Surgical advancements to salvage the diabetic foot



By Shobha Shukla, CNS
September 8, 2013
The author is the Managing Editor of Citizen News Service - CNS. She is a J2J Fellow of National Press Foundation (NPF) USA and received her editing training in Singapore. She has earlier worked with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also co-authored and edited publications on childhood TB, childhood pneumonia, Hepatitis C Virus and HIV, violence against women and girls, and MDR-TB. Email: shobha@citizen-news.org, website: www.citizen-news.org

Some years ago, 30 years old Tanveer (name changed), a noted tabla percussionist, sustained a fall that lead to a spinal fracture and complete paralysis of both his lower limbs. Although orthopaedic surgeons fixed his spinal bony fracture, he continued to have paraplegia.

After a couple of years of intense physiotherapy, strength started returning to his legs gradually and he started ambulating on a ‘walker’. However, after a few months of ambulating, due to autonomic neuropathy sustained in the spinal cord injury, he started developing classical ‘Charcot’ destruction of the hind and mid foot bones of his right foot, even though he did not have diabetes.

His foot bones became markedly destroyed, to the extent that the ankle joint became flail and non-functional. He went from one hospital to another, but instead of relief, he got the same cruel advise from all of them-- a below knee amputation of his right leg. Finally, about one year back, destiny brought him to the Department of Endocrinology and Podiatric Surgery at Amrita Institute of Medical Sciences and Research Centre, Kochi, India. Here, under the guidance of Dr Ajit Kumar Varma, Diabetic lower limb and foot & ankle reconstructive surgeon, the doctors planned to replace the destroyed foot and ankle bones of his right foot with ‘Polymethyl methacrylate’ (PMMA). Three dimensional CT Scans of his normal left foot were taken, and mirror images of the hind foot and mid foot bones were made in the laboratory to use them as replacement prosthesis of his right foot bones. This was followed by a meticulously planned surgery in which the completely destroyed hind and mid foot bones were removed and replaced with PMMA prosthesis by using titanium compression screws and the now world famous ‘Amrita Sling Technique’. Tanveer was mobilized after four months of surgery to allow enough time for good healing of the operated tissues and bones. This unique surgery gave him a new lease of life.

Now Tanveer is ambulant in prescription footwear. As the powers of his both lower limbs are still grade 4/6, he has to use a ‘walker’. But, he has recovered enough to lead a normal life and earn a living to support his family and aged parents. Most importantly, he is now able to perform on the stage giving tabla concerts. This is just one of the many success stories which Dr Varma and his team of doctors at AIMS can boast of. During the past few years they have performed a large number of foot bone PMMA replacement prosthetic surgeries (of bones destroyed due to ‘Charcot’ disease or due to Osteomyelitis) with excellent results.

The ‘Amrita Sling Technique’, invented at AIMS, is a novel surgical technique to permanently stabilize the foot and ankle after conventional reconstruction of destroyed mid foot and hind foot bones, in case of ‘Charcot disease’-- usually seen as a result of autonomic neuropathy in diabetes mellitus and other neurological conditions. In Charcot disease, the bones of the foot become very soft and brittle--like keeping a wooden board in water for a few weeks, and trying to pass a screw through it. The screws will never hold, due to the soft nature of the wood. Very few centres in the world are carrying out Charcot reconstruction surgeries. AIMS is the only institute in India carrying out these surgeries routinely. In the west, where these type of surgeries are done, an external fixator, like an Illizarov frame is used for about four months, to stabilize the bones after conventional internal fixation using titanium compression screws or intramedullary rods.

However, these external fixators have their own problems. Many studies have shown, that the K-Wires passing through the flesh and bone, cause pin tract infections to the rate of 25% to 100%. In a patient living with diabetes, this could be disastrous, as it may lead to major amputations. Also, once these frames are removed after four months and the patient is ambulant, the screws invariably become loose after about one or two years, leading to a re-collapse and failure of surgery. In ‘Amrita Sling Technique’ (devised to obviate these complications associated with external fixators), the reconstructed bones are permanently stabilized and fixed using a 2.0 Fibre wire-- the strongest suture material available in the world. During the last 5 years more than 100 surgeries have been performed at AIMS using this technique, with excellent results and no major complications. All operated patients are normally ambulant in prescription diabetic footwear, now for over four years.

Dr Varma informed Citizen News Service – CNS in an exclusive interview that, “Our management techniques of limb salvage in infected diabetic lower limb wounds and foot and ankle reconstructive surgeries in patients living with diabetes have very high success rates which are not only comparable but even better than that in the west. At our institute, major amputation rates in diabetic lower limb wounds are very low--only 8.5%, as compared to the 25% in USA and 9% in the UK (as per data of the International Diabetic Federation). Other developing countries, including India, have major amputation rates as high as of 45% for diabetic foot wounds.”

--- Shared under Creative Commons (CC) Attribution License

Posted on: September 08, 2013 12:57 PM IST