today , in india , there are more than 45 million diabetes patients and an estimated 50,000 amputations occurring every year due to diabetes - related foot problems .
india had the largest number of diabetic patients in the world till the year 2006 as claimed in the  international diabetic federation conference at copenhagen , in november 2006 .
latest statistics however state that china has overtaken india as the diabetic capital of the world .
the commonest cause of diabetic foot is the infected neuropathic foot , which is potentially preventable .
there are very few organised diabetic foot screening programs and podiatric services available only in major centres in india but a multidisciplinary team approach is mostly lacking .
socioeconomic factors like barefoot walking , inappropriate footwear usage , lack of awareness of the seriousness of diabetic foot problems among doctors and patients and hence , late reference to specialty centres are too matters of concern .
70% of the population in india lives in the rural area and 40% stay in one - room tenements .
inadequate sanitation , improper foot offloading due to lack of facilities and awareness are common .
diabetic foot conditions develop from a combination of the twin causes of poor circulation and neuropathy .
diabetic neuropathy can cause insensitivity or a loss of ability to feel pain , heat and cold .
diabetics suffering from neuropathy can develop minor cuts , scrapes , blisters or pressure sores that they may not be aware of due to the insensitivity .
if these minor injuries are left untreated , complications may result and lead to ulceration and possibly even amputation .
neuropathy can also cause deformities such as bunions , hammer toes and charcot 's foot .
these are resulting from undue bony prominences with high pressure points , leading to callosities and ulcerations .
these are small portals for bacterial entry , leading to the development of serious limb and life - threatening infections in these immunocompromised patients .
the concept of surgical correction for the diabetic foot and ankle deformity has evolved as a means to correct foot deformities secondary to long - standing diabetes .
this reshaping of a deformed foot or toes by surgical correction is presently being done routinely only in a few selected centres worldwide , as in the u.s , u.k , russia , germany , spain and australia , to name a few .
these surgeries help to normalise raised plantar pressures and thus prevent the formation of callus and ulcers of the foot and thus prevent amputations in diabetics
. over - riding of the big toe and crowding of toes can cause skin breakdown , thus resulting in ulcers and infection .
if the foot is not properly aligned , then again high pressures build up in the soles causing ulceration . 
charcot 's foot is a severe complication of diabetes , which leads to erosions and collapse of the foot and ankle bones and the planter arches , which in turn lead to marked deformities , raised plantar pressures and thus formation of ulcers .
different types of surgical corrections are carried out so as to normalise the shape and function of these grossly deformed feet .
pinzur et al . collected data over a 10-year period on treating charcot arthropathy of the foot and ankle . according to the data ,
48.5% of patients were treated with conservative therapy , while 50.6% of patients underwent surgery .
the surgical procedures included 21 major limb amputations , 29 ankle fusions , 26 hind foot fusions , 23 exostectomies and 23 debridements for osteomyelitis .
conservative management of charcot deformities ( stage i or stage ii ) , in the form of total contact casts , bracing devices and/or accommodative footwear , is approximately 75% effective .
myerson and edwards found that surgical correction resulted in lower - extremity stabilisation in 93% of patients who presented with severe foot and ankle deformity .
charcot 's destruction does not occur in the absence of peripheral neuropathy and approximately 30 to 50% of patients with diabetes have peripheral neuropathy .
unfortunately , there is a significant discrepancy in the literature when it comes to the incidence of charcot in patients with diabetes as the incidence ranges from 0.2 to 29% .
although charcot represents one end of the spectrum of diabetic foot deformities , longstanding , motor - sensory neuropathy secondary to diabetes represents the other end of the spectrum . on average , a majority of the mild to moderate foot deformities is amenable to accommodative footwear , conservative management and/or bracing . in recent years
, reconstructive foot surgery has assumed an important role in the management of charcot feet that can not be effectively treated by casting , bracing or footwear therapy .
although the appropriateness of reconstructive surgery during the acute phase is still a matter of debate , surgery on the chronically deformed or unstable quiescent charcot foot has become rather common in current practice .
the majority of operations consist of plantar exostectomies in combination with achilles tendon lengthening to remove bony prominences associated with recurrent ulcers and high plantar foot pressures .
complex reconstructive procedures with arthrodeses are more frequently reserved for realignment and stabilisation of severely deformed feet or ankles in an effort to avoid amputation [ figures 13 ] .
midfoot charcot reconstruction photos ( a ) pre operative ( b ) post operative charcot ankle fracture , internal fixation ( a ) pre operative ( b ) post operative trimalleolar charcot ankle fracture , reconstruction ( a ) pre operative c. t. scan ( b ) post operative x ray the choice of internal or external fixation depends on the quality of the bone . generally , in charcot syndrome , the bone stock is poor and external fixation provides better compression with fewer fixation failures . when internal fixation is used , locking plates may prevent backing out of hardware .
due to its ability to correct multiplanar deformities in osteopenic bone even in the presence of open wounds , the ilizarov external fixation is routinely used in charcot foot reconstructions .
external fixation is associated with a high rate of complications ( pin tract infections and wire breakage ) , but if recognised early , these can be easily treated and are non - limb - threatening .
nonetheless , the surgeon should not apply these frames without anticipating such complications at the outset and be prepared to manage them accordingly .
the use of silver - impregnated foam as a pin site dressing can help to prevent pin tract infections [ figure 4 ] .
ilizarov external fixator the post - treatment prevention of recurrence , contralateral charcot 's joint and ulceration is equally as important as the treatment phase . once the foot becomes stable through medical or surgical means , the emphasis must be on prevention of recurrent ulcers .
custom braces and orthoses such as the charcot restraint orthotic walker ( crow ) can be an effective method to brace a deformed extremity .
in general , custom - fabricated patellar tendon - bearing braces , crow devices or ankle - foot orthoses are advised for at least 12 months after reconstructive surgery ; some patients may require the device for their lifetime .
critically important , appropriately designed or fitted shoes with weight - dispersing accommodative insoles are necessary for protection and gentle support .
these patients are at high risk for subsequent ulceration and therefore require close follow - up and life - long surveillance .
early diagnosis is a key factor in the management of the charcot foot and plays a central role in the prevention of severe deformity .
surgery is most often reserved for those patients with severe or unstable deformities that are not amenable to long - term bracing or footwear therapy alone .
a team approach is recommended to prevent patients with these high - risk foot deformities from succumbing to limb loss .
adult - acquired flatfoot deformity or posterior tibial tendon dysfunction is a gradual but progressive loss of one 's arch .
it has a long tendon that extends from above the ankle and attaches into several sites around the arch of the foot .
the muscle acts like a stirrup on the inside of the foot to help support the arch .
the posterior tibial muscle stabilises the arch and creates a rigid platform for walking and running .
if the posterior tibial tendon becomes damaged or tears , the arch loses its stability and as a result , collapses causing a flatfoot .
adult flatfoot deformity can occur in people of all ages and gender ; however , it occurs most commonly in sedentary middle - aged to elderly females .
there are several risk factors for posterior tibial tendon dysfunction that include diabetes , obesity , steroid use and systemic inflammatory diseases such as rheumatoid arthritis , trauma and congenital low arch .
it occurs most commonly in one foot ; however , it can occur in both feet , especially in people with systemic diseases such as diabetes and rheumatoid arthritis .
the goals of surgery are to create a more functional and stable foot .. there are multiple procedures like fixation with compression screws , placement of subtalar titanium implant , with or without soft tissue reconstructions which are available to the surgeon and it may take several sittings to correct a flatfoot deformity [ figure 5 ] . ( a ) pre - operative photo ( b )
post - operative x - ray showing subtler implant for correction of adult flatfoot deformity hallux valgus is a condition where the great toe is deviated laterally at the metatarsophalangeal joint .
this causes raised plantar pressure at the region of the metatarsal head , leading to the formation of callosities and subsequent ulcers .
a bunion actually refers to the bony prominence or exostosis on the side of the big toe .
a large sac of fluid , known as a bursa , can form over the enlarged joint , which can then become inflamed and painful .
smaller bunions can also develop on the outside of the little toe joint , these are known as tailors bunions and are also treated surgically .
hallux valgus ( reconstruction ) ( a ) pre operative ( b ) post operative hallux limitus or rigidus of the big toe joint can cause pain and loss of motion . walking requires the big toe to bend upward or dorsiflex . without this movement ,
the condition can be treated using a variety of surgical techniques like metatarsal head resection or arthroplasty .. it is essential to find the true cause of the condition .
the condition is known to be caused by a long metatarsal , or by a number of other biomechanical imbalances .
prosthetic joints can be used to treat the condition if the joint is beyond repair .
arthritis of the joints of the arch of the foot often goes unnoticed until it has become quite advanced .
there are many types of arthritis but osteoarthritis is the most common type to affect these joints .
in later stages , there may be persistent swelling around the joint or hard lumps around the edge of the joints . in some patients , these lumps ( called  osteophytes )
are the cause of additional symptoms because they cause pressure on adjacent soft tissue structures .
removal of the osteophytes or surgical fusion of the damaged joints is the usual surgical treatment .
hammer , mallet and claw toes are deformities of the lesser toes usually caused by tendon or joint imbalance .
surgery to correct the hammer , mallet or claw toe deformity will usually permanently cure the formation of painful corns on skin overlying these joints .
neuromas are enlarged nerves , usually between the third and fourth toes , caused by nerve irritation and entrapment between bones .
ablative surgery under magnification generally result in permanent resolution of this sometimes extremely painful condition .
plantar fasciitis is an inflammation of the connective tissue found on the underside of the foot .
most patients respond to non - surgical treatment such as the prescription of orthoses , but on occasion , surgery is required .
haglund 's deformity is an enlargement of the bone at the back of the heel , which can encourage bursitis to develop .
various operations are utilised , ranging from bone removal to the  tilting of bones into a better position to alleviate the problem .
occasionally , surgical intervention is required where the tendon is stripped of its inflamed thickened tissue .
however , this may at times lead to the tendon getting adhered to the surrounding soft tissues .
many a times , tendon lengthening , by various techniques , is required to treat the condition .
commonly carried tendon transfer surgery is the tibialis anterior total or split transfer in the correction of usually occurring equinovarus deformity after a transmetatarsal or a chauparts midfoot amputation .
many other such tendon transfer surgeries are recommended for the correction of various foot and ankle deformities .
occasionally , surgical intervention is required where the tendon is stripped of its inflamed thickened tissue . however , this may at times lead to the tendon getting adhered to the surrounding soft tissues .
many a times , tendon lengthening , by various techniques , is required to treat the condition .
commonly carried tendon transfer surgery is the tibialis anterior total or split transfer in the correction of usually occurring equinovarus deformity after a transmetatarsal or a chauparts midfoot amputation .
many other such tendon transfer surgeries are recommended for the correction of various foot and ankle deformities .
the department of endocrinology , diabetic lower limb and podiatric surgery , amrita institute of medical sciences and research center , kochi , kerala , is the only centre in india where these reconstructive and corrective surgeries are being performed in large numbers , exclusively in high - risk diabetic foot patients . by employing these surgical techniques ,
a large number of amputations in patients with diabetic foot ulcers and deformed diabetic feet are being prevented . to avoid the serious complications of pin tract infections , wire breakage and others associated with the application of ilizarov frames and other types of external fixators in diabetic patients , we have devised a novel technique of foot and ankle stabilisation ,  the amrita sling technique. by comprehensive management
, we have been able to maintain a limb salvage rate of 91.5% , in diabetic foot and ankle diseases , comparable to the best centres in the world .
 diabetic foot and ankle deformities are secondary to long - standing diabetes and neglected foot care . 
 the concept of surgical correction for these deformities is quite recent . 
 the primary objective of reconstructive foot and ankle surgery is the reduction of increased plantar pressures , reduction of pain and the restoration of function , stability and proper appearance . 
 foot and ankle deformities can result in significant disability , loss of life style , employment and even the loss of the lower limb . 
 therefore , restoration of normal , problem free foot function and activities will have a significant impact on peoples lives . 
 reconstructive surgical procedures are complex and during reconstruction , internal and external fixation devices , including pins , compression screws , staples , and wires , may be used for repair and stabilization . 
 the surgeries performed depend on the type and severity of the condition . 
 surgery can involve any part of the foot and ankle , and may involve tendon , bone , joint , tissue or skin repair . 
 corrective surgeries can at times be performed on an outpatient basis with minimally invasive techniques . 
 recovery time depends on the type of condition being treated . 
INTRODUCTION
REVIEW OF LITERATURE
DIABETIC FOOT RECONSTRUCTIVE SURGERIES
Achilles tendon problems
Tendon transfer surgeries
CONCLUSIONS