Diabetic Foot Disease

Rizki Yaruntradhani Pradwipa MD, B. Med. Sc.

Department Of Internal Medicine
School of Medicine University of Indonesia

This Slide Used With Permission From

Prof. Dr. dr. Sarwono Waspadji, SpPD KEMD

Hyperglycemia
Sorbitol Pathway, PKC, Non-enzymatic Glycation
Endothelium
- basement membrane
glycation
- Ab(N) formation of
endothelial cell product

Haemodynamic

Blood Rheology

- blood flow
- microvascular
pressure

- viscosity
- Ab(N) platelet
function

-Basement membrane thickening

- permeability
Tissue hypoxia & damage
Organ failure

Hiperglikemia
Jalur Poliol
Defens
Antioksidan

Glikasi Protein

Autooksidasi
Glukosa

Faktor
Oksidatif

Stres Oksidatif
O2
/ NO
NO dependent
Vasodilatation
Proliferasi Otot
Polos

Vaskulopati

Oksidasi LDL
Perubahan Hemoreologis
Aktivasi Koagulasi
Hipoksia

Retinopati

Heparan
Sulfat
NCV
Drh Endoneural

Neuropati

Nefropati

Mekanisme Terjadinya Berbagai Komplikasi Vaskular pada DM

Diabetic Foot
The most devastating and dreading complication
of DM, both for the patients and doctors alike
Mortality rate high
Amputation rate high
Longer hospital stay
Very costly,
Interest to deal with foot problems - limited
No specific education / training to cope with
podiatrist - chiropodist
Patients ignorance
Financial problems insufficient

Fakta-fakta
1. 4-10 % penderita diabetes akan
mengalami ulkus pada kaki
2. Risiko untuk mengalami kaki diabetes
25 %
3. Insidens luka pada kaki 2-7 % per
tahun
4. Risiko amputasi kaki > 15 kali dari
non diabetes
5. 80 % amputasi didahului oleh ulkus

Pathophysiology of Diabetic Foot Ulcer

Hyperlipidemia
Smoking

Diabetes Mellitus
Neuropathy

Peripheral
Vasc. Disease

Somatic Neuropathy

Pain Sensation
Proprioseptive

Autonomic Neuropathy

Ortopedic

Limited Joint

Problem

Sweating

Abnormal

Mobility

PlantarPressure

blood distribution

Dry Skin
Fissures

Engorged vein,
Warm foot

Hypotrophy
Muscle / Abn.Gait

Callus
Deformity

Source: Boulton AJM. Diabetic Med 1996: 3: (Suppl.1)

Foot Ulcer
Infection

Ischemic foot

Biomekanika Kaki
Gaya yang mempengaruhi kaki
saat berdiri/ berjalan
Dipengaruhi oleh berat badan
Keadaan dinamik
Kaki normal distribusi merata
pada seluruh permukaan kaki
Deformitas : distribusi tidak
merata
Risiko timbulnya kalus atau luka

Biomekanik Kaki Diabetes

Neuropati motorik
Hipotrofi otot intrinsik
Deformitas
Distribusi tekanan kaki
Luka atau Kalus

Neuropati Motorik
Kelemahan otot intrinsik
Gangguan kesimbangan
ekstensi dan fleksi jari kaki

Penonjolan kaput tulang

metatarsal
Deformitas
Peningkatan tekanan pada
MTP

Bagaimana bisa terjadi luka ?

Peningkatan tekanan pada telapak kaki
Iskemia jaringan kaki saat menapak
Gangguan mikrosirkulasi, aliran lymphe,
transport jaringan interstisial
Recovery tekanan O2 transcutaneus
menurun
Recovery jaringan elastik menurun

Tekanan pada telapak kaki

2 faktor yang berpengaruh :
- gaya gesekan ( friction )
- gaya tekanan ( pressure )

Pengukuran Tekanan Telapak Kaki

Pengukuran tekanan plantar

Identifikasi daerah kaki dengan
tekanan yang tinggi
Menentukan jenis
sepatu/modifikasi
Pencegahan ulkus diabetes
Mencegah amputasi

Tekanan pada telapak kaki

dipengaruhi oleh :
Ketebalan
jaringan
Bentuk
deformitas
Derajat
deformitas
Elastisitas
jaringan
Mobilisasi sendi

Deformitas (1)

Pes Cavus

Halux valgus

Hammer toes
Claw toes

Deformitas (2)

Bunion

Charcots

arthropathy

Hammer toe

Clawed

Deformitas Pasca Amputasi

Pasca amputasi/operasi

Pemeriksaan Kaki Diabetik

Statis
Pemeriksaan dalam
posisi duduk/berbaring
Melihat kelainan fisik
Pemeriksaan penunjang
Stagging kelainan kaki

Dinamis
Pada saat berjalan/berdiri
Cara berjalan

Menilai fungsi otot-otot, sendi dan

tulang
Tekanan pada telapak kaki
Distribusi tekanan
Pengaruh neuropati
Peran off loading
Pengaruh gesekan

Risiko Ulkus pada Kaki Diabetik

Riwayat ulkus/amputasi
Neuropati

Sensorik-motorik-otonom

Trauma

Sepatu tidak adekuat

Tidak pakai alas kaki
Jatuh/kecelakaan
Benda asing dalam sepatu

Kelaianan biomekanik

Gengguan gerak sendi

Penonjolan tulang
Deformitas/osteoartopati
Kalus

Penyakit pembuluh darah perifer

Sosial-ekonomi

Kemiskinan
Sarana kesehatan kurang
Ketidak tahuan
Pendidikan rendah

Faktor yang mempengaruhi tekanan pada

kaki
Faktor intrinsik

Faktor ekstrinsik

Penonjolan tulang
Gangguan mobilisasi gerak
sendi
Kerusakan pada sendi
Kalus
Perubahan struktur jaringan

Sepatu tidak cocok

Berjalan tanpa alas kaki

Riwayat operasi kaki

Neuro-osteoarthropatic joint

Jatuh/kecelakaan
Benda asing dalam sepatu
Aktivitas fisik

Impaired Perfusion

Grade

1 = none
2 = PAD + but not critical
3 = Critical Limb Ischemia

Size/Extent in MM2
Tissue Loss/ Depth 1 =

Superficial fullthickness, not deeper

than dermis
2 = Deep ulcer, below dermis, involving subcutaneous
structures, fascia muscle or tendon
3 = All subsequent layers of the foot involved
including bone and or joint

Infection

Grade

1 = No symptoms or signs of infection

2 = Infection of skin and subcutaneous tissue only
3 = Erythema > 2cm or infection involving
subcutaneous structure(s)
No systemic sign(s) of inflammatory response
4 = Infection with systemic manifestation:
fever, leucocytosis, shift to the left
metabolic instability
hypotension, azotemia

Impaired Sensation

Grade

1 = absent
2 = present

International Consensus on the Diabetic Foot 2003

PrImary Care

Secondary and Tertiary Care

Natural History of Diabetic Foot

Stage 1 : Normal Foot

Primary
Prevention

Stage 2 : High Risk Foot

Stage 3 : Ulcerated Foot

Stage 4 : Infected Foot

Stage 5 : Necrotic Foot

Secondary
Prevention

Stage 6 : Unsalvable Foot

Edmonds: Kings College Hospital London 2004

Primary Prevention
Attending Physician
Nurse
Dietician
Medical Rehabilitationist
DM Educators, etc.

Secondary Prevention
Attending Physician
Nurse
Dietician
Medical Rehabilitationist
DM Educators, etc.

Consultant physicians from

other disciplins:
Surgeon
- vascular, plastic, orthopedic
Specialist for Rehabilitation
Specialist for Infection, etc

Diabetic Foot Management

Multidisciplinary Management
Educational Control
Metabolic Control
Mechanical Control
Wound Control
Microbiological Control
Vascular Control
Edmonds: Kings College Hospital London 2004

Pillars of Diabetic Foot Prevention

Education to the patients, family and Health care providers

Optimal Management of the DM
Identification of patients with high risk diabetic foot
Regularly observe and examine the foot and foot wear
Suitable and appropriate foot wear
Management of all the plausible factors for
diabetic ulcer development (smoking, BP, Dyslipidemia)
Motto:
Take care of your feet as you take care your face
nail care, daily foot inspection,

FOOT RISK Categories

Based on the Possible Problems Ahead
(Frykberg)
1.

Normal Sensation without Deformity

2.

Normal Sensation with Deformity or

High Plantar Pressure

3.

Insensitivity without Deformity

4.

Ischemia without Deformity

5.

Combination / Complicated:
Combination of insensitivity, ischemia and/or deformity
History of ulcer, Charcot Deformity

Management of Diabetic Ulcer

Measures to save the limb in general:
Improve the general condition of the patients (Metabolic)
Evaluate the wound condition regularly
(Wound)
Treat the ulcer as recommended
(Wound-Infection)
Improve the vascular impairment if any
(Vascular)
Provide special foot wear /shoes
(Pressure)
Provide ample patients education
(Education)
Provision of a good team care approach/teamwork
Multidisciplinary Management
Educational Control
Metabolic Control
Mechanical Control
Wound Control
Microbiological Control
Vascular Control
Edmonds: Kings College Hospital London 2004

Metabolic Control
Improve the pts general condition
Normalized Blood glucose - Insulin
Nutritional Status
*Hb, *Albumin

Facilitate tissue oxygenation

Cardiovascular system
Respiratory system

Infection Control
Microbiological culture, aerobic and anaerobic

Provision of appropriate and suitable antibiotic

Regular Antibiotic Profile Update

Wound Control
Evaluate the wound condition regularly
Debridement surgical
autolytic debridement
chemical debridement
enzymatic debridement
mechanical debridement

Treat the ulcer as recommended

Spesific Dressing
Alginate
Hydrocolloid, hydrogels
Absorbent dressing
Medicated dressing

Vascular Control
PAD - Management
Management depends on the stage of disease progression
STAGE I
(asypmtomatic)
Elimination of risk
factors

STAGE II
(intermitten claudication)

STAGE III and IV

(rest pain, serious trophic
disorders)

Lifestyle hygiene

Balloon angioplasty

Vasoactive agents

Surgical treatment:
Thromboendarterectomy
Vascular bypass grafts
Lumbar sympathectomy
As a last resort,
amputation

Platelet aggregation
inhibitors
Balloon angioplasty in
certain specific cases

Pressure Control (Mechanical Control)

Off weight bearing
Provide special foot wear /shoes
Crutches
Total contact casting

Education Control
Provide ample patient education
Education during hospitalization
Education in policlinic setting
Training for the nurses : wound care

Acute versus chronic

Acute

Chronic

coagulation

migration

remodeling

proliferation

Chronic
wound

proliferation
remodeling

inflammation

inflammation

coagulation

Supporting Measures
Good and adequate wound care
Appropriate wound dressing as needed

Reduce edema
Non weight bearing,
bed rest, crutches, wheel-chair,
custom / special / tailored shoes,
total contact casting etc.

Vascular rehabilitation vascular surgery

Reconstructive surgery
Rehabilitation

Rehabilitation
Rehabilitative prevention before the ulcer development
(special / tailor made foot wear, continous rehabilitation)
Rehabilitation during hospitalization
Rehabilitation to prevent new ulcer development
Reulceration has worse prognosis

Diabetes Foot Clinic

Plantar Ulcer
Needs Special Foot Wear

Special Foot Wear

Pressure Ulcer
Needs Meticulous Care

Canna indica

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