2010 Dr SC Misra Oration Award was conferred upon Dr Ajith Kumar Varma at the 55th Foundation Day of Department of Surgery (General), Chhatrapati
(upgraded King George's Medical
College - KGMC). Dr Varma
is an assistant Professor in the Department of Endocrinology at Amrita
Institute of Medical Sciences in Kochi,
Kerala. After serving the army for 15 years, he is doing excellent work in the
field of podiatric surgery, related to the diabetic foot. I had the opportunity
to meet him when he was recently in Lucknow to
attend the 55th Foundation Day Celebration of Department of General Surgery, CSM Medical
University, where he
charmed everyone with his suave manners and modesty, as well as his passionate
zeal for improving the quality of life of those living with diabetes.
This article is based on an
exclusive interview given by him to Citizen News Service (CNS).
The concept of reconstructive and
corrective surgery for the diabetic foot has evolved very recently, as a means
to correct foot deformities. This latest technique is presently being practised
in very few countries of the world. There are a few selected centres in the US, UK,
Germany, Russia, Spain
and Australia, with USA, which has
7 podiatric schools performing such operations, topping the list. In India,
Amrita Institute of Medical Sciences, situated in Kochi, is the only institute doing this type
of reconstructive surgery in high risk patients of totally deformed diabetic
foot, thus obviating the traumatic need for amputations.
There is an entity called 'Charcot' in
diabetic foot problems. In prolonged diabetic foot problems there is an
increased blood flow to the lower limbs, due to autonomic neuropathy, which
causes demineralisation of the bones. It is a tsunami like effect, just washing
away the minerals of the bones. Moreover, it stimulates certain cells which
simply eat up the bones. All this weakens the bones, and makes them soft and
pudgy. This results in the collapse of the foot and ankle bones, making it impossible
for the patient to walk. Moreover, multiple increased pressure points are
developed on the soles of the affected feet, where ulcers and calluses develop.
These act as portals for entry of bacteria. As the cellular immunity of the
patient is suppressed, even the slightest bacterial infection can cause a
serious life threatening problem, so much so that if the patient is not given
proper treatment within 24 to 48 hours of the infection setting in, it may
result in amputations or even death.
Worldwide, 50% of all leg
amputations happen to people living with diabetes. In India, an
estimated 50,000 amputations are carried out every year due to diabetes related
foot problems. By employing reconstructive and corrective surgical techniques,
to correct the shape of the deformed feet and remove the high pressure points,
a large number of such amputations can be prevented. Thus the patient can lead
a near normal life, free from complications.
After having trained in the US, two years
ago, Dr Varma has been performing different types of foot and ankle corrective
surgeries, at the Amrita Institute, to normalise the shape and function of the
grossly deformed diabetic feet. Last year, more than 25 such surgeries were
performed. The best, amongst the 8 to 10 types of surgical techniques currently
available, is the Triple Arthodesis Surgery, which costs around Rs 30,000. The
costs of implants, titanium screws and suture fibre wires are additional. This,
according to Dr Varma, is quite reasonable, especially when compared to the
exorbitant fees charged in the USA
for a similar operation.
Not only this, Dr Varma and his
team have developed a new 'Amrita Sling Technique' for foot stabilisation,
which is one of its kinds in the entire world. This obviates many complications
which routinely occur after the reconstructive surgery.
In normal corrective surgery of
'Charcot's Foot' (as is being done in the US and elsewhere), the patient has to
take rest for 4 to 5 months before s/he can start walking, as the bones need
time to reconsolidate gradually. Moreover, during this period, an external
fixture called 'Illazarov Frame' has to be fixed on the foot with screws and
pins, which penetrate the bones and flesh. When the patient starts walking, it
is very likely for infection to set in, paving the way for amputation.
But the Amrita Sling Technique,
when applied once the reconstruction is done, results in quick normalisation of
the gait bio-mechanics and ambulation of the patient. This reduces the long
recuperation period, and also minimises the post operative complications. It
has been successfully tested on 10 patients at the institute who are now
leading a normal life.
Apart from doing pioneering work
in the field of podiatric surgery, the Amrita Institute happens to be the only
one in Asia, offering three specialised courses under one roof,
informed Dr Varma. It conducts a one year post doctoral fellowship programme in
podiatric surgery with a view to train more doctors in this field. Another 4
year course in diabetes and diabetic foot surgery exists for MBBS students, as
also a course for training paramedical staff for management of diabetic foot.
Dr Varma stressed upon the importance of proper and
timely foot care and foot wear advice to patients, to prevent limb and life threatening
infections. From the day the patient is diagnosed with diabetes, proper foot
care and foot wear advice must be instituted to prevent further complications.
As far as a good foot wear prescription is concerned, it has to be given with
utmost care. Diabetic foot wear are not off-the-counter purchases. They are
made of specific material, like micro cellular rubber, micro cellular polymer,
or ethyl vinyl acetate, which distribute pressure evenly on the surface, and
prevent build up of pressure points, to avoid formation of calluses which are
entry points for bacterial infection. Proper footwear should ideally be
prescribed only after doing a pedopodogram, in which plantar pressure at each
point of the under surface of the feet is measured. This is as necessary as
testing the blood sugar levels of a patient before prescribing insulin or other
With India earning the dubious
distinction of being the diabetic capital of the world, Dr Varma rightly
stressed upon the need for awareness about the complications of the disease in
the public, in the patients, and, above all, in the primary care physicians,
working in rural areas. In his words 'Pick up the lesion at the earliest', so
that the problem can be resolved without amputation. In developing countries,
as in India, the amputation
rate is over 45%, whereas in the USA, and also in patients at Amrita
Institute, it is a mere 8.5%, thanks to the novel surgical techniques
available. Not only this, as diabetes is a disease of the blood vessels, all
the organs get affected, especially the heart, which is strained over 15%. Even
with the best of processes in place, there is 85% mortality, within 5 years of
the amputation, due to cardiac arrest. Hence it is imperative to salvage the
limb. Only then can we improve the quality, as well as quantity of life of
patients, many of whom may be bread winners of their families.
Through good healthcare and
informed self-care, it is possible to prevent diabetes-related amputations in
the majority of cases. Prevention is always better than cure, more so in the
case of diabetes.
Contributed by: Bobby Ramakant