INTRODUCTION
The Diabetic Foot Clinic of M.V. Hospital for Diabetes, Royapuram provides routine integrated examination of the feet of diabetic patients. The services of the clinic include education of the patient in practical aspects of foot care. The early recognition of feet at risk and foot complication is emphasized and special advice is given about selection of footwear.

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The hospital is known for its excellent and extensive facilities for the treatment of diabetes.

> The patient will find one source for all his requirements for the treatment and control of diabetes.
> Efforts are taken to achieve the target of making every person with diabetes lead a healthy life.
> This is ensured by helping the    patients to have good control of diabetes by appropriate means.

The Diabetes Research Centre Foundation is Situated at Royapuram, Madras. This hospital was started in 1954 as a general hospital. In 1971 it became a hospital exclusively for diabetes care. It has, at present, 80 beds for the treatment of diabetes. Over the years this has grown to be one of the largest referral centers for diabetes, with more than 1,30,000 patients registered to-date.

In 1983 it was recognized by the department of science and technology (D.S.T), Government Of India, New Delhi, as a research Institute.

About

Foot care and Prevention of Amputation in Diabetic Patients

The foot of the patient with a long standing Diabetes is often the site of neuropathic and vascular process which pose a considerable threat, not only to the lower limb but also to the life of the patient. This demands much care and attention by both the patient and health care personnel. Two major problems which predispose the diabetic patients to amputation are the development of neuropathy due to

uncontrolled diabetes over several years while result in damage to the nerves in the Â feet leading to the loss of sensation. They also develop certain high pressure points under the feet which result in the formation of callus which later turns in to an ulcer. In addition cigarette smoking will lead to nerve damage and reduced blood flow in the feet.

Early diagnosis of foot problem

All the patients are examined for loss of sensation (neuropathy) and also for reduced blood flow towards the limbs (peripheral vascular disease). Neuropathy is diagnosed by simple foot examination and by the use of very simple devices like Biothesiometry, Monofilament and Nerve Conduction studies and Peripheral Vascular disease by Peripheral and Colour Doppler test at the hospital.. These tests are very simple and very in-expensive.

Improper foot care

Lack of awareness, together with a host of other factors, play an important role in the neglect of the feet by people with diabetes who have insensitive feet. It is common practice to use a blade or a pair of scissors to cut one’s toenails. This can certainly cause an injury in this area. Fissures in the heel are a very common occurrence in the feet of people who often walk barefoot. Infection of these fissured soles is one of the causes of the diabetic foot. The constant contact of the feet with water during the washing of clothes, or other cleaning jobs, could lead to fungal infection of the nails between the toes. In addition to the above, the importance of foot care, with regular cleaning of the toes, is not understood by many, even in the urban areas. Improper footwear, tight or ill fitting, could also cause foot injury. Thorough education in proper foot care, especially for people with diabetes is highly necessary to avoid the detrimental effects of the diabetic foot.

Disease Process

The diabetic is especially susceptible to foot complications because of the poor blood circulation to the foot and leg. This condition is called Peripheral Vascular Disease (PVD) or arterial insufficiency and nerve disease is called peripheral neuropathy.

• PERIPHERAL NEUROPATHY
• INFECTION
• TRAUMA

Prevention

Aspects of prevention must include the maintenance of as near to normoglycemia (normal blood glucose level) as possible. This is accomplished by a team approach, reinforcing lifestyle adjustments in eating and exercise patterns , pharmalogical support in the form of oral or parenteral hypoglycemia agents , and last but not the least , continuous and sustained diabetes education and support. The person with diabetes must be advised on how to care of the foot. They need to carry out regular routine inspections of the foot , and promptly visit a health care facility at the slightest indication of a problem. A small foot lesion may lead to infection or even gangrene and can even result in loss of toes, foot or leg if neglected. However, you can prevent this from happening by following the under mentioned do’s and don’ts.

• The do’s
• The dont’s

PVD

PVD – Peripheral arterial insufficiency with gangrene in a diabetic foot Diabetes is a risk factor for atherosclerosis, which leads to peripheral ischaemia, as well as to coronary artery insufficiency and stroke. Thrombo-embolic occlusion of a stenosed atheromatous artery leads to tissue infarction with non-viable ischaemic tissue rapidly becoming infected, leading to life-threatening gangrene.

Services

Patients with various diabetic complications are referred to our centre . Our centre is one of the largest diabetic centres in Asia. The foot care department of our centre is actively involved in the treatment and research of diagnostic foot problems. The services and facilities available are given in the following paragraphs.

Introduction

The Diabetic Foot Clinic of M.V.Hospital for Diabetes, Royapuram called M.V.Centre for Diabetic Foot Care, Podiatry, Research and Management, provides routine integrated examination for diabetic patients. The services of the clinic include education of the patient in practical aspects of foot care, the early recognition of foot at risk, special advice on selection of footwear, and providing a comprehensive care for all diabetic foot complications
Staffing Pattern

FACILITIES & SERVICE

The clinic has the required facilities and staff to provide the following services.

(a) Education of Patients & Carers,

(b) Timely detection of high risk foot through routine foot examination by specially trained staff capable of recognizing risk factors for ulceration and amputation,

(c) Measures to reduce risk, including Chiropody, appropriate footwear and vascular and orthopedic interventions,

(d) Prompt and effective treatment of active problems, including ulcers, infection and ischemia.

Scope and Activities

The Clinic emphasizes that most of the complications are preventable with adequate education, routine foot care and attention to footwear, early detection followed by specific advice and treatment. The services offered by the Clinic provide the best opportunity to prevent complications resulting in amputations. The Foot Clinic includes the following modern units with state of the art facilities.

1. Foot Laboratory

Foot Laboratory provides the following services.

(i) Doppler Studies – These non-invasive vascular tests can be used for:
(a) diagnosis and quantification of PVD (Peripheral Vascular Disease)
(b) predicting wound healing of a diabetic foot ulcer
(c) follow-up and control of treatment
(d) Colour Doppler (Duplex) scan to study the extent and severity of PVD and to aid the vascular surgeon to decide about management.

(ii) Biothesiometry Test (BT Test):
This study is done using a small electronic instrument to determine vibration perception. These tests have been shown to be a good indicator of diabetic neuropathy.

(iii) Monofilament Test:
10g monofilament is used for this test. Inability to perceive the 10g monofilament at the toes or dorsum of the foot predicts future occurrence of a diabetic foot ulcer.

DIASTEP

This branded off the shelf footwear is the research product of M.V.Hospital for Diabetes and the Central Leather Research Institute, Chennai, supported by Novo Nordisk Educational Foundation. It is specially designed for diabetic patients who have neuropathy, minor foot deformation and have developed minor foot complications earlier.

Its special features are:

• PU sole with extra depth for more effective pressure distribution
• The extra depth sole has a special tread for better grip and traction
• Specially designed insole bed and foam layer for added comfort
• Rigid counter to ensure limited joint mobility
• Specially designed upper with leather lining for comfortable wear
• Adjustable Velcro fasteners to take care fluctuations in foot volume

Apart from these features, a specially derived angle of slant has been provided in the sole to give the “rocker” effect which is used to offload pressure from planter surface of the feet.

All these features incorporated after considerable research and after testing on people with Diabetes Mellitus at MV Hospital for Diabetes, Royapuram, Chennai make DIASTEPTM footwear an essential item for people with diabetes. Constant wear of this footwear will prevent foot ulcers and foot infection.

(iv) Nerve Conduction Studies:
Slowing of Nerve Conduction Velocity is one of the earliest neuropathic abnormalities in Diabetes Mellitus. Early diagnosis of Diabetic Peripheral Neuropathy is necessary to prevent fissure formation, infection and ulceration of the feet. In recent years, a number of Electro Physiological testing methods have been developed for early detection and diagnosis of Diabetic Neuropathies. These tests quantify nerve conduction and help to localize the lesions. These studies are carried out by this department.

(v) Tip Therm:
This instrument determines the thermal perception in the nerve endings, measuring warm and cold perception separately. This quantitative measurement helps an early diagnosis and staging of neuropathy.

2. Foot Care Education

All patients with foot complications are educated by the Foot Care Educator regarding:

(a) General principles of Foot Care like nail cutting, cleanliness of the foot, fungal infection between the toes and the heel fissures.

(b) Knowledge about the right type of footwear and also the importance of wearing them. Patients are also provided with books and pamphlets.

3. Pedicure Unit

Plantar aspect of the foot is examined by the Pedicurist for the presence of potential foot problems like heel fissures, in-growing toe nails, callus, dry skin, etc. Foot cleaning is taught along with nail filing.

4. In-house Footwear manufacturing unit

Proper footwear is one of the most important aspects of preventive foot care. New types of footwear are now being prepared at M.V. Hospital, Royapuram with technical assistance from Central Leather Research Institute, (CLRI) Chennai, for diabetic patients with foot complications. Patients in risk category 0,1 (low risk) are provided comfortable footwear made of good insole materials. These patterns are more attractive & acceptable to the patients, than the conventional MCR footwear. Patients in risk category 2, 3 (high risk) are given custom-made footwear. Those patients with previous ulceration, foot deformity are given custom made footwear with moulded insole.

New Equipment To Prepare Customised Insoles

Electronic Baropedometer

Foot ulceration in persons with diabetes is the frequent causes for amputation. Several studies have shown that the regular wear of therapeutic footwear, foot education, and diabetic foot care, prevents ulceration, reduces re-ulceration and amputation. Apart from these, Customized insoles are prescribed to offload high pressures from the metatarsal heads and from other areas, which helps in reducing the risk of plantar ulceration. The M.V. Hospital for Diabetes has introduced a new equipment, the ELECTRONIC BAROPEDOMETER to prepare customized therapeutic insoles.

Electronic podometer is used to evaluate in an accurate way the following parameters

• Pressure distribution in orthostatic condition
• Stabilometry of the patient in static position
• Dynamic evolution of the pressure during the dynamic phase of step
• Peaks of pressures and time of contact on the ground
• Individualization of areas at risk for the foot
• Comparison of the results of therapies adopted in time
• Helps in the design of plantar orthesis.

Different steps in preparing customized insoles

• Identify the pathology
• Select treatment
• Make a customized insoles

5. Surgical Care

A dedicated team of, general, podiatry, vascular, plastic and orthopedic surgeons provide surgical care for patients requiring operative care of their diabetic foot infection. Patients referred to our hospital are given prompt surgical care and measures are taken to ensure limb salvage to the extent possible.