Diabetic Foot

Des Riyadi Anas

Bagian Ilmu Penyakit Dalam FK UNDIP/RS dr Kariadi

Semarang
2016
 Definition
Infection, ulceration and /or destruction
of deep tissue associated with
neurological abnormalities
and
various degrees of peripheral vascular
disease in
the lower limb.
PATOFISIOLOGI
 Diabetic foot infection
• Diabetic foot infection:
– any infra-malleolar infection in a person
with diabetes mellitus.

– Includes:
• paronychia, cellulitis, myositis, abscesses,
necrotizing fasciitis, septic arthritis, tendinitis,
and osteomyelitis.
 Definition of diabetic neuropathy

• Diabetic neuropathy
– Presence of symptoms and/or signs of
peripheral nerve dysfunction in people
with diabetes, after exclusion of other
causes.

– Charcot-foot
• Non-infectious destruction of bone and joint
associated with neuropathy :
Neuro-osteoarthropathy.
Artropati Charcot
 Definition of PAD
• Peripheral arterial disease (PAD)
– Disease of mostly small blood vessels in
the extremities (hands and feet), as
narrowing of arteries.
– Claudication
• Pain in foot, thigh or calf during walking, which
is relieved
 Ulcus
(diabetic ulcer)
• Foot deformity
• Structural deformities in the foot such as presence of
hammertoes, claw-toes, hallux valgus, prominent
metatarsal heads, status after neuro-osteoarthropathy,
amputation or other foot surgery.

– Deep ulcus
• Definision
– Full thickness of the skin extending the sub cutis,
which may involve muscles, tendon, bone and joint.
 Klasifikasi

• P : Perfusi ( grade 1,2 , 3)

• E : Ekstensi
• D : Depth/dalam (grade 1,2 3)
• I : Infeksi (grade 1,2 3 4)
• S : sensasi (grade 1,2)
 Perfusi
Grade Uraian
I Pulsasi a. dorsalis pedis &
a. tibialis posterior teraba.
gejala & tanda PAD (-) ABI normal
II Claudicatio (+)
ABI < 0,9
gejala & tanda PAD
(+) tapi iskemia (-)
III ABI < 0,9
Sistolik ankle < 50 mmHg
PAD (+) Iskemia (+)
Sistolik Toe < 30 mmHg
 Ekstensi/ukuran

Cara Ukuran dalam cm

menilai luka setelah
debridement
Depth/tissue loss/ kedalaman

Grade Uraian

I Ulkus superfisial, tidak merusak

dermis
II Ulkus dalam menembus fascia
sampai tendon atau otot
II Ulkus dalam sampai menembus
tulang
 INFEKSI

I GEJALA DAN TANDA INFEKSI (-)

II Infeksi superfisial dan subkutan
Edema, eritema < 2 cm
III Infeksi lebih dalam, edema dan eritema
> 2 cm, infeksi sistemik (-)
IV Infeksi lebih dalam, edema dan eritema
> 2 cm, infeksi sistemik (+) SIRS (+)
 Sensasi

Grade Uraian
I Sensasi masih baik

II Test Monofilament 10 gr (-
)
Test Garpu tala (-)
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6

Normal Kaki resiko Kaki ulkus Kaki infeksi Kaki nekrosis/ Kaki yg tidak
Tidak terdapat tinggi Ulkus pada Edema gangren dapat di
kelainan Deformitas plantar Kulit merah melibatkan selamatkan
Kelainan kuku Neuropati kulit sub kutis Nekrosis luas
Infeksi fasia , sendi,
Kulit kering Kalus Osteomielitis harus amputasi
tulang.
Otot hipotrofi Ulkus dasar Gejala sistemik
nya otot

Klasifikasi Wagner
 Critical limb ischemia

– Persistent rest pain requiring

regular analgesia for more than 2
weeks, ulceration or gangrene
attributable to objectively proven
peripheral arterial disease.
Dokumentasi pribadi, 2006
Dokumentasi pribadi, 2006
Dokumentasi pribadi, 2006
Dokumentasi pribadi, 2006
 Gangrene
• Necrosis (mortification) of the skin and
underlying structures (muscles, tendon,
joint or bone) with irreversible damage
where healing can not be anticipated
without loss of some part of the extremity.
 Risk Factors
Sensoris Neuropathy Lack of protective sensation

Neuropathy Motoris Neuropathy Changes in foot anatomy

Otonom Neuropathy Lack of sweat

Neuro-
Pressure points
arthropathy

PVD Iskemia

decreased immune
defenses,
Hyperglycemia
poor wound healing
 Patients Factors
Poor eye sight
Patient
disabilities
Previous amputations

Compliance with
preventive measures,
Patient
behaviour
Hygiene

Lack of patient
education

Health care system Glycemic control

failures targets not met

poor implementation of
preventive strategies
 Clinical manifestation
Kaki neuropati
Gangren jari
Osteomielitis

Kaki iskemik
 Clinical manifestation
• Superficial infection
– An infection of the skin
• (not extending trough muscles, tendon,
• bone and joint).
– A pathological state caused by invasion and multiplication of
microorganisms in tissues accompanied by tissuedestruction
and/or a host inflammatory response.

• Superficial ulcer
– Full thickness of the skin not extending the sub cutis

• Ulcer
– Sore; full thickness of the skin.
Nail abnormality
 Physical Examination

• Wound
– Size and depth:
• necrosis, gangrene, foreign body
• involvement of muscle, tendon, bone, or joint –
• inspect, debride, and probe the wound

– Presence, extent and cause of infection:

• purulence, warmth, tenderness, induration, cellulitis,
• bullae, crepitus, abscess, fasciitis, osteomyelitis
History ulcus or amputation

Dokumentasi pribadi, 2007

History ulcus or amputation

Dokumentasi pribadi, 2007

History ulcus or amputation

Dokumentasi pribadi, 2006

Approach to treating
foot wound
 Slide 33

5 Cornerstones of diabetes foot care

management
1. Foot examination
regularly

2. Identification of
4. Treatment before
risk factors
Ulcer occurs

3. Education
(patients, providers 5. Use appropriate
and family) footwear
 Principles of therapy (1)
1. Avoid prescribing antibiotics for uninfected
ulcerations.

2. Determine the need for hospitalization

(severe infection or critical limb ischemia require
hospitalization)

3. Stabilize the patient

– Restoration of fluid and electrolyte balance
– Correction of hyperglycemia, hyperosmolarity, acidosis,
and azotemia
– Treat other exacerbating factors
 Principles of therapy (2)
3. Choose an antibiotic regimen
– Severe infection:
• start broad spectrum IV abx (ensure GPC, gram
negative and anaerobic coverage)
– Mild-Moderate infection:
• Relatively narrow spectrum only covering aerobic
GPC
• No evidence for anti-anaerobic therapy
• Oral therapy with highly bioavailable agents is
appropriate
– Mildly infected open wounds with minimal
cellulitis:
• Limited data support the use of topical antimicrobial
therapy.
 Principles of therapy (3)
4. Determine the need for surgery

– Debridement to revascularization
– Urgent surgical consultation for life- or
limb-threatening infections
• (eg nec fasc, gas gangrene, compartment
syndrome, critical ischemia, etc)
 Principles of therapy (4)
5. Adjunctive treatment
– G-CSF:
does not speed healing but reduces the need
for operative procedures
(preliminary meta-analysis of 5 randomized
trials)

– Hyperbaric oxygen therapy:

reserved for chronic, non-healing ulcers.
Evidence indicates it reduces the risk of major
amputation related to a diabetic foot ulcer
(Cochrane review)
Phases of normal wound healing
Scar maturation
Collagen fibril crosslingking

Remodeling 1 week to 6 months

Endothelial cells

Epithelial cells
Wounding

Colagen

Fibroblasts

Proliferation days 2 through 20

Lymphocytes
Macrophages

Neutrophiles

Inflammation days 1 through 7

Proteoglicans

Fibrin

Platelets

Hemostasis 1 hour

Time from injury

Lobmann et al. Diabetes Care 2005

 Follow up
1. Re-evaluate the wound
2. Review the offloading and wound-
care regimens –
determine effectiveness of the regimen
and patient’s compliance
3. Evaluate the glycemic control
 Summary

• Foot infections
– Large morbidity and mortality
– Frequent visits to health care professionals
– First cause of leg amputation

• Diabetic foot infections require attention to

local (foot) and systemic (metabolic) issues
by a multidisciplinary foot care team.
 LINGGA

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