Diabetic Foot DiseaseRizki 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 GlycationEndotheliumHaemodynamicBlood Rheology- basement membrane glycation- Ab(N) formation of endothelial cell product- blood flow- microvascular pressure- viscosity- Ab(N) platelet function-Basement membrane thickening- permeabilityTissue hypoxia & damageOrgan failure

Stres Oksidatif O 2 / NOHiperglikemiaJalur PoliolGlikasi ProteinAutooksidasi GlukosaDefensAntioksidanFaktor OksidatifNO dependentVasodilatationProliferasi OtotPolosOksidasi LDLHeparan SulfatPerubahan HemoreologisAktivasi KoagulasiHipoksiaNCVDrh Endoneural VaskulopatiRetinopatiNeuropati Nefropati Mekanisme Terjadinya Berbagai Komplikasi Vaskular pada DM (Dari Giugliano D, Ceriello A, Paolisso G. Diabetes Care 1996;19(3):258

Diabetic FootThe most devastating and dreading complication of DM, both for the patients and doctors alike Mortality rate highAmputation rate highLonger hospital stayVery costly, Interest to deal with foot problems - limitedNo specific education / training to cope with podiatrist - chiropodistPatients ignoranceFinancial problems insufficient

Fakta-fakta 4-10 % penderita diabetes akan mengalami ulkus pada kakiRisiko untuk mengalami kaki diabetes 25 %Insidens luka pada kaki 2-7 % per tahun Risiko amputasi kaki > 15 kali dari non diabetes80 % amputasi didahului oleh ulkus

Pathophysiology of Diabetic Foot Ulcer Diabetes Mellitus HyperlipidemiaSmokingNeuropathy Peripheral Vasc. Disease

Somatic Neuropathy Autonomic Neuropathy

Pain Sensation Proprioseptive Ortopedic Limited Joint Sweating Abnormal Problem Mobility blood distribution PlantarPressure Dry Skin Engorged vein, Fissures Warm footHypotrophyMuscle / Abn.GaitCallus Foot Ulcer Ischemic foot InfectionSource: Boulton AJM. Diabetic Med 1996: 3: (Suppl.1) Deformity

Biomekanika KakiGaya yang mempengaruhi kaki saat berdiri/ berjalanDipengaruhi oleh berat badanKeadaan dinamikKaki normal distribusi merata pada seluruh permukaan kakiDeformitas : distribusi tidak merataRisiko timbulnya kalus atau luka

Biomekanik Kaki Diabetes

Neuropati Motorik

Bagaimana bisa terjadi luka ?

Peningkatan tekanan pada telapak kakiIskemia jaringan kaki saat menapak Gangguan mikrosirkulasi, aliran lymphe, transport jaringan interstisialRecovery 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

Tekanan pada telapak kaki dipengaruhi oleh :

Deformitas (1)Halux valgusHammer toesClaw toesPes Cavus

Deformitas (2)Bunion Charcots arthropathyHammer toe Clawed toes

Deformitas Pasca Amputasi Pasca amputasi/operasi

Pemeriksaan Kaki Diabetik

StatisDinamisPemeriksaan dalam posisi duduk/berbaringPada saat berjalan/berdiriMelihat kelainan fisikCara berjalanPemeriksaan penunjangMenilai fungsi otot-otot, sendi dan tulangStagging kelainan kakiTekanan pada telapak kakiDistribusi tekananPengaruh neuropatiPeran off loadingPengaruh gesekan

Risiko Ulkus pada Kaki Diabetik

Faktor yang mempengaruhi tekanan pada kaki

Impaired PerfusionGrade 1 = none 2 = PAD + but not critical 3 = Critical Limb IschemiaSize/Extent in MM2Tissue 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 InfectionGrade 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 leftmetabolic instabilityhypotension, azotemiaImpaired Sensation Grade 1 = absent2 = present

International Consensus on the Diabetic Foot 2003

Natural History of Diabetic FootStage 1 : Normal FootStage 2 : High Risk FootStage 3 : Ulcerated FootStage 4 : Infected FootStage 5 : Necrotic FootStage 6 : Unsalvable FootEdmonds: Kings College Hospital London 2004PrimaryPreventionSecondaryPreventionP r I m a r y C a r e Secondary and Tertiary Care

Primary PreventionAttending PhysicianNurseDieticianMedical RehabilitationistDM Educators, etc.

Secondary PreventionAttending PhysicianNurseDieticianMedical RehabilitationistDM Educators, etc.

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

Multidisciplinary ManagementEducational Control Metabolic Control Mechanical ControlWound ControlMicrobiological ControlVascular Control

Edmonds: Kings College Hospital London 2004Diabetic Foot Management

Pillars of Diabetic Foot PreventionEducation to the patients, family and Health care providers Optimal Management of the DM Identification of patients with high risk diabetic footRegularly observe and examine the foot and foot wearSuitable and appropriate foot wearManagement of all the plausible factors for diabetic ulcer development (smoking, BP, Dyslipidemia)

Motto:Take care of your feet as you take care your facenail care, daily foot inspection,

FOOT RISK Categories Based on the Possible Problems Ahead (Frykberg)1. Normal Sensation without Deformity2. Normal Sensation with Deformity or High Plantar Pressure3. Insensitivity without Deformity4. Ischemia without Deformity5.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 oxygenationCardiovascular systemRespiratory systemInfection ControlMicrobiological culture, aerobic and anaerobicProvision of appropriate and suitable antibioticRegular Antibiotic Profile Update

Wound ControlEvaluate the wound condition regularlyDebridement surgical autolytic debridement chemical debridement enzymatic debridement mechanical debridement Treat the ulcer as recommendedSpesific DressingAlginateHydrocolloid, hydrogelsAbsorbent dressingMedicated dressing

Vascular Control PAD - ManagementManagement depends on the stage of disease progression

Pressure Control (Mechanical Control) Off weight bearing Provide special foot wear /shoes Crutches Total contact castingEducation Control Provide ample patient educationEducation during hospitalizationEducation in policlinic setting Training for the nurses : wound care

coagulationinflammationproliferationmigrationremodelingChronic woundproliferationinflammationcoagulationremodeling Acute Chronic Acute versus chronic

Supporting MeasuresGood and adequate wound care Appropriate wound dressing as neededReduce edema Non weight bearing, bed rest, crutches, wheel-chair, custom / special / tailored shoes, total contact casting etc.Vascular rehabilitation vascular surgeryReconstructive surgery Rehabilitation

RehabilitationRehabilitative prevention before the ulcer development (special / tailor made foot wear, continous rehabilitation) Rehabilitation during hospitalizationRehabilitation to prevent new ulcer development

Reulceration has worse prognosis

Diabetes Foot Clinic

Plantar UlcerNeeds Special Foot Wear

Special Foot WearPressure UlcerNeeds Meticulous Care

Hatur NuhunCanna indica

****Any foot that is deformed such as a foot with bunions (left) can lead to problems: a bunion fits into shoes with difficulty. This area of the foot can rub on the shoe, leading to ulceration.

Charcots arthropathy (right, the mid-foot in this case has collapsed) causes severe deformity. It is very difficult for this sort of foot to fit into a normal shoe. Looking at the foot on the left, we can see a corn on the top of the fourth digit which was probably caused by a shoe that was too tight at the toe.

People require shoes from a specialized orthopaedic footwear dealer that are wide and deep enough to accommodate foot deformities.

People should be aware of the need to check bunions for redness and hard skin. Corns should be removed by someone who is skilled in sharp debridement.

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