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ROLE OF CO2 LASER IN THE MANAGEMENT OF DIABETIC FOOT/ULCER. Prof.Dr.A.R.UNDRE Consultant Surgeon: Saifee Hospital, Jaslok Hospital & Research Centre Mumbai, India. Diabetes is the Greatest health problem of the 21st Century. In a 24-hour period of time----

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  1. ROLE OF CO2 LASER IN THE MANAGEMENT OF DIABETIC FOOT/ULCER Prof.Dr.A.R.UNDREConsultant Surgeon: Saifee Hospital, Jaslok Hospital & Research CentreMumbai, India

  2. Diabetes is the Greatest health problem of the 21st Century. In a 24-hour period of time---- • 4,100 people diagnosed with Diabetes, • 230 amputations in people with Diabetes. 25 % of admissions in any hospital are Diabetic. • Still a large number of undiagnosed cases of diabetes • Today 1.8% of total population is Diabetic • By 2025 one out of every 5 Indian will be a high risk case by 2025.

  3. INDIA - THE WORLD CAPITAL OF DIABETES 57.2 million 2025 AD 140 % 19.4 million 1995 AD - WHO ESTIMATE

  4. India World Diabetes Capital 2025

  5. Diabetic Foot An Overview • People with diabetes have a 15% lifetime risk of developing a foot ulcer • They also have 15 to 40% higher risk of lower extremity amputation • Varied methods of treatment are available with varying degree of success

  6. Amputation is a mean operation in Diabetic Foot. • Amputation reduces remaining life span of the patient. • Amputation makes the person crippled, dependent & a mental wreck.

  7. Therefore all attempts should be made to conserve the limb in Diabetic Foot

  8. Path-physiology Of Vascular Disease In A Diabetic • Macro vascular disease • Non-occlusive micro vascular disease

  9. MACROVASCULAR Disease • Similar to that noted in non-diabetic patients with athero-sclerotic disease except… • Generally occurring at an earlier age • Affects men and women equally • Involves more frequently the TIBIAL and PERONEAL arteries

  10. Non-occlusive MICRO VASCULAR Disease • Inability of the capillaries to vasodialate in response to injury • Decreased number of WBCs reaching injury site • Over abundance of oxygen derived free radicals

  11. Diabetes (Pathophysiology) High sugar(prone to infection) Ischemia Neuropathy Gangrene Motor loss Sensory loss Tissue Necrosis Abnormal pressure Repeated Trauma Ulceration

  12. Causes of Ulcerations in the Diabetic Foot • Absence of protective sensation • Arterial insufficiency • Foot deformity and callus formation resulting in focal areas of high pressure • Autonomic neuropathy causing decreased sweating and dry, fissured skin

  13. Causes of Ulcerations in the Diabetic Foot • Obesity • Impaired vision • Poor glucose control leading to impaired wound healing • Poor footwear that causes skin breakdown or inadequately protects the skin from high pressure and shear forces

  14. Peripheral vascular disease Biomechanical dysfunction and deformities Trauma High plantar pressure Limited joint mobility Duration of diabetes Elevated glycosylated hemoglobin levels Risk Factors For Foot Ulceration

  15. INVESTIGATIONS • Routine blood inv. • Diabetic status • Doppler studies • X-ray • Pus culture and sensitivity • Ankle-Brachial Pressure index (ABPI)

  16. INVESTIGATIONS • Angiography (preferably DSA) • Pulse volume recorder (PVR) • Transcutaneous oxygen tension • MRA with contrast

  17. CONVENTIONAL Prevention Medical treatment Estimate and treat vascular insufficiency Surgical: debridement and amputation (Minimum) OTHER METHODS Hyperbaric oxygen Tissue Granulation Factor (Bionect) Co2 Laser (The Latest) Treatment Modalities

  18. PREVENTION • Identify and treat HIGH risk patients early • Regular blood sugar level check • Advice on ideal foot care

  19. Tips to keep your feet healthyA) Do’s • Check your bottom of feet with mirror every day and consult your doctor at very first sign of redness, swelling, pain, numbness or tingling in any part. • Check inside of your shoes every day for things like gravel or a torn lining & remove dirt and dust. If shoes are torn, replace immediately. • Regular check up of your feet by doctor Cont.

  20. Tips to keep your feet healthyA) Do’s (Cont.) • Choose the right shoes with a good arch support which fit properly. • Wear white socks and check for any blood or fluid from a sore on them. • Wash your feet daily in lukewarm water. Dry them well,especially between the toes with a soft towel and blot gently; don't rub. • Keep your feet skin smooth with a cream or lotion. • If your feet sweat easily, keep them dry with nonmedicated powder

  21. Tips to keep your feet healthyB) Don'ts • Do not walk barefoot. • Do not wear stretch socks, nylon socks, socks with inside seams. • Do not wear socks with a tight elastic band or garter at the top. • Do not put hot water, electric blanket or heating pads on your feet. • Do not use iodine, or astringents on your feet. • Avoid things that are bad for you feet.

  22. MEDICAL TREATMENT • Early and prompt control of diabetes with low threshold for use of INSULIN • Drugs to improve vascularity • Correction of anemia • Antibiotics to control infection

  23. Treatment of Vascular Insufficiency • MAJOR vessels : a) Angioplasty • b) Vascular Neurolysis • MINOR vessels : Lumbar sympathetectomy

  24. SURGICAL Treatment • Debridement • Amputation (Minimum)


  26. BOHR’S Theory • Laser are produced by three basic interactions between PHOTONS and ELECTRONS • Absorption • Spontaneous emission • Stimulated emission

  27. Characteristics of Laser Light • COLLIMATED • COHERENT • MONOCHROMATIC • POLARISED

  28. Types of LASER • SOLID state e.g. Ruby & Nd YAG laser • LIQUID • GAS e.g. HeNe laser CO2 & Argon laser

  29. CO2 Laser gas mixture consist of 70%, helium, 15% Co2 & 15% N2

  30. Laser Tissue Interaction • Photochemical : Ablative decomposition & Photodynamic therapy • Thermal : Photocoagulation & Photovaporisation • Mechanical : Photo disruption & Explosive vaporization

  31. GAS LASER DESIGN • Consists of • Gas filled cavity • External optical pumping lights • Resonator with partially and totally reflecting mirrors

  32. Mechanism of Action Laser Therapy is though to act through a variety of Mechanisms. • Photons from laser probe are absorbed into the mitochondria and membranes of the cell. • Single oxygen molecules build up which influences the formation of adenosine triphosphate which in turn leads to replication of DNA. • Increased DNA leads to increased neurotransmission. • A cascade of Metabolic effects results in various physiological changes. In summary, this results in improved tissue repair.

  33. Biophysics • Laser photostimulation promotes tissue repair process by accelerating Collagen production & promoting overall connective tissue stability. • CO2 kills bacteria • Converts moist gangrene to dry gangrene. • Probably promotes neoangiogenesis (as skin grafts take well following Co2 Laser Therapy in an otherwise ischaemic foot)

  34. Laser Tissue Interaction in CO2 LASER • The mode of action is PHOTOTHERMAL by two ways • PHOTOCOAGULATION : Laser light is absorbed by target tissue,generating heat leading to denaturation of protein • PHOTOVAPORISATION : High pors of laser beam lead to vaporization of tissues, used for cutting tissues

  35. Operation Modes • CUT : Laser used to incise or cut tissue by using #continuous wave #super pulse wave • ABLATE : Superficial ablation of tissue using #continuous wave

  36. Presentations of Diabetic Foot

  37. I – Case illustration • Huge,circumferential ulcers of unknown etiology on both lower limbs • EIGHT sittings over a period of a month • This was followed by regular dressings and split skin graft • End result completely healed wounds

  38. II – Case illustration • Cellulites both lower limbs for which fasciotomy was done and 1.5 LITRES of pus drained,leaving him with infected wounds • He was given 16 sittings of laser • Wounds healed rapidly leaving ulcers 1/3rd original size,which were grafted • End result completely healed wounds

  39. III – Case illustration • Resident of SULTANATE OF OMAN,came to us for treatment after being advised amputation of left foot for gangrene • We did multiple fasciotomies leaving raw areas • These infected areas were subjected to 8 sittings of laser,along with last two toes amputation • All ulcers healed,and foot saved

  40. Heel getting involved

  41. Deeper Infection -Tendons affected

  42. Transmetatarsal Spread

  43. Infarction of 1st metatarsal

  44. Metatarsal Ulceration – involvement of tendon sheath

  45. Sole Ulceration-Instep region

  46. Near total sole affection

  47. Charcot Joint

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