Diabetic Foot

SURGERY DEPARTMENT FACULTY OF MEDICINE YARSI UNIVERSITY JAKARTA

Introduction
Epidemiology Pathophysiology Classification Treatment

Epidemiology
DM largest cause of neuropathy in N.A. 1 million DM patients in Canada Half dont know Foot ulcerations is most common cause of hospital admissions for Diabetics Expensive to treat, may lead to amputation and need for chronic institutionalized care

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

Pathophysiology
Vascular disease? Neuropathy
Sensory Motor autonomic

Vascular Disease
30 times more prevalent in diabetics Diabetics get arthrosclerosis obliterans or lead pipe arteries Calcification of the media Often increased blood flow with lack of elastic properties of the arterioles Not considered to be a primary cause of foot ulcers

Peripheral Artery Disease

Prevalence (ABI < 0.9):
10%-20% in type 2 diabetes at diagnosis 30% in diabetics age 50 years 40%-60% in diabetics with foot ulcer

Complications:
Claudication Associated coronary and cerebral vascular disease Delayed ulcer healing
Diabet Med. 2005;22:1310 Diabetes Care. 2003;26:3333

Neuropathy
Changes in the vasonervorum with resulting ischemia ? cause
Increased sorbitol in feeding vessels block flow and causes nerve ischemia Intraneural acculmulation of advanced products of glycosylation

Abnormalities of all three neurologic systems contribute to ulceration

Sensory Neuropathy
Loss of protective sensation Starts distally and migrates proximally in stocking distribution Large fibre loss light touch and proprioception Small fibre loss pain and temperature Usually a combination of the two

Sensory Neuropathy
Two mechanisms of Ulceration
Unacceptable stress few times
rock in shoe, glass, burn

Acceptable or moderate stress repeatedly

Improper shoe ware deformity

Motor Neuropathy
Mostly affects forefoot ulceration
Intrinsic muscle wasting claw toes Equinous contracture

Autonomic Neuropathy
Regulates sweating and perfusion to the limb Loss of autonomic control inhibits thermoregulatory function and sweating Result is dry, scaly and stiff skin that is prone to cracking and allows a portal of entry for bacteria

Autonomic Neuropathy

Gangguan Neuropati
Paralisis
Perubahan faal muskuloskeletal kaki Perubahan anatomi Titik tekan di telapak kaki lain

Mati rasa
Cedera tak disadari Tekanan pada luka tak dihindari

Gangguan faal saraf otonom

Perfusi kulit kurang Pintas arteri vena kulit terbuka

PATHOGENESIS OF DIABETIC FOOT ULCER AND AMPUTATION

Sensory Joint Neuropathy Mobility Motor Neuropathy Autonomic Neuropathy PAD

Protective
sensation

Muscle atrophy and 2 foot deformities

Sweating Ischemia 2 dry skin

Foot pressure Minor trauma recognition

Foot pressure Fissure esp. over bony prominences

Healing

Callus

Pre-ulcer

ULCER

Infection

AMPUTATION

Minor Trauma: Mechanical Chemical Thermal

Interdigital Maceration (Moisture, Fungus)

2006. American College of Physicians. All Rights Reserved.

Pathway to diabetic foot problems

Nerve damage Poor blood supply

Injury

Ulcer
Infection

Amputation

Causal Pathways for Foot Ulcers

Neuropathy % Causal Pathways Neuropathy: Minor trauma: Deformity: 78% 79% 63%

Deformity

Minor Trauma
- Mechanical (shoes) - Thermal - Chemical

Behavioral

Poor self-foot care

ULCER

Diabetes Care. 1999; 22:157

PENYEBAB
Angiopati
Perdarahan jaringan marginal

Neuropati
Paralisis otot kaki Rasa mati Gangguan saraf otonom

Trauma

Motor Neuropathy and Foot Deformities

Hammer toes
Claw toes

Prominent metatarsal heads

Hallux valgus

Collapsed plantar arch

Hammer Toes

Claw Toes
2002 American Diabetes Association From The Uncomplicated Guide to Diabetes Complications Reprinted with permission from The American Diabetes Association

Hallux Valgus

2002 American Diabetes Association From The Uncomplicated Guide to Diabetes Complications Reprinted with permission from The American Diabetes Association

Boulton, et al. Guidelines for Diagnosis of Outpatient Management of Diabetic Peripheral Neuropathy. Diabetic Medicine 1998, 15:508-512

Pre-ulcer Cutaneous Pathology Persistent erythema after shoe removal

Callus Callus with subcutaneous hemorrhage Fissure Interdigital maceration, fungal infection Nail pathology

Pre-ulcer

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

Sukar sembuh karena:

Trauma terus menerus Tekanan abnormal Lingkungan diabetes subur untuk berkembangnya kuman patogen Perfusi jaringan kulit kurang baik Kurang mendapat nutrien

Monofilament Testing
Test characteristics:
Negative predictive value = 90%-98% Positive predictive value = 18%-36%

Prospective observational study:

80% of ulcers and 100% of amputations occur in insensate feet Superior predictive value vs. other test modalities

J Fam Pract. 2000;49:S30 Diabetes Care. 1992;15:1386

Using the Monofilament

Demonstrate on forearm or hand Place monofilament perpendicular to test site Bow into C-shape for 1 second Test 4 sites/foot Heel testing does not predict ulcer Avoid calluses, scars, and ulcers

Monofilament Testing Tips

Insensate at 1 site = insensate feet

Falsely insensate with edema, cold feet

Test annually when sensation normal

Use monofilament
< 100 times day Replace if bent

Replace every 3 months

Vibration Testing
Biothesiometer
Best predictor of foot ulcer risk

128-Hz tuning fork at halluces

Equivalent to 10-g monofilament Newly recommended by ADA

Diabetes Care. 2006;29(Suppl 1):S25 Diabetes Res Clin Pract. 2005;70:8

Diagnosis Angiopati Diabetes

Gambaran klinis
Derajat kelainan kaki

Tipe angiopati
Makroangiopati Mikroangiopati

Sifat Obstruksi
Akut Kronik

Status pembuluh darah

Pulsasi denyut nadi Doppler

BASIC FOOT CARE CONCEPTS

Daily foot inspection
May require mirror, magnification, or caregiver Educate patient to recognize/report ASAP:
Persistent erythema Enlarging callus Pre-ulcer (callus with hemorrhage)

2006. American College of Physicians. All Rights Reserved.

BASIC FOOT CARE CONCEPTS

Commitment to self-care:
Wash/dry daily
Avoid hot water; dry thoroughly between toes

Lubricate daily (not between toes) Debride callus/corn to reduce plantar pressure 25%
Avoid sharp instruments, corn plasters

No self-cutting of nails if:

Neuropathy, PAD, poor vision
2006. American College of Physicians. All Rights Reserved.

BASIC FOOT CARE CONCEPTS

Protective behaviors:
Avoid temperature extremes No walking barefoot/stocking-footed Appropriate 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.

Basic Footwear Education

Avoid: Pointed toes Slip-ons Open toes High heels Plastic Black color Too small
Favor: Broad-round toes Adjustable (laces, buckles, Velcro) Athletic shoes, walking shoes Leather, canvas White/light colors between longest toe and end of shoe
Diabetes Self-Management. 2005;22:33

2006. American College of Physicians. All Rights Reserved.

Patient Evaluation
Medical Vascular Orthopedic Identification of Foot at Risk
? Our job

Patient Evaluation
Semmes-Weinstein Monofilament Aesthesiometer 5.07 (10g) seems to be threshold 90% of ulcer patients cant feel it Only helpful as a screening tool

Patient Evaluation
Medical
Optimized glucose control Decreases by 50% chance of foot problems

Patient Evaluation
Vascular
Assessment of peripheral pulses of paramount importance If any concern, vascular assessment
ABI (n>0.45)
Sclerotic vessels

Toe pressures (n>40-50mmHg) TcO2 >30 mmHg

Expensive but helpful in amp. level

Patient Evaluation
Orthopedic
Ulceration Deformity and prominences Contractures

Patient Evaluation
X-ray
Lead pipe arteries Bony destruction (Charcot or osteomyelitis) Gas, F.B.s

Patient Evaluation

Patient Evaluation
Nuclear medicine
Overused Combination Bone scan and Indium scan can 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 bone and soft tissue infection

Patient Evaluation
CT can be helpful in visualizing bony anatomy for abscess, extent of disease MRI has a role instead of nuclear medicine scans in uncertain cases of osteomyelitis

Derajat Kelainan Kaki Diabetik (WAGNER)

Derajat Luka 0 I II Superfisial sampai tendo/ tulang Dalam Dalam Ganggren Sifat Abses Selulitis Osteo mielitis Gang gren -

III IV V

++ +/-

+/+/-

+/+/-

Jari Seluruh kaki

Ulcer Classification
Wagners Classification 0 Intact skin (impending ulcer) 1 superficial 2 deep to tendon bone or ligament 3- osteomyelitis 4 gangrene of toes or forefoot 5 gangrene of entire foot

Classification Type 2 or 3

Classification Type 4

Treatment
Patient education
Ambulation Shoe ware Skin and nail care Avoiding injury
Hot water F.Bs

Treatment
Wagner 0-2
Total contact cast Distributes pressure and allows patients to continue ambulation Principles of application
Changes, Padding, removal

Antibiotics if infected

Treatment

Treatment
Wagner 0-2
Surgical if deformity present that will reulcerate
Correct deformity exostectomy

Treatment
Wagner 3
Excision of infected bone Wound allowed to granulate Grafting (skin or bone) not generally effective

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 ulceration Two theories
Neurotraumatic Neurovascular

Charcot Foot
Neurotraumatic
Decreased sensation + repetitive trauma = joint and bone collapse

Neurovascular
Increased 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 infection

2 coalescing phase 3 - consolidation

Classification
Location
Forefoot, midfoot (most common) , hindfoot

Atrophic or hypertrophic
Radiographic finding Little treatment implication

Case 1

Case 1

Case 1

Case 2

Case 2

Case 3

Case 3

Case 4

Case 4

Indications for Amputation

Uncontrollable infection or sepsis Inability to obtain a plantar grade, dry foot that can tolerate weight bearing Non-ambulatory patient Decision not always straightforward

Low Risk
Annual comprehensive foot examination
Questionnaire completed by patient Examination

Self-management and footwear education

Brief counseling Written handout

JAMA. 2005;293:217

High Risk
Annual 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

Therapeutic Footwear Goals feet Protect

Reduce 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

Therapeutic Footwear Components(e.g., CoolMax, Padded socks

Duraspun, others)

Shoe inserts/insoles (closed-cell foam,

viscoelastic)

Therapeutic shoes

Therapeutic Footwear Efficacy plantar pressure 50%-70% Decreases

Uncertain reduction in ulcer rate

Diabetes Care. 2004;27:1774

Conclusion
Diabetic foot ulcer is common Foot ulcers have devastating consequences Screening is simple Screening and team care reduce diabetic foot ulcers and amputations

Conclusion
Multi-disciplinary approach needed Going to be an increasing problem High morbidity and cost Solution is probably in prevention Most feet can be sparedat least for a while

2006. American College of Physicians. All Rights Reserved.

Thank You