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
In a 24-hour period of time---
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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.
INDIA - THE WORLD CAPITAL OF DIABETES
57.2 million
2025 AD
140 %
19.4 million
1995 AD
- WHO ESTIMATE
India
World Diabetes Capital
2025
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
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.
Therefore all attempts
should be made to
conserve the limb in
Diabetic Foot
Path-physiology Of Vascular
Disease In A Diabetic
Macro
vascular disease
Non-occlusive
micro
vascular disease
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
PERONEAL arteries
and
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
Diabetes
Ischemia
(Pathophysiology)
High sugar
(prone to infection)
Neuropathy
Gangrene
Motor loss
Tissue Necrosis
Sensory loss
Abnormal pressure Repeated Trauma
Ulceration
Causes of Ulcerations in the Diabetic Foot
1.Absence of protective sensation
2.Arterial insufficiency
3.Foot deformity and callus formation
resulting in focal areas of high pressure
4.Autonomic neuropathy causing
decreased sweating and dry, fissured
skin
Causes of Ulcerations in the Diabetic Foot
5.Obesity
6.Impaired vision
7.Poor glucose control leading to impaired
wound healing
8.Poor footwear that causes skin
breakdown or inadequately protects the
skin from high pressure and shear forces
Risk Factors For Foot Ulceration

Peripheral vascular
disease
 Biomechanical
dysfunction and
deformities
 Trauma
 High plantar pressure

Limited joint
mobility
 Duration of
diabetes
 Elevated
glycosylated
hemoglobin levels
INVESTIGATIONS
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Routine blood inv.
Diabetic status
Doppler studies
X-ray
Pus culture and
sensitivity
Ankle-Brachial
Pressure index (ABPI)
INVESTIGATIONS

Angiography
(preferably DSA)
 Pulse volume recorder
(PVR)
 Transcutaneous
oxygen tension
 MRA with contrast
Treatment Modalities

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)
PREVENTION

Identify and treat HIGH risk patients early
 Regular blood sugar level check
 Advice on ideal foot care
Tips to keep your feet healthy
A) 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.
Tips to keep your feet healthy
A) 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
Tips to keep your feet healthy
B) 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.
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
Treatment of Vascular
Insufficiency

MAJOR vessels : a) Angioplasty

b) Vascular Neurolysis
 MINOR vessels : Lumbar
sympathetectomy
SURGICAL Treatment

Debridement

Amputation (Minimum)
LASER

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L ~ LIGHT
A ~ AMPLIFICATION by
S ~ STIMULATED
E ~ EMISSION of
R ~ RADIATION
BOHR’S Theory

Laser are produced by three basic
interactions between PHOTONS and
ELECTRONS



Absorption
Spontaneous emission
Stimulated emission
Characteristics of Laser Light

COLLIMATED
 COHERENT
 MONOCHROMATIC
 POLARISED
Types of LASER

SOLID state e.g. Ruby & Nd YAG laser

LIQUID

GAS
e.g. HeNe laser
CO2 & Argon laser
CO2 Laser gas mixture consist
of 70%, helium, 15% Co2 &
15% N2
Laser Tissue Interaction
 Photochemical : Ablative
decomposition
& Photodynamic therapy
 Thermal
: Photocoagulation &
Photovaporisation
 Mechanical
: Photo disruption &
Explosive vaporization
GAS LASER DESIGN

Consists of
1) Gas filled cavity
2) External optical pumping lights
3) Resonator with partially and totally reflecting
mirrors
Mechanism of Action
Laser Therapy is though to act through a variety of Mechanisms.



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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.
Biophysics

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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)
Laser Tissue Interaction in
CO2 LASER

The mode of action is PHOTOTHERMAL by
two ways
1)
PHOTOCOAGULATION : Laser light is
absorbed by target tissue,generating heat leading to
denaturation of protein
2)
PHOTOVAPORISATION : High pors of laser beam
lead to vaporization of tissues, used for cutting
tissues
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
Presentations of Diabetic Foot
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
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
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
Heel getting involved
Deeper Infection -Tendons affected
Transmetatarsal Spread
Infarction of 1st metatarsal
Metatarsal Ulceration – involvement of tendon sheath
Sole Ulceration-Instep region
Near total sole affection
Charcot Joint
ADVANTAGES
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Presence of diabetic neuropathy and non-invasive
nature of CO2 laser allows most cases to be done
under IV sedation
Good patient compliance
Early feeding so minimum fasting period
Minimal need for post procedure analgesia
Negligible blood loss
Patient can attend procedure on OPD basis
Summary
Lasers are a treatment choice that appeals to
patients. Early research suggest that laser therapy
may have a role to play in the treatment of:
A) Diabetic Ulcer
B) Non Healing wounds
C) Bed Sores.
It is ideal for diabetic ulcer as the principle of
conservatism is well applied. In deep ulcers like
bed sores, laser therapy helps to limit destruction
of surrounding tissues.
Over 100 patients have been treated
successfully with CO2 Laser Therapy in
the last 5 years. The patients are evaluated
fully for anemia, diabetic status, bone
involvement & vascular insufficiency. In
case of large ulcers, the patient undergoes
conventional slough excision followed by
CO2LaserTherapy.
This protocol helps to reduce the hospital
stay considerably.
Thank You