Bambang Tiksnadi Consultant Orthopedic Surgeon, Department of Orthopedics and Traumatology

Hasan Sadikin Hospital, Faculty of Medicine Universitas Padjadjaran

Bandung, Indonesia

Diabetic limb Problems in Indonesia: Experience in A TERTIARY CARE LEVEL Hospital

in BANDUNG, West Java

The islands of Indonesia

BANDUNG

Estimated size comparison

Australia 7.683.700m2

Indonesia (land)1.922.570m2 Indonesia (water) 3.257.483m2

Population Indonesia (4th) 253,60 million people Australia (54th) 7.741.220 people

Prevalence of Diabetes in Indonesia

International Diabetes Federation :

Indonesia among the 10 countries with largest population of diabetic individuals estimated 7,6 million Indonesian living with diabetes

Only 39% received treatment

68% with peripheral neuropathy high risk for diabetic ulcer

Prevalence of Diabetic Limb Problem in

Indonesia

15-20% of diabetic individuals at risk of experiencing diabetic ulcer during lifetime, therefore;

The number of diabetic limb problems is expected to increase hand-in-hand with the increasing number of individuals with diabetes in Indonesia within the decades to come

Exact number?? Still unknown

Need more primary data

Problems we Face in Indonesia

Late presentation of cases often with life threatening conditions Why?

Neglect or lack of awareness (most from low-education backgrounds, reliance on traditional

methods)

Financial problems (lack of health insurance coverage)

Difficult access to health centers

Lack of specialized centers to care for diabetic limbs

Limited number of health care providers specializing in diabetic limb management

MANAGEMENT in GENERAL

Screening for feet at risk primary health care centers, endocrinology clinics, family physicians

Range from simple and conventional (moist gauze dressings) to sophisticated (Hyperbaric O2 chamber)

Major limb amputations are still frequently performed, although the rate is decreasing

Number of surgeons preferring limb conservation increasing

No uniform standard procedure exist yet between centers treating Diabetic Limbs

Diabetic foot clinics (not all centers)

Common Type of DLP we often see

Cellulitis

Ulcer

Abscess

Osteomyelitis

Joint infection

Gangrene : Dry , Wet

Charcot Joint

Necrotising Fasciitis

Ascending infection

WHERE ARE our patients SEEN?

Outpatient clinics :

Orthopedic

Internal Medicine / Endocrinology

Vascular Surgery

Plastic Surgery

Acute and Emergency Dept. Mostly referrals from 1st centers and 2nd care level

Hospitals Many cases with significant complications

Assessment & Investigation of DFU

ASSESMENT GENERAL STATUS OF DIABETIC PTS

ASSESMENT OF DIABETIC FOOT

INSPECTION : DERMATOLOGIC AND MUSCULOSKELETAL CONDITIONS

NEUROLOGIC ASSESMENT Peripheral neuropathy

VASCULAR ASSESMENT PAD

LABORATORY GENERAL

CULTURE Swabs for infected ulcers

RADIOLOGICAL assess bone structure involvement

HIGH RISK PATIENTS

(Peripheral Neuropathy,PAD,Deformity)

1. EVERY EFFORT MUST BE MADE TO LIMIT THE

RISK

2. ENSURE THE PATIENTS UNDERSTAND THE

BASIC RULES OF FOOT CARE

3. WHENEVER SKIN BREAK OCCUR AGGRESSIVE MANAGEMENT

Diabetic Foot Outpatient Clinic

Treat minor ailments in the outpatient clinic (callosities, ingrown toenails ),

perform bedside debridement, culture

swabs of infected ulcers

Teaching proper assessment & intensive foot care to the pts and

relatives

WOUND MANAGEMENT

(IMPORTANT CONSIDERATION)

DISEASE CONTROL : Diabetes and comorbidities

OFF LOADING : Adequate footwear, Total contact cast, correction of foot deformities

INFECTION PREVENTION AND TREATMENT

VASCULARISATION vascular surgeon consultation

CLEANSING & DEBRIDEMENT

DRESSING biological dressings, Vacuum assisted

TOTAL MANAGEMENT TO REMOVE IMPEDIMENTS TO HEALING AND TO ENCHANCE THE ABILITY OF

TISSUE TO HEAL

Hasan Sadikin Hospital, Bandung

Tertiary Care Level Hospital, Referral center for West Java

Current policies only complicated cases not treatable at a lower level hospital are allowed to be referred

MULTIDISCIPLINARY TEAM CLINICS

PREVENTION OF FOOT ULCER AND

AMPUTATION

PREVENT DEVELOPMENT OF DIABETIC NEUROPATHY

PREVENT ULCER DEVELOPMENT,

REGULAR FOOT SCREENING,

EARLY INTERVENTION pressure offloading, correction of deformities

PREVENT AMPUTATION BY CONTROL OF DIABETIC STATUS AND GOOD CARE OF THE FEET

SURGERY

SURGICAL DEBRIDEMENT

Formal debridement or bedside debridement

Re-VASCULARISATION

Prevent pressure points deformity correction?

Soft tissue coverage skin grafts, flaps

AMPUTATION

Flowchart of

Diabetic Foot

Management

OUR EXPERIENCE

23-27% inpatient diabetics diabetic limb complications, consulted to our department

74% of these patients are unaware of their diabetes prior to non-healing wound in the foot

Significant risk factor for diabetic limb complications in our patients:

presence of peripheral neuropathy monofilament test

Hba1C, poor regular f.u for control of the diabetes

Poor footwear and/or poor foot care

OUR EXPERIENCE Case series of infected diabetic feet admitted with infection

:

61 cases of admitted infected diabetic feet 46% with life threatening sepsis, >80% presented with Wagner 4

and above

sepsis presented with wounds more than 20 days

Significant predictors found (compared to non sepsis group) : decreased ABI, wound duration >20 days,

advanced Wagner grade, higher ESR/CRP levels,

increased creatinine levels

Management : IV Antibiotics, Early Goal Directed Therapy (EGDT), urgent source control debridement when possible, minor amputation, major amputation

OUR EXPERIENCE

Follow up during post amputation care : 11 % required second amputation procedure at

a higher level

21 % of limb salvage converted to amputation Identified risk factors :

Low protein/albumin levels HbA1C above 7mg/dL Failure of disease control : poor patient

compliance

Late Cases we find

Major Limb amputations

A large number of our patients present with ascending, deep

infections with sepsis condition

life threatening

Major limb amputation still a mainstay of treatment for

some patients

AMPUTATIONS VS SALVAGE

Cost effectiveness for our patient population?

Salvage associated with repeated surgery some patient may not be amenable or opt for repeated surgery

Indications for amputation : 3 Ds

Dead limb

Dangerous limb

Damn nuisance limb

Rehabilitation

Trained orthopaedic nurses

- wound care

- teach pts for self foot care

Physiotherapist

- teach pts to alleviate joint stiffness and improving walking gait and endurance

Orthotist/Prosthetist to make custom footwear

In our experience, FAMILY INVOLVEMENT in care is very important in this

OUTCOME Approximately 40 % of our patients treated without

major limb amputation experience diabetic limb

complication at the contralateral limb within 1 year

Identified risks : poor diabetic control, low adherence to self foot care

Low awareness and lack of education

Only 28% of major limb amputees were rehabilitated with prosthesis, others using wheelchair / bed ridden

Identified causes : preexisting comorbidities precluding use of prosthesis

LOW motivation for rehabilitation no social support network??

Health promotion :

Outpatient clinics

Primary health centers

Non-government organizations

Advocacy

Involve policy-makers and

administration

into the effort

Promotion and Advocacy

New hope in the horizon

Giving better access to proper medical care : New forms of social security and health

insurance, starting 2014 more people have access to medical service

Better health insurance coverage : Starting 2014, diabetic patients to receive

coverage from BPJS (national health insurance)

Coverage for diabetic limb problems?

Conclusion

We are still in the process of improving ourselves to improve our care of our patients

Increase efforts to promote awareness, and reduce the number of late cases

aim is to decrease number of major limb amputations performed on diabetic limbs

Need national uniform standard procedure