diabetic foot kuliah
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Diabetic Foot
SURGERY DEPARTMENT
FACULTY OF MEDICINE
YARSI UNIVERSITY
JAKARTA
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IntroductionEpidemiology
Pathophysiology
Classification
Treatment
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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
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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
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PathophysiologyVascular disease?
Neuropathy
Sensory
Motor
autonomic
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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
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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
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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
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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
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Sensory NeuropathyTwo mechanisms of Ulceration
Unacceptable stress few times
rock in shoe, glass, burn
Acceptable or moderate stress repeatedly
Improper shoe ware
deformity
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Motor NeuropathyMostly affects forefoot ulceration
Intrinsic muscle wasting – claw toes
Equinous contracture
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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
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Autonomic Neuropathy
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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
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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
©2006. American College of Physicians. All Rights Reserved.
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Nerve damage Poor blood supply
Injury
Infection
Amputation
Ulcer
Pathway to diabetic foot problems
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Causal Pathways for Foot
UlcersNeuropathy
Deformity
ULCER
% 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
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PENYEBAB
AngiopatiPerdarahan jaringan marginal
NeuropatiParalisis otot kaki
Rasa mati
Gangguan saraf otonom
Trauma
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Motor Neuropathy and Foot
DeformitiesHammer toes
Claw toes
Prominent metatarsal heads
Hallux valgus
Collapsed plantar arch
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Hammer Toes
Claw Toes
© 2002 American Diabetes Association
From The Uncomplicated Guide to Diabetes Complications Reprinted with permission from The American Diabetes Association
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© 2002 American Diabetes Association
From The Uncomplicated Guide to Diabetes Complications Reprinted with permission from The American Diabetes Association
Hallux Valgus
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Boulton, et al. Guidelines for Diagnosis of Outpatient Management of Diabetic
Peripheral Neuropathy. Diabetic Medicine 1998, 15:508-512
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Pre-ulcer Cutaneous
PathologyPersistent erythema after shoe removal
Callus
Callus with subcutaneous hemorrhage
Fissure
Interdigital maceration, fungal infection
Nail pathology
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AJM Boulton, H Connor, PR Cavanagh, The Foot in Diabetes, 2002
Pre-ulcer
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Sukar sembuh karena:
Trauma terus menerus
Tekanan abnormal
Lingkungan diabetes subur untukberkembangnya kuman patogen
Perfusi jaringan kulit kurang baik
Kurang mendapat nutrien
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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
Diabetes Care. 1992;15:1386
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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
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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
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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
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Diagnosis Angiopati Diabetes
Gambaran klinisDerajat kelainan kaki
Tipe angiopatiMakroangiopati
Mikroangiopati
Sifat ObstruksiAkut
KronikStatus pembuluh darah
Pulsasi denyut nadi
Doppler
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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)
©2006. American College of Physicians. All Rights Reserved.
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BASIC FOOT CARE CONCEPTS
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
©2006. American College of Physicians. All Rights Reserved.
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BASIC FOOT CARE CONCEPTS
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
©2006. American College of Physicians. All Rights Reserved.
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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
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©2006. American College of Physicians. All Rights Reserved.
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Patient EvaluationMedical
Vascular
Orthopedic
Identification of “Foot at Risk”
? Our job
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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
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Patient EvaluationMedical
Optimized glucose control
Decreases by 50% chance of footproblems
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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
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Patient EvaluationOrthopedic
Ulceration
Deformity and prominencesContractures
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Patient EvaluationX-ray
Lead pipe arteries
Bony destruction (Charcot or osteomyelitis)Gas, F.B.’s
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Patient Evaluation
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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
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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
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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
kaki
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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
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Classification
Type 2 or 3
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Classification
Type 4
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Treatment
Patient education
Ambulation
Shoe wareSkin and nail care
Avoiding injury
Hot waterF.B’s
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Treatment
Wagner 0-2
Total contact cast
Distributes pressure and allows patients tocontinue ambulation
Principles of application
Changes, Padding, removal
Antibiotics if infected
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Treatment
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Treatment
Wagner 0-2
Surgical if deformity present that will
reulcerateCorrect deformity
exostectomy
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Treatment
Wagner 3
Excision of infected bone
Wound allowed to granulateGrafting (skin or bone) not generallyeffective
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Treatment
Wagner 4-5
Amputation
Level ?
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Treatment
After ulcer healed
Orthopedic shoes with accommodative
(custom made insert)Education to prevent recurrence
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Charcot Foot
More dramatic – less common 1%
Severe non-infective bony collapse with
secondary ulcerationTwo theories
Neurotraumatic
Neurovascular
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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
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Classification
Eichenholtz
1 – acute inflammatory process
Often mistaken for infection2 – coalescing phase
3 - consolidation
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Classification
Location
Forefoot, midfoot (most common) ,
hindfootAtrophic or hypertrophic
Radiographic finding
Little treatment implication
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Case 1
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Case 1
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Case 1
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Case 2
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Case 2
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Case 3
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Case 3
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Case 4
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Case 4
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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
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Low RiskAnnual comprehensive foot examination
Questionnaire completed by patient
Examination
Self-management and footwear educationBrief counseling
Written handout
JAMA. 2005;293:217
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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
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Therapeutic Footwear
GoalsProtect feetReduce plantar pressure, shock, and shear
Accommodate, stabilize, support deformities
Suitable for occupation, home, leisure
Diabetes Care. 2004;27:1832
Diab Metab Res Rev. 2004;20(Suppl1):S51
Th ti F t
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Therapeutic Footwear
ComponentsPadded socks (e.g., CoolMax,Duraspun, others)
Shoe inserts/insoles (closed-cell foam,
viscoelastic)Therapeutic shoes
Th ti F t
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Therapeutic Footwear
EfficacyDecreases plantar pressure 50%-70%Uncertain reduction in ulcer rate
Diabetes Care. 2004;27:1774
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ConclusionDiabetic foot ulcer is common
Foot ulcers have devastatingconsequences
Screening is simple
Screening and team care reducediabetic foot ulcers and amputations
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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
while
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