Kaki Diabetes

Diabetic Foot • A diabetic foot is a foot that exhibits any pathology that results directly

from diabetes mellitus or any long-term (or "chronic") complication of diabetes mellitus.[1]

• Presence of several characteristic diabetic foot pathologies is called diabetic foot syndrome. These are thus umbrella terms.

• The most serious foot complications in diabetes are:[2]• Diabetic foot ulceration. It occurs in 15% of all patients with

diabetes and precedes 84% of all diabetes-related lower leg amputations.[3]

• Diabetic foot infections• Neuropathic osteoarthropathy of the foot[

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DiabeticRetinopathyLeading causeof blindnessin adults1,2

DiabeticNephropathy

Leading cause of end-stage renal disease3,4

CardiovascularDisease

Stroke2- to 4-fold increase in cardiovascular mortality and stroke5

DiabeticNeuropathy

8/10 individuals with diabetes die from CV events6

Type 2 Diabetes is Associated with Serious Complications

1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5Kannel WB, et al. Am Heart J 1990; 120:672–676.

6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7King’s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.

Diabetic Foot

Microangiopathy Macroangiopathy

Patogenesis Kaki diabetes

Why does acute DFU be chronic• Hyperglycemia and insulin resistance• Impaired oxygenisasion• Reduce macro and micricirculation• Pheriperal neuropathy• Wound pressure/ weingt bearing• Edema, pain• Oxidative stress• Malnutrition , mineral and vitamin• Infections, MMPs• GF retardation• Decrease hyaluronoic acid• compliance

Patofisiologi Luka Kaki Diabetes

Kaki Diabetik: Faktor-Faktor Risiko

Periferal neuropati: sensorik (>>), motorik, otonom

Perubahan biomekanik kaki

Peningkatan pressure pada telapak kaki

Deformitas tulang/biomekanik

Penyakit pembuluh darah tepi (PAD)

Riwayat ulkus atau amputasi

Kelainan kuku yang berat

ADA, Standard of Medical Care in Diabetes 2008

Neuropati Perifer

Neuropati motorikKelemahan otot intrinsik

Perubahan ekstensi dan fleksi

Penonjolan kaput tulang

Deformitas kaki (Biomekanik )

Peningkatan distribusi tekanan

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Stratification of NeuropatiUlcer

High

Low

High-risk foot clinicIntensive foot education and podiatry

Neuropathy, previous amputation or ulcer

Peripheral vascular diseaseUnable to feel monofilamentNeuropathy, no previous amputation or ulcer

No neuropathy

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Peripheral Arterial Disease ( PAD )

• Is a condition characterized by atherosclerotic occlusive disease of the lower extremities

• as a major risk factor for lower extremities amputation

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Penyakit Pembuluh Darah Perifer

Makrovascular

Mikrovaskular

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Makrosirkulasi

NormalFatty

StreakFibrousPlaque

Athero-scleroticPlaque

PlaqueRupture/Fissure &

Thrombosis

Clinically Silent

Increasing Age

Angina, TIA`s, PAD

Ischemic Stroke

Myocardial Infarction

Critical Leg Ischemia

Cardiovascular Death

Mikrosirkulasi • Fungsi nutrisi : 15 %• Fungsi termoregulasi

melalui endotel - prostaglandin - prostacycline - endotheline, - nitrid oxide ( NO )

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ANGIOPATIHiperglikem

iaSorbitol pathwayGlucose autoxidationAGE formation

Oxidative stress Antioxidants

Hypercoagulability:

Fibrinolysis

platelet reactivity

coagulability

Endothelial dysfunction:

NO

Endothelin 1

Prostacyclin

Thromboxan

leukocyte adhesion

lipid peroxidation

foam cell formation

TNF a

Komplikasi pembuluh darah

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Risk Factors of PAD in Diabetic(UKPDS)

1. Hyperglycemia 2. Eleveted systolic blood pressure 3. Low HDL cholesterol 4. Smoking 5.Cardiovascular disease

Fig: Arterial anastomosis around the ankle joint. The foot is supplied by the Dorsalis pedis, Posterior tibial and peroneal arteries. There is good Communication between these important vessels through the collateral arteries.

AB C

A. Dorsalis pedis artery B. Posterior tibial artery C. Peroneal artery

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Measurement of the Ankle–Brachial Index (ABI).

Survival probability curves derived from Kaplan-Meier analysis of percentages of patients remaining alive (or deceased from noncardiac causes) in two groups of subjects defined by baseline ABI (P < 0.0001, log-rank test). In each case, censored data points are indicated by crosses

Hubungan antara ABI dengan Risiko Kematian

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Biomekanika kaki

• Gaya yang mempengaruhi kaki saat berdiri/ berjalan

• Dipengaruhi oleh berat badan• Keadaan dinamik

• Kaki normal distribusi merata pada seluruh permukaan kaki

• Deformitas : distribusi tidak merata• Resiko timbulnya kalus atau luka

Intrinsic – biomechanical

Wagner’s classification • Grade-0 High risk foot and no ulceration.

• Grade -1 Superficial Ulcer.• Grade -2 Deep Ulcer ( cellulitis )• Grade -3 Osteomylitis with Ulcer or abscess.• Grade -4 Gangrenous Patches. Partial foot gangrene.• Grade -5 Gangrene of entire foot

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Bagaimana bisa terjadi luka ?Peningkatan tekanan pada telapak kaki

Iskemia jaringan kaki saat menapak

Gangguan mikrosirkulasi, aliran lymp, transport jaringan interstisial

Recovery tekanan O2 transcutaneus menurun

Recovery jaringan elastik menurun

Tekanan pada telapak kaki

Dipengaruh oleh : - gaya gesekan ( friction )

- gaya tekanan ( pressure )

Pengukuran tekanan telapak kaki

Perubahan biomekanik yang mempengaruhi tekanan pada kaki

Faktor intrinsik Faktor ekstrinsikPenonjolan tulang Sepatu tidak cocok

Gangguan mobilisasi gerak sendi

Berjalan tanpa alas kaki

Kerusakan pada sendi Jatuh/kecelakaan

Kalus Benda asing dalam sepatu

Perubahan struktur jaringan Aktivitas fisik

Riwayat operasi kaki

Neuro-osteoarthropatic joint

Deformitas (1)

Halux valgusHammer toesClaw toes

Pes Cavus

Deformitas pasca amputasi (4)

Pasca amputasi/operasi

Ketebalan jaringan

Bentuk deformitas

Derajat deformitas

Elastisitas jaringan

Mobilisasi sendi

Tekanan pada telapak kaki dipengaruhi oleh :

Most foot problems are preventable

Most foot problems are preventable through early identification & prompt

treatment by skilled health professionals

Holistic Management of Diabetic Foot Ulcer

Wound control

Metabolic control

Infection control

Vascular control

Mechanic control

Education control

Internatonal Working Group on the Diabetic Foot, 2007

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Kesimpulan

• Kaki diabetik merupakan salah satu komplikas kronis diabetes

• Patofisiologisnya sangat komplek• Lambat pada proses penyembuhan, risiko ulkus

menjadi kronis dan angka amputasi tinggi• Management harus holistik dan melibatkan berbagai

disiplin ilmu lainnya• Sebagian besar ulkus atau luka pada kaki diabetes

dapat dicegah dengan melakukan deteksi dini dan pencegahan pada kaki dengan faktor risiko

Terima Kasih

References• ^ [1] [2] Boulton in Diabetes, 30;36 2002^ • Frykberg RG, Armstrong DG, Giurini J, et al. (2000). "Diabetic foot

disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons". J Foot Ankle Surg 39 (5 Suppl): S1–60. PMID 11280471.^

• Brem Harold, Tomic-Canic Marjana (2007). "Cellular and Molecular basis of wound healing in diabetes". JCI 117 (5): 1219–1222. doi:10.1172/JCI32169. PMC 1857239. PMID 17476353.^

• Arad Y, Fonseca V, Peters A, Vinik A (2011). "Beyond the Monofilament for the Insensate Diabetic Foot: A systematic review of randomized trials to prevent the occurrence of plantar foot ulcers in patients with diabetes". Diabetes Care 34 (4): 1041–6. doi:10.2337/dc10-1666. PMC 3064020. PMID 21447666.

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