Diabetic Foot Kuliah

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Diabetic Foot

SURGERY DEPARTMENT

FACULTY OF MEDICINE

YARSI UNIVERSITY

JAKARTA

IntroductionEpidemiology

Pathophysiology

Classification

Treatment

EpidemiologyDM largest cause of neuropathy in N.A.

1 million DM patients in Canada

Half don’t know Foot ulcerations is most common cause of hospitaladmissions for Diabetics

Expensive to treat, may lead to amputation and need

for chronic institutionalized care

Epidemiology$34,700/year (home care and social services) inamputee

After amputation 30% lose other limb in 3 years

After amputation 2/3rds die in five years

Type II can be worse

15% of diabetic will develop a foot ulcer

PathophysiologyVascular disease?

Neuropathy

Sensory

autonomic

Vascular Disease30 times more prevalent in diabetics

Diabetics get arthrosclerosis obliterans or “lead pipearteries”

Calcification of the mediaOften increased blood flow with lack of elasticproperties of the arterioles

Not considered to be a primary cause of foot ulcers

Peripheral Artery DiseasePrevalence (ABI < 0.9):

10%-20% in type 2 diabetes at diagnosis

30% in diabetics age 50 years

40%-60% in diabetics with foot ulcerComplications:Claudication

Associated coronary and cerebral vascular

diseaseDelayed ulcer healing

Diabet Med. 2005;22:1310

Diabetes Care. 2003;26:3333

NeuropathyChanges in the vasonervorum with resultingischemia ? cause

Increased sorbitol in feeding vessels block flowand causes nerve ischemia

Intraneural acculmulation of advanced products ofglycosylation

Abnormalities of all three neurologic systemscontribute to ulceration

Sensory NeuropathyLoss of protective sensation

Starts distally and migrates proximally in

“stocking” distribution Large fibre loss – light touch andproprioception

Small fibre loss – pain and temperature

Usually a combination of the two

Sensory NeuropathyTwo mechanisms of Ulceration

Unacceptable stress few times

rock in shoe, glass, burn

Acceptable or moderate stress repeatedly

Improper shoe ware

deformity

Motor NeuropathyMostly affects forefoot ulceration

Intrinsic muscle wasting – claw toes

Equinous contracture

Autonomic NeuropathyRegulates sweating and perfusion to the limb

Loss of autonomic control inhibits

thermoregulatory function and sweatingResult is dry, scaly and stiff skin that is proneto cracking and allows a portal of entry forbacteria

Autonomic Neuropathy

Gangguan Neuropati

ParalisisPerubahan faal muskuloskeletal kaki

Perubahan anatomi

Titik tekan di telapak kaki lain

Mati rasaCedera tak disadari

Tekanan pada luka tak dihindariGangguan faal saraf otonom

Perfusi kulit kurang

Pintas arteri vena kulit terbuka

Sensory Joint Motor Autonomic PAD

Neuropathy Mobility Neuropathy Neuropathy

Protective Muscle atrophy and Sweating Ischemia

sensation 2° foot deformities 2° dry skin

Foot pressure Foot pressure Fissure HealingMinor trauma esp. overrecognition bony prominences

Callus Pre-ulcer ULCER Infection AMPUTATION

Minor Trauma: Interdigital Maceration

Mechanical (Moisture, Fungus)

Chemical

Thermal

PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION

Nerve damage Poor blood supply

Injury

Infection

Amputation

Pathway to diabetic foot problems

Causal Pathways for Foot

UlcersNeuropathy

Deformity

% Causal Pathways

Neuropathy: 78%

Minor trauma: 79%

Deformity: 63%

Behavioral ?

Diabetes Care. 1999; 22:157

Poor self-foot care

Minor Trauma

- Mechanical (shoes)

- Thermal

- Chemical

PENYEBAB

AngiopatiPerdarahan jaringan marginal

NeuropatiParalisis otot kaki

Rasa mati

Gangguan saraf otonom

Trauma

Motor Neuropathy and Foot

DeformitiesHammer toes

Claw toes

Prominent metatarsal heads

Hallux valgus

Collapsed plantar arch

Hammer Toes

Claw Toes

From The Uncomplicated Guide to Diabetes Complications Reprinted 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

PathologyPersistent erythema after shoe removal

Callus

Callus with subcutaneous hemorrhage

Fissure

Interdigital maceration, fungal infection

Nail pathology

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

Pre-ulcer

Sukar sembuh karena:

Trauma terus menerus

Tekanan abnormal

Lingkungan diabetes subur untukberkembangnya kuman patogen

Perfusi jaringan kulit kurang baik

Kurang mendapat nutrien

Monofilament TestingTest characteristics:

Negative predictive value = 90%-98%

Positive predictive value = 18%-36%

Prospective observational study:80% of ulcers and 100% of amputations occur ininsensate feet

Superior predictive value vs. other test

modalities

J Fam Pract. 2000;49:S30

Using the MonofilamentDemonstrate on forearm or hand

Place monofilament perpendicular totest site

Bow into C-shape for 1 second

Test 4 sites/foot

Heel testing does notpredict ulcer

Avoid calluses, scars,

and ulcers

Monofilament Testing TipsInsensate at 1 site = insensate feet

Falsely insensate with edema, cold feet

Test annually when sensation normalUse monofilament

< 100 times day

Replace if bentReplace every 3 months

Vibration TestingBiothesiometer

Best predictor of foot ulcer risk

128-Hz tuning fork at halluces

Equivalent to 10-g monofilamentNewly recommended by ADA

Diabetes Care. 2006;29(Suppl 1):S25

Diabetes Res Clin Pract. 2005;70:8

Diagnosis Angiopati Diabetes

Gambaran klinisDerajat kelainan kaki

Tipe angiopatiMakroangiopati

Mikroangiopati

Sifat ObstruksiAkut

KronikStatus pembuluh darah

Pulsasi denyut nadi

Doppler

BASIC FOOT CARE CONCEPTS

Daily foot inspection

May require mirror, magnification, or

caregiverEducate patient to recognize/report ASAP:

Persistent erythema

Enlarging callus

Pre-ulcer (callus with hemorrhage)

Commitment to self-care:Wash/dry daily

Avoid hot water; dry thoroughly between toesLubricate daily (not between toes)

Debride callus/corn to reduce plantar pressure25%

Avoid sharp instruments, corn plastersNo self-cutting of nails if:

Neuropathy, PAD, poor vision

Protective behaviors:Avoid temperature extremes

No walking barefoot/stocking-footedAppropriate exercise if sensory neuropathy

Bicycle/swim > walking/treadmill

Inspect shoes for foreign objects

Optimal footwear at all times

Basic Footwear Education

Avoid:

Pointedtoes

Slip-onsOpen toes

High heels

Plastic

Black color

Too small

Favor:

Broad-round toes

Adjustable (laces,buckles, Velcro)

Athletic shoes, walkingshoes

Leather, canvas

White/light colors½” between longest toeand end of shoe

Diabetes Self-Management. 2005;22:33

Patient EvaluationMedical

Vascular

Orthopedic

Identification 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 EvaluationMedical

Optimized glucose control

Decreases by 50% chance of footproblems

Patient EvaluationVascular

Assessment of peripheral pulses of paramountimportance

If any concern, vascular assessmentABI (n>0.45)

Sclerotic vessels

Toe pressures (n>40-50mmHg)

TcO2 >30 mmHgExpensive but helpful in amp. level

Patient EvaluationOrthopedic

Ulceration

Deformity and prominencesContractures

Patient EvaluationX-ray

Lead pipe arteries

Bony destruction (Charcot or osteomyelitis)Gas, F.B.’s

Patient Evaluation

Patient EvaluationNuclear medicine

Overused

Combination Bone scan and Indium scancan be helpful in questionable cases (i.e.Normal X-rays)

Gallium scan useless in these patients

Best screen – indium – and if Positive – bone scan to differentiate between boneand soft tissue infection

Patient EvaluationCT can be helpful in visualizing bonyanatomy for abscess, extent of disease

MRI has a role instead of nuclearmedicine scans in uncertain cases ofosteomyelitis

Derajat Kelainan Kaki Diabetik

Derajat Kelainan Kaki Diabetik(WAGNER)

DerajatSifat

Luka Abses Selulitis Osteomielitis

Ganggren

0 - - - - -

I Superfisial - - - -

II sampaitendo/tulang

- - - -

III Dalam ++ +/- +/- -

IV Dalam +/- +/- +/- Jari

V Ganggren Seluruh

Ulcer ClassificationWagner’s Classification

0 – Intact skin (impending ulcer)

1 – superficial2 – deep to tendon bone or ligament

3- osteomyelitis

4 – gangrene of toes or forefoot5 – gangrene of entire foot

Classification

Type 2 or 3

Classification

Type 4

Treatment

Patient education

Ambulation

Shoe wareSkin and nail care

Avoiding injury

Hot waterF.B’s

Treatment

Wagner 0-2

Total contact cast

Distributes pressure and allows patients tocontinue ambulation

Principles of application

Changes, Padding, removal

Antibiotics if infected

Treatment

Wagner 0-2

Surgical if deformity present that will

reulcerateCorrect deformity

exostectomy

Treatment

Wagner 3

Excision of infected bone

Wound allowed to granulateGrafting (skin or bone) not generallyeffective

Treatment

Wagner 4-5

Amputation

Level ?

Treatment

After ulcer healed

Orthopedic shoes with accommodative

(custom made insert)Education to prevent recurrence

Charcot Foot

More dramatic – less common 1%

Severe non-infective bony collapse with

secondary ulcerationTwo theories

Neurotraumatic

Neurovascular

Charcot Foot

NeurotraumaticDecreased sensation + repetitive trauma = joint and bonecollapse

NeurovascularIncreased blood flow → increased osteoclast activity →

osteopenia → Bony collapse

Glycolization of ligaments → brittle and fail →

Joint collapse

Classification

Eichenholtz

1 – acute inflammatory process

Often mistaken for infection2 – coalescing phase

3 - consolidation

Classification

Location

Forefoot, midfoot (most common) ,

hindfootAtrophic or hypertrophic

Radiographic finding

Little treatment implication

Case 1

Case 2

Case 3

Case 4

Indications for Amputation

Uncontrollable infection or sepsis

Inability to obtain a plantar grade, dry

foot that can tolerate weight bearingNon-ambulatory patient

Decision not always straightforward

Low RiskAnnual comprehensive foot examination

Questionnaire completed by patient

Examination

Self-management and footwear educationBrief counseling

Written handout

JAMA. 2005;293:217

High RiskAnnual comprehensive foot exam

Inspect feet every office visit

Podiatry care as needed

Intensive patient education

Detect/manage barriers to foot care

Therapeutic footwear, as needed

Th ti F t

Therapeutic Footwear

GoalsProtect feetReduce plantar pressure, shock, and shear

Accommodate, stabilize, support deformities

Suitable for occupation, home, leisure

Diab Metab Res Rev. 2004;20(Suppl1):S51

Th ti F t

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

Shoe inserts/insoles (closed-cell foam,

viscoelastic)Therapeutic shoes

Th ti F t

EfficacyDecreases plantar pressure 50%-70%Uncertain reduction in ulcer rate

ConclusionDiabetic foot ulcer is common

Foot ulcers have devastatingconsequences

Screening is simple

Screening and team care reducediabetic foot ulcers and amputations

Conclusion

Multi-disciplinary approach needed

Going to be an increasing problem

High morbidity and costSolution is probably in prevention

Most feet can be spared…at least for a

Thank You

Diabetic Foot Kuliah

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