Diabetes affects 88 million people in south-east Asia with a regional prevalence of 8.8%, and of them, 77 million live in India. [1]. The age-adjusted comparative prevalence of Diabetes in India is 10.4%. [2] Diabetic Foot Disease is an important complication that accounts for significant morbidity and mortality in a diabetic individual. [3]. The global prevalence of diabetic foot ulcers was estimated to be 6.3% and is more prevalent in those who have Type 2 Diabetes and in males.[4]. The prevalence of diabetic foot disease is expected to rise even more in the coming decade . [5,6]. This rise is not only due to poor glycaemic control, poor foot care, lack of education, lack of proper healthcare facilities, trauma and secondary infections but also due to the co-existence of predisposing factors like Peripheral Neuropathy, Peripheral Vascular Disease and Previous History of Diabetic Foot Disease. [7,8]. In a developing country like India, the health care system has greatly improved and have become modernized to provide better care to the large population of the country especially in states like Kerala, over the last decade. However, the covid pandemic and the consequent frequent regional lockdowns have severely hindered the access of patients to nearby hospitals, in addition to crippling the already overburdened healthcare system. Besides, there are only a few published studies from India on Diabetic Foot Disease. Hence the objective of conducting this study was to determine the stage of presentation of diabetic foot disease during the pandemic period as seen at a tertiary care hospital in North Kerala.

Setting: This study was carried out on patients diagnosed with diabetic foot and admitted to the Department of Surgery of a tertiary care hospital in North Kerala.

Duration and Type of Study: The was a retrospective cohort study conducted on patients admitted during the period of 6months from July 2020 to December 2020.

Sampling Methods: Consecutive Sampling method was used to include all patients that met the inclusion criteria.

Sample Size Calculation: A sample size of 63 was calculated. The following formula was used for calculating the adequate sample size

Grade 3 - Deep ulcer with abscess formation or osteomyelitis

Grade 4 - Localised gangrene of the toes or partial foot gangrene

Grade 5 - Whole foot gangrene

Surgical Procedures: Surgical intervention as necessitated by the patient's condition was done during the inpatient stay and included Wound Debridement, Fasciotomy, Incision and Drainage and amputations of the toe, foot and leg. This retrospective study, however, did not have the type of procedures that were done as part of the treatment of the patient.

Ethical Considerations and Permissions: The study was conducted after obtaining Institutional Ethics Committee approval, and the patient's treatment was not altered in any form for this study.

Statistical Analysis: The collected data was analyzed using Frequency, Mean and Standard Deviation.

In this study, a total of 63 patients were included. Of the 63 patients, 51(80.9%) were males, and 12 (19.0%) were females with a male to female ratio of 4.25:1. The mean age of the patients was 57.74 years, with a standard deviation of 8.37 (Table/Chart 1). In this study, as per the Wagner-Meggitt Classification of diabetic foot, the most common stage of presentation of diabetic foot encountered was Grade III (42.9%) followed by Grade IV (28.6%), Grade II (19.0%) and Grade V (9.5%) (Table/Chart 2). All of the 63 patients admitted had poor glycemic control with an HbA1C value of at least 7%, and of them, 12 patients had an HbA1c value of more than 13% (Table/Chart 3). The mean value of HbA1C was 11.71%, with a standard deviation of 1.90. Out of the 63 patients, 57 had an FBS value of more than 120mg/dl, and of them, 27 had a value more than 250mg/dl. Out of the 63 patients, 57 patients showed pathogenic bacteria in the culture and sensitivity study of discharge from the ulcer. Eighteen patients had elevated serum creatinine values. A serum creatinine value of more than 2mg/dl was present in 6 patients. The presence of bone involvement was detected in 19% of the patients. 33 patients out of the 63 had coexisting peripheral vascular disease. There was a previous history of diabetic foot disease requiring treatment in 24 patients (Table/Chart 4).

Globally, Diabetes mellitus affected approximately 463 million people in 2019 and is estimated to affect up to 700 million people by 2045.[9] In India, this number is expected to rise from 77 million in 2019 to approximately 134 million by 2045.[2]. Diabetes increases the risk of several diseases like atherosclerosis and coronary artery disease and leads to several life-disabling complications. The complications associated with Diabetes is responsible for the increased morbidity and mortality in people with Diabetes. Diabetes can result in a spectrum of complications that include Cardiovascular Disease, Diabetic Eye Disease, Diabetic Kidney Disease, Peripheral Neuropathy, Peripheral Vascular Disease and Diabetic Foot Disease.[8].

The study by Yazdanpanah L et al. has shown that the annual incidence of Diabetic Foot Disease is 2.8%.[10]. Several studies and past literature have revealed that the etiology of Diabetic Foot Disease is multifactorial and is closely associated with three main components- Peripheral neuropathy (motor, sensory and autonomous), Peripheral vascular disease and Immunodeficiency. [5,8,11,12]. Altered foot biomechanics and gait, along with the above three components, play an important role in the pathophysiology of Diabetic Foot Ulceration. [11]. Other causes include poor glycemic control, calluses, foot deformities, improper foot care and ill-fitting footwear.[7].

Diabetes-related microvasculopathy and Immunodeficiency predispose and eventually result in multi-floral soft tissue infections and ulcerations, which may locally advance to involve deeper tissues like bone. Persistent infection and underlying osteomyelitis along with Peripheral arterial occlusive disease and varying degrees of peripheral neuropathy together lead to gangrene of the foot. [11,13]. Several studies have shown that Diabetic Foot Disease is responsible for a significant proportion of non-traumatic lower-limb amputations.[11,12,14]. The Wagner Meggitt Classification System is one of the most commonly used systems to classify Diabetic Foot Ulcers. It classifies foot ulcers into six grades (0-5) and is based on the depth of the ulcer, presence of abscess, osteomyelitis or gangrene and the extent of involvement of foot. [15,16].

Radiographs of the foot revealed osteomyelitis in 19% of the patients. These two findings suggest that proper and timely wound care was not provided to these patients leading to worsening of the foot. This study revealed that 28.6% of the patients had altered renal parameters at the time of admission. This may be related to worsening infection or the onset of Diabetic Nephropathy in these patients. The presence of monophasic or biphasic waveform with loss of reverse flow Arterial Doppler Ultrasound Imaging is regarded as a reliable indicator of significant ischaemic disease in the lower limbs.[23]. In this study, 52.4% of the patients had Peripheral Vascular Disease in their arterial doppler findings. The frequency of coexisting peripheral vascular disease was higher than that in previous literature. [7,19,24]. This may be related to the higher mean value of HbA1C in this study group, as stated in a study by Selvin E et al., which found a positive association between the HbA1C value and the risk of Peripheral Vascular Disease in diabetic patients.[25].

Though the distribution of frequencies of different stages of presentation of diabetic foot disease is comparable to other studies, the higher proportion of Grade III, grade IV and grade V diabetic feet indicates the co-existence of secondary infections, deep-seated abscesses, osteomyelitis and gangrene in the affected limb. This rise is due to poor glycaemic control and undetected or untreated coexisting diseases that predispose to Diabetic foot disease. This is in part may be due to financial constraints of the patient's families due to lack of job, transportation difficulties, shortage of medicines, shutting down of small scale health care facilities and pharmacies, prolonged neglect of wounds, discontinuing of regular medications and poor home wound care which in turn are due to the frequent regional lockdowns as a result of the covid pandemic.

This study highlights a recent increase in the burden of Diabetes in Kerala on account of undetected or neglected life-disabling Diabetic Foot Disease despite the presence of a reasonably adequate and easily accessible health care system covering all parts of Kerala.