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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Type 2 Diabetes is Associated with Serious Complications

Microangiopathy
Diabetic Retinopathy
Leading cause of blindness in adults1,2

Macroangiopathy
Stroke
2- to 4-fold increase in cardiovascular mortality and stroke5

Diabetic Nephropathy
Leading cause of end-stage renal disease3,4

Cardiovascular Disease
8/10 individuals with diabetes die from CV events6

Diabetic Neuropathy

Diabetic Foot

Prospective Diabetes Study Group. Diabetes Res 1990; 13:111. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99S102. 3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94S98. 5Kannel WB, et al. Am Heart J 1990; 120:672676. 3 6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7Kings Fund. Counting the cost. The real impact of 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78S79. non-insulin dependent diabetes. London: British Diabetic Association, 1996.

1UK

Patofisiologi Kaki diabetes Patogenesiskaki diabetik

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

K a k i

Faktor-Faktor Risiko
Periferal neuropati: sensorik (>>), motorik, otonom Perubahan biomekanik kaki Peningkatan pressure pada telapak kaki

D i a b e t i k :

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 motorik
Kelemahan otot intrinsik Perubahan ekstensi dan fleksi Penonjolan kaput tulang Deformitas kaki (Biomekanik ) Peningkatan distribusi tekanan

Stratification of Neuropati
Ulcer
Intensive foot education and podiatry

High-risk foot clinic

High

Low

Neuropathy, previous amputation or ulcer Peripheral vascular disease Unable to feel monofilament Neuropathy, 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

Makro
vascular

Mikro
vaskular

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Makrosirkulasi
Normal Fatty Streak Fibrous Plaque

Atherosclerotic Plaque

Plaque Rupture/ Fissure & Thrombosis

Myocardial

Infarction
Ischemic

Stroke
Critical Leg Ischemia

Clinically Silent Angina, TIA`s, PAD Increasing Age

Cardiovascular Death
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Mikrosirkulasi
Fungsi nutrisi : 15 % Fungsi termoregulasi melalui endotel - prostaglandin - prostacycline - endotheline, - nitrid oxide ( NO )

ANGIOPATI
Hiperglikemia
AGE formation Glucose autoxidation Sorbitol pathway

Oxidative stress
leukocyte adhesion
lipid peroxidation foam cell formation TNF a

Antioxidants

Endothelial dysfunction:
NO
Endothelin 1 Prostacyclin Thromboxan

Hypercoagulability:
Fibrinolysis platelet reactivity

coagulability

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

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

B C

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.

Measurement of the AnkleBrachial Index (ABI).

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Hubungan antara ABI dengan Risiko Kematian

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

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
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Intrinsic biomechanical

Wagners classification
Grade-0 Grade -1 Grade -2 Grade -3 Grade -4 High risk foot and no ulceration. Superficial Ulcer. Deep Ulcer ( cellulitis ) Osteomylitis with Ulcer or abscess. Gangrenous Patches. Partial foot gangrene. Gangrene of entire foot

Grade -5
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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

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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
Penonjolan tulang

Faktor ekstrinsik
Sepatu tidak cocok

Gangguan mobilisasi gerak sendi Kerusakan pada sendi

Kalus Perubahan struktur jaringan Riwayat operasi kaki Neuro-osteoarthropatic joint

Berjalan tanpa alas kaki

Jatuh/kecelakaan Benda asing dalam sepatu Aktivitas fisik

Deformitas (1)

Halux valgus

Hammer toes Claw toes

Pes Cavus

Deformitas pasca amputasi (4)

Pasca amputasi/operasi

Tekanan pada telapak kaki dipengaruhi oleh :

Ketebalan jaringan Bentuk deformitas Derajat deformitas Elastisitas jaringan Mobilisasi sendi

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

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
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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): S160. PMID 11280471.^ Brem Harold, Tomic-Canic Marjana (2007). "Cellular and Molecular basis of wound healing in diabetes". JCI 117 (5): 12191222. 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): 10416. doi:10.2337/dc10-1666. PMC 3064020. PMID 21447666.

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