOOT CAN NOTHUMAN FOOT CAN NOT
BE STUDIED INBE STUDIED IN
EXPERIMENTAL ANIMALEXPERIMENTAL ANIMAL
MODELSMODELS

107. FUNDAMENTAL PRINCIPLEFUNDAMENTAL PRINCIPLE
OF DIABETIC FOOTWEAROF DIABETIC FOOTWEAR
FOOTWEARFOOTWEAR
SHOULD DOSHOULD DO
WHAT FOOT CANWHAT FOOT CAN
NOT DONOT DO

109. TAKE HOME MESSAGETAKE HOME MESSAGE
KNOWLEDGE OF FOOTKNOWLEDGE OF FOOT
ANATOMY &ANATOMY &
BIOMECHANICS ISBIOMECHANICS IS
ESSENTIAL FORESSENTIAL FOR
PREVENTION OF HIGHERPREVENTION OF HIGHER
LEVEL AMPUTATION INLEVEL AMPUTATION IN
DIABETESDIABETES

110. An ancient Sanskrit saying.
“The one who walks, his good fortune also
marches ahead.”
PRESERVE &
PROTECT THEM

111. THANK YOUTHANK YOU