diabetic foot kuliah

Diabetic FootDiabetic Foot

SURGERY DEPARTMENTSURGERY DEPARTMENTFACULTY OF MEDICINEFACULTY OF MEDICINE

YARSI UNIVERSITYYARSI UNIVERSITYJAKARTAJAKARTA

Introduction

EpidemiologyPathophysiologyClassification Treatment

EpidemiologyDM largest cause of neuropathy in N.A.1 million DM patients in CanadaHalf don’t knowFoot ulcerations is most common cause of hospital admissions for DiabeticsExpensive to treat, may lead to amputation and need for chronic institutionalized care

Epidemiology$34,700/year (home care and social services) in amputeeAfter amputation 30% lose other limb in 3 yearsAfter amputation 2/3rds die in five yearsType II can be worse15% of diabetic will develop a foot ulcer

Pathophysiology

Vascular disease?Neuropathy

SensoryMotor autonomic

Vascular Disease30 times more prevalent in diabeticsDiabetics get arthrosclerosis obliterans or “lead pipe arteries”Calcification of the mediaOften increased blood flow with lack of elastic properties of the arteriolesNot considered to be a primary cause of foot ulcers

Peripheral Artery Disease

Prevalence (ABI < 0.9):Prevalence (ABI < 0.9):10%-20% in type 2 diabetes at diagnosis10%-20% in type 2 diabetes at diagnosis30% in diabetics 30% in diabetics age 50 years age 50 years40%-60% in diabetics with foot ulcer40%-60% in diabetics with foot ulcer

Complications:Complications:ClaudicationClaudicationAssociated coronary and cerebral vascular Associated coronary and cerebral vascular diseasediseaseDelayed ulcer healingDelayed ulcer healing

DiabetDiabet Med.Med. 2005;22:1310 2005;22:1310DiabetesDiabetes Care.Care. 2003;26:3333 2003;26:3333

NeuropathyChanges in the vasonervorum with resulting ischemia ? cause

Increased sorbitol in feeding vessels block flow and causes nerve ischemiaIntraneural acculmulation of advanced products of glycosylation

Abnormalities of all three neurologic systems contribute to ulceration

Sensory NeuropathyLoss of protective sensationStarts distally and migrates proximally in “stocking” distributionLarge fibre loss – light touch and proprioceptionSmall fibre loss – pain and temperatureUsually a combination of the two

Sensory Neuropathy

Two mechanisms of UlcerationUnacceptable stress few times

rock in shoe, glass, burn

Acceptable or moderate stress repeatedly

Improper shoe waredeformity

Motor Neuropathy

Mostly affects forefoot ulcerationIntrinsic muscle wasting – claw toesEquinous contracture

Autonomic NeuropathyRegulates sweating and perfusion to the limbLoss of autonomic control inhibits thermoregulatory function and sweatingResult is dry, scaly and stiff skin that is prone to cracking and allows a portal of entry for bacteria

Autonomic Neuropathy

Gangguan NeuropatiGangguan Neuropati

Paralisis Paralisis Perubahan faal muskuloskeletal kakiPerubahan faal muskuloskeletal kakiPerubahan anatomiPerubahan anatomiTitik tekan di telapak kaki lainTitik tekan di telapak kaki lain

Mati rasaMati rasaCedera tak disadariCedera tak disadariTekanan pada luka tak dihindariTekanan pada luka tak dihindari

Gangguan faal saraf otonomGangguan faal saraf otonomPerfusi kulit kurangPerfusi kulit kurangPintas arteri vena kulit terbukaPintas arteri vena kulit terbuka

Sensory Joint Motor Autonomic PADNeuropathy Mobility Neuropathy Neuropathy

Protective Muscle atrophy and Sweating Ischemia sensation 2° foot deformities 2° dry skin

Foot pressure Foot pressure Fissure HealingMinor trauma esp. over recognition bony prominences

Callus Pre-ulcer ULCER Infection AMPUTATION Minor Trauma: Interdigital Maceration Mechanical (Moisture, Fungus) Chemical Thermal

PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION

©2006. American College of Physicians. All Rights Reserved.

Nerve damage Poor blood supply

Injury

Infection

Amputation

Ulcer

Pathway to diabetic foot problems

Causal Pathways for Causal Pathways for Foot UlcersFoot Ulcers

NeuropathyNeuropathy

DeformityDeformity

ULCERULCER

% Causal Pathways% Causal Pathways

Neuropathy: Neuropathy: 78% 78%

Minor trauma:Minor trauma: 79%79%

Deformity:Deformity: 63%63%

Behavioral Behavioral ? ?

DiabetesDiabetes Care.Care. 1999; 22:157 1999; 22:157

Poor self-foot carePoor self-foot care

Minor TraumaMinor Trauma

- Mechanical (shoes)- Mechanical (shoes)

- Thermal- Thermal

- Chemical- Chemical

PENYEBABPENYEBAB

AngiopatiAngiopatiPerdarahan jaringan marginalPerdarahan jaringan marginal

NeuropatiNeuropatiParalisis otot kakiParalisis otot kakiRasa matiRasa matiGangguan saraf otonomGangguan saraf otonom

TraumaTrauma

Motor Neuropathy and Foot Deformities

Hammer toesHammer toes

Claw toesClaw toes

Prominent metatarsal headsProminent metatarsal heads

Hallux valgusHallux valgus

Collapsed plantar archCollapsed plantar arch

Hammer Toes

Claw Toes

© 2002 American Diabetes AssociationFrom The Uncomplicated Guide to Diabetes ComplicationsReprinted with permission from The American Diabetes Association

© 2002 American Diabetes AssociationFrom The Uncomplicated Guide to Diabetes ComplicationsReprinted with permission from The American Diabetes Association

Hallux Valgus

Boulton, et al. Guidelines for Diagnosis of Outpatient Management of Diabetic Peripheral Neuropathy. Diabetic Medicine 1998, 15:508-512

Pre-ulcer Cutaneous Pathology

Persistent erythema after shoe Persistent erythema after shoe removalremoval

CallusCallus

Callus with subcutaneous Callus with subcutaneous hemorrhagehemorrhage

FissureFissure

Interdigital maceration, fungal Interdigital maceration, fungal infectioninfection

Nail pathologyNail pathology

AJM Boulton, H Connor, PR Cavanagh, The Foot in Diabetes, 2002

Pre-ulcer

Sukar sembuh karena:Sukar sembuh karena:

Trauma terus menerusTrauma terus menerus

Tekanan abnormalTekanan abnormal

Lingkungan diabetes subur untuk Lingkungan diabetes subur untuk berkembangnya kuman patogenberkembangnya kuman patogen

Perfusi jaringan kulit kurang baikPerfusi jaringan kulit kurang baik

Kurang mendapat nutrienKurang mendapat nutrien

Monofilament TestingTest characteristics:Test characteristics:

Negative predictive value = 90%-98%Negative predictive value = 90%-98%

Positive predictive value = 18%-36%Positive predictive value = 18%-36%

Prospective observational study:Prospective observational study:80% of ulcers and 100% of amputations 80% of ulcers and 100% of amputations occur in insensate feetoccur in insensate feet

Superior predictive value vs. other test Superior predictive value vs. other test modalitiesmodalities

J Fam Pract. 2000;49:S30Diabetes Care. 1992;15:1386

Using the MonofilamentDemonstrate on forearm or handDemonstrate on forearm or hand

Place monofilament perpendicular Place monofilament perpendicular to test siteto test site

Bow into C-shape for 1 secondBow into C-shape for 1 second

Test 4 sites/foot Test 4 sites/foot

Heel testing does Heel testing does notnot predict ulcer predict ulcer

Avoid calluses, scars, Avoid calluses, scars, and ulcersand ulcers

Monofilament Testing Tips

Insensate at 1 site = insensate feetInsensate at 1 site = insensate feet

Falsely insensate with edema, cold Falsely insensate with edema, cold feetfeet

Test annually when sensation Test annually when sensation normalnormal

Use monofilament Use monofilament < 100 times day < 100 times day

Replace if bentReplace if bent

Replace every 3 monthsReplace every 3 months

Vibration TestingBiothesiometerBiothesiometer

Best predictor of foot ulcer riskBest predictor of foot ulcer risk

128-Hz tuning fork at halluces128-Hz tuning fork at hallucesEquivalent to 10-g monofilamentEquivalent to 10-g monofilamentNewly recommended by ADANewly recommended by ADA

DiabetesDiabetes Care.Care. 2006;29(Suppl 1):S25 2006;29(Suppl 1):S25DiabetesDiabetes ResRes ClinClin PractPract. 2005;70:8. 2005;70:8

Diagnosis Angiopati Diagnosis Angiopati DiabetesDiabetes

Gambaran klinisGambaran klinisDerajat kelainan kakiDerajat kelainan kaki

Tipe angiopatiTipe angiopatiMakroangiopatiMakroangiopatiMikroangiopatiMikroangiopati

Sifat ObstruksiSifat ObstruksiAkutAkutKronik Kronik

Status pembuluh darahStatus pembuluh darahPulsasi denyut nadiPulsasi denyut nadiDoppler Doppler

BASIC FOOT CARE CONCEPTS

Daily foot inspectionMay require mirror, magnification, or caregiverEducate patient to recognize/report ASAP:

Persistent erythemaEnlarging callusPre-ulcer (callus with hemorrhage)



Commitment to self-care:Wash/dry daily

Avoid hot water; dry thoroughly between toes

Lubricate daily (not between toes)Debride callus/corn to reduce plantar pressure 25%

Avoid sharp instruments, corn plasters

No self-cutting of nails if:Neuropathy, PAD, poor vision



Protective behaviors:Avoid temperature extremesNo walking barefoot/stocking-footedAppropriate exercise if sensory neuropathy

Bicycle/swim > walking/treadmill

Inspect shoes for foreign objectsOptimal footwear at all times


Basic Footwear Education

AvoidAvoid::Pointed Pointed toestoesSlip-onsSlip-onsOpen toesOpen toesHigh heelsHigh heelsPlasticPlasticBlack colorBlack colorToo smallToo small

FavorFavor::

Broad-round toesBroad-round toes

Adjustable (laces, Adjustable (laces, buckles, Velcro)buckles, Velcro)

Athletic shoes, walking Athletic shoes, walking shoesshoes

Leather, canvasLeather, canvas

White/light colorsWhite/light colors

½” between longest ½” between longest toe and end of shoetoe and end of shoe

Diabetes Self-Management. 2005;22:33

Patient Evaluation

MedicalVascular OrthopedicIdentification of “Foot at Risk”

? Our job

Patient EvaluationSemmes-Weinstein Monofilament Aesthesiometer

5.07 (10g) seems to be threshold

90% of ulcer patients can’t feel it

Only helpful as a screening tool

Patient Evaluation

Medical Optimized glucose controlDecreases by 50% chance of foot problems

Patient EvaluationVascular

Assessment of peripheral pulses of paramount importanceIf any concern, vascular assessment

ABI (n>0.45)Sclerotic vessels

Toe pressures (n>40-50mmHg)TcO2 >30 mmHg

Expensive but helpful in amp. level

Patient Evaluation

OrthopedicUlcerationDeformity and prominencesContractures

Patient Evaluation

X-rayLead pipe arteriesBony destruction (Charcot or osteomyelitis)Gas, F.B.’s

Patient Evaluation

Patient EvaluationNuclear medicine

OverusedCombination Bone scan and Indium scan can be helpful in questionable cases (i.e. Normal X-rays)Gallium scan useless in these patientsBest screen – indium – and if Positive – bone scan to differentiate between bone and soft tissue infection

Patient Evaluation

CT can be helpful in visualizing bony anatomy for abscess, extent of diseaseMRI has a role instead of nuclear medicine scans in uncertain cases of osteomyelitis

Derajat Kelainan Kaki Derajat Kelainan Kaki Diabetik (WAGNER)Diabetik (WAGNER)

DerajatDerajat SifatSifat

LukaLuka AbsesAbses SelulitisSelulitis OsteoOsteomielitismielitis

GangGanggrengren

00 -- -- -- -- --

II SuperfisialSuperfisial -- -- -- --

IIII sampai sampai tendo/tendo/tulangtulang

-- -- -- --

IIIIII DalamDalam ++++ +/-+/- +/-+/- --

IVIV DalamDalam +/-+/- +/-+/- +/-+/- JariJari

VV GanggrenGanggren Seluruh Seluruh kakikaki

Ulcer ClassificationWagner’s Classification0 – Intact skin (impending ulcer)1 – superficial2 – deep to tendon bone or ligament3- osteomyelitis4 – gangrene of toes or forefoot5 – gangrene of entire foot

ClassificationType 2 or 3

ClassificationType 4

Treatment

Patient educationAmbulationShoe wareSkin and nail careAvoiding injury

Hot waterF.B’s

Treatment

Wagner 0-2Total contact castDistributes pressure and allows patients to continue ambulationPrinciples of application

Changes, Padding, removal

Antibiotics if infected

Treatment

Treatment

Wagner 0-2Surgical if deformity present that will reulcerate

Correct deformityexostectomy

Treatment

Wagner 3Excision of infected boneWound allowed to granulateGrafting (skin or bone) not generally effective

Treatment

Wagner 4-5Amputation

Level ?

Treatment

After ulcer healedOrthopedic shoes with accommodative (custom made insert)Education to prevent recurrence

Charcot FootMore dramatic – less common 1%Severe non-infective bony collapse with secondary ulcerationTwo theories

NeurotraumaticNeurovascular

Charcot FootNeurotraumatic

Decreased sensation + repetitive trauma = joint and bone collapse

NeurovascularIncreased blood flow → increased osteoclast activity → osteopenia → Bony collapseGlycolization of ligaments → brittle and fail →

Joint collapse

Classification

Eichenholtz1 – acute inflammatory process

Often mistaken for infection

2 – coalescing phase3 - consolidation

Classification

LocationForefoot, midfoot (most common) , hindfoot

Atrophic or hypertrophic Radiographic findingLittle treatment implication

Case 1

Case 2

Case 3

Case 4

Indications for Amputation

Uncontrollable infection or sepsisInability to obtain a plantar grade, dry foot that can tolerate weight bearingNon-ambulatory patientDecision not always straightforward

Low RiskAnnual comprehensive foot Annual comprehensive foot examinationexamination

Questionnaire completed by patient Questionnaire completed by patient

ExaminationExamination

Self-management and footwear Self-management and footwear educationeducation

Brief counselingBrief counseling

Written handoutWritten handout

JAMA. 2005;293:217

High RiskAnnual comprehensive foot examAnnual comprehensive foot exam

Inspect feet every office visitInspect feet every office visit

Podiatry care as neededPodiatry care as needed

Intensive patient educationIntensive patient education

Detect/manage barriers to foot Detect/manage barriers to foot carecare

Therapeutic footwear, as neededTherapeutic footwear, as needed

Therapeutic Footwear Goals

Protect feetProtect feetReduce plantar pressure, shock, and Reduce plantar pressure, shock, and shear shear Accommodate, stabilize, support Accommodate, stabilize, support deformitiesdeformitiesSuitable for occupation, home, leisureSuitable for occupation, home, leisure

DiabetesDiabetes Care.Care. 2004;27:1832 2004;27:1832DiabDiab MetabMetab ResRes RevRev. 2004;20(Suppl1):S51. 2004;20(Suppl1):S51

Therapeutic Footwear Components

Padded socks Padded socks (e.g., CoolMax, (e.g., CoolMax, Duraspun, others)Duraspun, others)

Shoe inserts/insoles Shoe inserts/insoles (closed-cell (closed-cell foam, viscoelastic)foam, viscoelastic)

Therapeutic shoesTherapeutic shoes

Therapeutic Footwear Efficacy

Decreases plantar pressure 50%-Decreases plantar pressure 50%-70%70%Uncertain reduction in ulcer rateUncertain reduction in ulcer rate

DiabetesDiabetes CareCare. 2004;27:1774. 2004;27:1774

ConclusionDiabetic foot ulcer is commonDiabetic foot ulcer is common

Foot ulcers have devastating Foot ulcers have devastating consequencesconsequences

Screening is simpleScreening is simple

Screening and team care reduce Screening and team care reduce diabetic foot ulcers and diabetic foot ulcers and amputationsamputations

Conclusion

Multi-disciplinary approach neededGoing to be an increasing problemHigh morbidity and costSolution is probably in preventionMost feet can be spared…at least for a while

Thank You

diabetic foot kuliah

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