Diabetic Foot Problems

HENDRATA ERRY ANDISARI

Rheumatology – Imunology Division,
Dept. of Medicine,
School of Medicine University of Hang Tuah,
Ramelan Naval Hospital
Surabaya, Indonesia
Type 2 Diabetes Mellitus Complications

MICROVASCULAR MACROVASCULAR
Retinopathy,
glaucoma or Cerebrovascular
cataracts disease

Cardiomyopathy Coronary
heart
Nephropathy disease

Peripheral
Neuropathy vascular
disease

Erectile dysfunction
 Hyperglycemia

 Sorbitol Pathway,  PKC,  Non-enzymatic Glycation

Endothelium Haemodynamic Blood Rheology

-  basement membrane -  blood flow -  viscosity
glycation - microvascular - Ab(N) platelet
- Ab(N) formation of pressure function
endothelial cell product

-Basement membrane thickening

-  permeability
Tissue hypoxia & damage

Organ failure
 Diabetic Neuropathy
• Diabetic neuropathy is one of the most common late
complications of diabetes. The most common form is
a peripheral sensorimotor polyneuropathy with or
without associated autonomic involvement.
• In one series, it was found that approximately 8% of
patients newly diagnosed with diabetes had clinical
evidence of a neuropathy, reaching 45% after a 25-
year follow-up.
• In another clinical study using electro-diagnostic
findings neuropathy was diagnosed in 61% of patients
with diabetes.
Manifestasi Neuropati Diabetik
Sangat bervariasi
Kesemutan, baal, kebas,
sering tidak terhiraukan
MERUPAKAN RISIKO TERJADINYA
ULKUS, KARENA SENSASI NYERI
TIDAK ADA
Nyeri (Painful Neuropathy)
Banyak Cara yang dipakai untuk
menentukan adanya Neuropati
Perbandingan angka prevalensi sering
sulit. Kisaran Prevalensi 0-93 %
Elektromiografi
Pemeriksaan Sensibilitas halus – kasar
Rasa getar – garpu tala – vibrameter
Monofilament Semmesweinstein
Rasa suhu
Refleks motorik - lutut
Keluhan pasien
 Alat Ukur

Palu Refleks Monofilamen

Palu Refleks

Biotesiometer Pengukur
Diabetic Foot
The most devastating and dreading complication
of DM, both for the patients and doctors alike
Mortality rate high
Amputation rate high
Longer hospital stay
Very costly,

Interest to deal with foot problems - limited

No specific education / training to cope with
podiatrist - chiropodist
Patient’s ignorance
Financial problems – insufficient
Diabetic Foot in CiptoMangunkusumo Hospital
RSCM 2003 (data lower class: 2 and 3 Internal Medicine Ward):
16.1 % died
25.5 % major amputation and then improved
25.5 % discharge on their own will
32.2 % improved without amputation
Mean Hospital stay: 51 days
RSCM 2007 (Em Yunir)
35 %
14.3% 5050
%%
Days until presentation 2-30
after onset of the wound
Days until hospitalized 5-300

Length of Hospitalization 2-110

(days)
Duration of Antibiotic 2-48
35 %% treatment
14.3

no amputation amputation died

 Levels of Amputation
10 %
10 %

70 %

10 %

Metatarsal Above knee

Toe Transtibial
 Pathophysiology of Diabetic Foot Ulcer
Hyperlipidemia
Diabetes Mellitus Smoking

Neuropathy Peripheral
Vasc. Disease
Somatic Neuropathy Autonomic Neuropathy

Pain Sensation
Proprioseptive Ortopedic Limited Joint Sweating Abnormal
Problem Mobility blood distribution

PlantarPressure Dry Skin Engorged vein,

Fissures Warm foot
Hypotrophy
Muscle / Abn.Gait Callus
Deformity Foot Ulcer Ischemic foot

Source: Boulton AJM. Diabetic Med 1996: 3: (Suppl.1)

Infection
Kaki Diabetes
Neuropati
Vaskular
Infeksi
 Neuropati Motorik
Kelemahan otot intrinsik

Gangguan kesimbangan
ekstensi dan fleksi jari kaki
Penonjolan kaput tulang
metatarsal

Deformitas

Peningkatan tekanan pada

MTP
 Biomekanik Kaki Diabetes
Neuropati motorik

Hipotrofi otot intrinsik

Deformitas

Distribusi tekanan kaki

Luka atau Kalus

Bagaimana bisa terjadi luka ?
Peningkatan tekanan pada telapak kaki
Iskemia jaringan kaki saat menapak
Gangguan mikrosirkulasi, aliran lymphe,
transport jaringan interstisial
Recovery tekanan O2 transcutaneus
menurun
Recovery jaringan elastik menurun
Tekanan pada telapak kaki
dipengaruhi oleh :
Ketebalan
jaringan
Bentuk
deformitas
Derajat
deformitas
Elastisitas
jaringan
Mobilisasi sendi
 Deformitas (1)

Pes Cavus

Hammer toes
Halux valgus Claw toes
 Deformitas (2)

Bunion Charcot’s arthropathy

Hammer toe Clawed toes

Deformitas Pasca Amputasi

Pasca amputasi/operasi
 Pemeriksaan Kaki Diabetik
Statis Dinamis
Pemeriksaan dalam Pada saat berjalan/berdiri
posisi duduk/berbaring
Melihat kelainan fisik Cara berjalan
Pemeriksaan penunjang Menilai fungsi otot-otot, sendi dan
tulang
Stagging kelainan kaki Tekanan pada telapak kaki
Distribusi tekanan
Pengaruh neuropati
Peran off loading
Pengaruh gesekan
 Risiko Ulkus pada Kaki Diabetik
Riwayat ulkus/amputasi
Neuropati Sensorik-motorik-otonom
Trauma Sepatu tidak adekuat
Tidak pakai alas kaki
Jatuh/kecelakaan
Benda asing dalam sepatu

Kelaianan biomekanik Gengguan gerak sendi

Penonjolan tulang
Deformitas/osteoartopati
Kalus

Penyakit pembuluh darah perifer

Sosial-ekonomi Kemiskinan
Sarana kesehatan kurang
Ketidak tahuan
Faktor yang mempengaruhi tekanan
pada kaki
Faktor intrinsik Faktor ekstrinsik
Penonjolan tulang Sepatu tidak cocok
Gangguan mobilisasi gerak Berjalan tanpa alas kaki
sendi
Kerusakan pada sendi Jatuh/kecelakaan
Kalus Benda asing dalam sepatu
Perubahan struktur jaringan Aktivitas fisik
Riwayat operasi kaki
Neuro-osteoarthropatic joint
Anatomi Kaki Penting sekali diperhatikan
Ruang-Rongga-rongga pada Kaki Distal
Medial Plantar Space
Central Plantar Space
Lateral Plantar Space
Muscle sheath
Contoh Konsekuensinya
Luka pada ibu jari kaki
Perluasan luka : di sisi medial ? atau
sudah sampai ke tengah ?
Luka di dorsum pedis, kalau perluasan sudah
sampai plantar, pasti sudah mengenai
central plantar space
Penjalaran infeksi yang sangat cepat melalui sarung
otot
 Pendarahan Kaki
Arteri Dorsalis Pedis
arteri perforata Arcus
Arteri Tibialis Posterior Plantaris
cabang lateral dan medial

Arteri Digitales
(end arteries)

Pengumpulan pus/abses pada Central Plantar Space akan

menutup aliran darah digitales (2,3,4) sehingga terjadi
gangren jari tengah
Wagner Classification
0. Skin intact
1. Superficial Ulcer
2. Deep Ulcer (up to tendon, bone)
3. Deep Ulcer with Infection
4. Ulcer with gangrene of 1-2 toes
5. Ulcer with gangrene involving the whole
foot
Liverpool Classification
Primary: Vascular
Neuropathy
Neuroischemic
Secondary:
Simple Ulcer, without complication
Complicated Ulcer
Texas Classification
Stad. Grade
0 1 2 3

A without ulcer superfisial ulcer, ulcer up Ulcer

or post ulcer, not involving to joint involving
skin intact tendon, joint or capsule joint and
bone bone

B ---------------------- W i t h I n f e c t i o n ----------------------

C ---------------------- W i t h I s c h e m i a -----------------------

D ------- W i t h Infect ion and I s c h em i a -------

Impaired Perfusion Grade 1 = none
2 = PAD + but not critical
3 = Critical Limb Ischemia
Size/Extent in MM2
Tissue Loss/ Depth 1 = Superficial fullthickness, not deeper
than dermis
2 = Deep ulcer, below dermis, involving subcutaneous
structures, fascia muscle or tendon
3 = All subsequent layers of the foot involved
including bone and or joint
Infection Grade 1 = No symptoms nor signs of infection
2 = Infection of skin and subcutaneous tissue only
3 = Erythema > 2 cm or infection involving
subcutaneous structure(s)
No systemic sign(s) of inflammatory response
4 = Infection with systemic manifestation:
fever, leucocytosis, shift to the left
metabolic instability
hypotension, azotemia
Impaired Sensation Grade 1 = absent
2 = present
International Consensus on the Diabetic Foot 2003
Klasifikasi Gabungan
Texas dan PEDIS
Natural History of Diabetic Foot
PrImary Care

Stage 1 : Normal Foot Primary

Prevention
Stage 2 : High Risk Foot
Secondary and Tertiary Care

Stage 3 : Ulcerated Foot

Stage 4 : Infected Foot Secondary
Prevention
Stage 5 : Necrotic Foot
Stage 6 : Unsalvable Foot

Edmonds: King’s College Hospital London 2004

Primary Prevention
Attending Physician
Nurse
Dietician
Medical Rehabilitationist
DM Educators, etc.
Consultant physicians from
other disciplins:
Secondary Prevention Surgeon
- vascular, plastic, orthopedic
Attending Physician Specialist for Rehabilitation
Specialist for Infection, etc
Nurse
Dietician
Medical
Rehabilitationist
DM Educators, etc.
Diabetic Foot Management
Multidisciplinary Management
Educational Control
Metabolic Control
Mechanical Control
Wound Control
Microbiological Control
Vascular Control

Edmonds: King’s College Hospital London 2004

Pillars of Diabetic Foot Prevention
• Education to the patients, family and Health care providers
• Optimal Management of the DM
• Identification of patients with high risk diabetic foot
• Regularly observe and examine the foot and foot wear
• Suitable and appropriate foot wear
• Management of all the plausible factors for
diabetic ulcer development

Foot wear is only beneficial if it is always be used

Motto:
Take care of your feet as you take care your face
nail care, daily foot inspection,
hot bottle (be careful)
FOOT RISK Categories
Based on the Possible Problems Ahead
(Frykberg)
1. Normal Sensation without Deformity
2. Normal Sensation with Deformity or
High Plantar Pressure
3. Insensitivity without Deformity
4. Ischemia without Deformity
5. Combination / Complicated:
Combination of insensitivity, ischemia and/or deformity
History of ulcer, Charcot Deformity
Penyuluhan perlu untuk semua kategori
risiko - The D0s and the DON’Ts
Kaki insensitif (kategori 3 dan 5),
alas kaki perlu diperhatikan
Kaki deformitas (kategori risiko 2 dan 5),
perhatian khusus mengenai sepatu / alas kaki
Kaki kategori risiko 4 (rmasalah vaskular),
latihan kaki perlu diperhatikan
Kaki dengan ulkus yang complicated,
semua usaha dan dana seyogyanya
dikerahkan
Biasanya perlu perawatan dan team approach yang lengkap
World Diabetes Day 2005
Diabetes and Foot Care
Put Feet First
Prevent Amputations
Diabetic Foot Clinic
Secondary and Tertiary
Prevention
Wound Healing Process
Inflamation
Proliferation
Wound Closure

All the processes occure consequtively

Non completion in one of the subsequent
process will impede the wound healing

Perfect Debridement is necessary

Acute versus chronic
Acute Chronic
coagulation
coagulation

inflammation
remodeling
inflammation
Chronic
wound
proliferation
migration
proliferation

remodeling
Management of Diabetic Ulcer
Measures to save the limb in general:
Improve the general condition of the patients (Metabolic)
Evaluate the wound condition regularly (Wound)
Treat the ulcer as recommended (Wound-Infection)
Improve the vascular impairment if any (Vascular)
Provide special foot wear /shoes (Pressure)
Provide ample patients education (Education)
Provision of a good team care approach/teamwork

Multidisciplinary Management
Educational Control
Metabolic Control
Mechanical Control
Wound Control
Microbiological Control
Vascular Control
Edmonds: King’s College Hospital London 2004
Clinical Actions
Evaluate the ulcer meticulously
(anamnesis, physical examination general and local condition, as well as
the other relevant supporting data)
Clinical condition, the depth, location, vascularization,
(PEDIS ulcer classification)
Radiological findings: foreign bodies?, osteomyelitis?, gas formation ?
Optimize the metabolic condition: generally insulin is needed
Minimize and treat factors hampering the wound healing
Adequate / radical Debridement up to the healthy tissue
Microbial culture aerobic and ananerobic
Adequate Antibiotic treatment, mostly parenteral
Metabolic Control
Improve the pts’ general condition
Normalized Blood glucose - Insulin
Nutritional Status *Hb, *Albumin
Facilitate tissue oxygenation
Cardiovascular system
Respiratory system

Infection Control
Microbiological culture, aerobic and anaerobic
Provision of appropriate and suitable antibiotic
Regular Antibiotic Profile Update
Biakan: Mikroorganisme multipel
Perlu antibiotik spektrum luas pada awal perawatan,
Antibiotik sering perlu kombinasi,
disesuaikan dengan hasil biakan dan resistensi kuman.

Sering perlu antibiotik untuk aerob dan anaerob.

Pola kuman dan resistensi antibiotik berbeda dari

tempat satu dengan yang lain.
Banyak data mengenai hal tersebut di kepustakaan.
Cara Mengambil Spesimen yang Baik
Bahan/jaringan dari bagian dalam
lebih baik daripada bahan superfisial
Bahan hasil kuret/ sampel jaringan
dengan sayatan lebih baik daripada bahan
yang didapat dari usapan/swab

Bahan harus segera dikirim,

seyogyanya dengan media transport
Antibiotics in Diabetic Foot
General principles
Treat all clinically infected wounds, but do not
prescribe antibiotics for uninfected wounds.
Select the narrowest spectrum therapy possible for
mild or moderate infections.
Choose initial therapy based on the commonest
pathogens and known local antibiotic sensitivity
data.
Adjust (broaden or constrain) empiric therapy based
on the culture results and clinical response to the
initial regimen.
Specific choices
Cover staphylococci and streptococci in almost all
cases.
Broaden the spectrum if necessary based on the
clinical picture, or previous culture or current
Gram-stained smear results.

Topical therapy for mild superficial infections has

not been adequately studied;
Oral therapy is effective for most mild to moderate
infections;
Parenteral therapy (at least initially) is advisable for
most severe infections.
Specific choices
Choose agents that have demonstrated efficacy.
These include: semi synthetic-penicillins,
cephalosporins,
fluoroquinolones ,
penicillin-β-lactamase inhibitors,
clindamycin,
carbapenems,
perhaps oxazolidinones.

Treat soft tissue infections for 1-2 weeks if mild

infections, and 2-4 weeks for most that are
moderate and severe.
Data dan Anjuran
di RSUPN-CM Jakarta
Biakan: Mikroorganisme multipel
Perlu antibiotik spektrum luas pada awal perawatan,
Antibiotik sering perlu kombinasi, disesuaikan
dengan hasil biakan dan resistensi kuman.

Sering perlu antibiotik untuk aerob dan anaerob.

Pola kuman dan resistensi antibiotik berbeda dari

tempat satu dengan yang lain.
 Arnadi et al. Jafes. 2002; 3 (1 suppl.):80

RSUPN-CM, Kasus Yang Dirawat dengan Ulkus/gangren)

Gram Negatif:
Proteus mirabilis 24,3 %
Pseudomonas aeruginosa 13,6 %
Escherichia coli 11,7 % Antibiotik yang sensitif
Klebsiella pneumoniae 3,9 % Vancomycin 93,75 %
Coliform bacteria 3,9 % Cyprofloxacine 85,42 %
Klebsiella oxytoca 3,9 % Cefpirome 81,55 %
Enterococcus aerogenes 2,9 % Amikacine 80,39 %
Serratia marcecens 1,9 % Cefotaxim 80,0 %
Acinetobacter spp 0,75 %
Alkaligenes faecalis 0,75 %
Providencia strantii 0,75 %
Gram Positif
Staphylococcus aureus 15,5 %
Streptococcus anhemolyticus 8,7 %
Streptococcus B hemolyticus 5,8 %
Staphylococcus epidermidis 2,9 %
Staphylococcus viridans 0,75 %
RS Sumber Waras Jakarta 2002
Dalam 6 bulan dirawat 37 pasien kaki DM dengan infeksi.
35 Biakan Pus Positif, 2 steril, 2 Candida spp.
Ditemukan 7 biakan positif anaerob
(6 Anaerob + Aerob, 1 anaerob tunggal)
terbanyak Bacteriodes fragilis dan Peptococcus spp

Aerob: 53,6 % G + , 46,4 % G-

G + terbanyak Steptococcus B hemolyticus 29,6 %
G - terbanyak E coli (14,3 %)

Biakan tumbuh 1 jenis kuman 23,2 %

2 jenis kuman 28,6 %
3 jenis kuman 10,7 %
Susilowati et al. 2003, Konas Perkeni Medan
Pola Kuman Kaki Diabetes di
RSUPN- CM dan Pilihan Antibiotik (2004)
Sebaran Kuman yang Tumbuh dari Hasil Biakan
Kaki Diabetes 2004
Jenis Kuman Jumlah Persentase

Aerob Gram pos 34 35

Aerob Gram neg 56 58
Anaerob 6 6
Total 96 100

Sebaran Biakan Kuman: 60 % polimikrobial

40 % monomikrobial
Gram negatif 46 %
Gram positif 29 %
Campuran 25 %
Kusmardi Sumarjo 2005
Anaerob Terbanyak
Bacterioides spp 66,7 %

Kepekaan Kuman Bacterioides spp terhadap

beberapa antibiotik
Amoksillin-Klavulanat 100 %
Sulbenisillin 67 %
Kloramfenikol 100 %
Eritromisin 100 %
Metronidazol 100 %
Ampisillin-Sulbaktam 100 %

Kusmardi Sumarjo 2005

 Urutan 10 Antibiotik dengan
Kepekaan Tertinggi pada Ulkus Kaki Diabetes
(RSUPN dr Ciptomangunkusumo 2004)

Imipenem 92,3 %
Sefepim 81,7 %
Sefpirom 78,3 %
Fosfomisin 78,1 %
Amikasin 76,0 %
Seftriakson 75,4 %
Seftazidim 70,3 %
Sefoperazon 65,6 %
Koamoksiklav 61,3 %
Kusmardi Sumarjo 2005
 Vascular Control
PAD - Management
Management depends on the stage of disease progression
STAGE I STAGE II
(asypmtomatic) (intermitten claudication)
• Elimination of risk • Lifestyle hygiene
factors
• Vasoactive agents
• Platelet aggregation
inhibitors
• Balloon angioplasty in
certain specific cases
STAGE III and IV
(rest pain, serious trophic
disorders)
• Balloon angioplasty
• Surgical treatment:
• Thrombo-
endarterectomy
• Vascular bypass grafts
• Lumbar sympathectomy
• As a last resort,
amputation
Clinical Examination
History of intermittent claudication or rest pain
Palpation of Dorsal Pedal and Posterior Tibial arteries
Potential signs of critical ischemia:
blanching on foot elevation, dependent rubor
ulceration, skin necrosis or gangrene

Non Invasive
Ankle Pressure – ankle brachial index > 0.9 normal
0.5 - 0.9 occlusive artery
Toe Pressure - toe brachial index < 0.5 severe occlusion
Segmental Pressures (critical ischemia)

Transcutaneous Oxygen Pressure (TcPO2)

Doppler-Ultrasound (Duplex USG-Doppler)

Invasive Vascular
Arteriography- digital substraction angiography
Magnetic Resonance Arteriography
Treatment of Vascular Problem
Risk Factor Modification
smoking cessation
associated atherosclerosis risk factors
Hyperglycemia
Hypertension
Dyslipidemia
Walking Program – Foot Exercise
Pharmacological Treatment
might be of some value
not sufficient evidence of efficacy
to advocate for routine use
Treatment of Vascular Problem
Revascularization
if the probability of healing is low
severe intermittent claudication
Angiography is necessary before the procedure

Open Bypass Procedure for longer occlusion

Thromboendarterectomy
Endovascular Procedure - PTCA for short occlusion
Wound Control
Evaluate the wound condition regularly
Debridement – surgical
autolytic debridement
chemical debridement
enzymatic debridement
mechanical debridement
Treat the ulcer as recommended
Spesific Dressing
Alginate
Hydrocolloid, hydrogels
Absorbent dressing
Medicated dressing
Pressure Control (Mechanical Control)
Off weight bearing
Provide special foot wear /shoes
Crutches
Total contact casting

Education Control
Provide ample patient education
Education during hospitalization
Education in policlinic setting
Training for the nurses : wound care
 Adjuvant Treatment
• Hyperbaric Oxygen Treatment
• Enzymatic debridement
• Growth Factor(s)
• Bioengenieered skin
• Stem cell therapy
• Gene Therapy
• Others- honey, coffee, Maggot therapy
electromagnetic stimulation, lasers,
Ultrasound,Topical negative pressure
Rehabilitation
Rehabilitative prevention before the ulcer development
(special / tailor made foot wear, continous rehabilitation)
Rehabilitation during hospitalization
Rehabilitation to prevent new ulcer development

Reulceration has worse prognosis

Multidisciplinary Management
Provision of a good team care
Regular case discussion
 DM Patient Education Case Presentation / Discussion

Bed Side Case Discussion Training Wound Care

Back Up In Patients Care for
Spesific Procedures/ Treatment
Complicated foot cases needs hospitalization
Complicated case needs surgical intervention
Complicated case needs specific procedures

Arteriography
 Male 70 years old
Newly diagnosed DM
Gross foot sepsis

Ray amputation
Distal arterial bypass
Split thickness skin grafting

Second amputation 5th toe

Limb Salvage succesful

Rehabilitation?
 Plantar Ulcer
Perlu Alas Kaki Khusus
Ulkus karena tekanan
Perlu perawatan yang baik

Alas Kaki Khusus

Matur Nuwun Hibiscus rosasinenis
Teknik Sural Flap
Canna indica
Hatur Nuhun