MANAGEMENT STRATEGIC OF DIABETIC FOOT

Raden Suhartono
Vascular and Endovascular Surgeon
Cipto Mangunkusumo Hospital/
Faculty of Medicine – University of Indonesia
For MABI XXI Makassar 2018
 DR. R. SUHARTONO, SPB(K)V
 Tempat Tgl lahir: Jakarta 25 Desember 1962
 Email: rsuhartono_md@yahoo.com
 Alamat: Pulomas Jakarta Timur, Kec Pulogadung Jakarta 13910
Riwayat Pendidikan
 S1 Dokter FKUI tamat 1988
 Sp1 Spesialis Bedah FKUI 1996
 Sp2 Vascular Endovascular FKUI 2000
Riwayat Pekerjaan
RSU Tanjung Selor - Kaltim 1989-1991
RSU Bangkinang - Riau 1997-2000
RSCM FKUI - Jakarta 2000-sekarang
Jabatan dan Pelayanan
 Ketua Yayasan Ambulance 118 tahun 2010-sekarang
 Ketua PESBEVI 2010-2014
 Kepala Departemen Bedah FKUI RSCM 2008-2011
 Ketua IKABI Jaya 2005-2009
 Ketua PP IKABI 2015-2018
 Carotis Team RSCM 2010-sekarang
 Komisi Hubungan Luar negeri KIBI 2014-2016
IDF. Diabetes atlas. 6 th edition 2014
TOP 10 COUNTRY WITH DM
Ranking 2000 2030
Country Million people Country Million people
1 India 31.7 India 79.4
2 China 20.8 China 42.3
3 USA 17.7 USA 30.3
4 Indonesia 8.4 Indonesia 21.3
5 Japan 6.8 Pakistan 13.9
6 Pakistan 5.2 Brazil 11.3
7 Russian Fed. 4.6 Bangladesh 11.1
8 Brazil 4.6 Japan 8.9
9 Italy 4.3 Philippines 7.8
10 Bangladesh 3.2 Egypt 6.7

1. Wild S, et al. Global prevalence of Diabetes. Diabetes care, vol 27, n. 5, may 2004
2. IDF. Diabetes atlas. 6 th edition 2014
PREVALENCY OF DM IN INDONESIA
HIGH COST FOR DM
LEG ULCERS

 Concern of the cost

 Pain & suffering
 Body image change
 Struggle for control, independence
 Depression, isolation
 Social Issues
 STAIRWAY TO AMPUTATION

Each step in this

stairway is a
target for
intervention to
prevent
amputation

Armstrong DG, et al. Guest editorial : are diabetes-related wounds and amputation worse than cancer? Int
Wound J. 4: 286-287. 2007
 WAGNER CLASSIFICATION
FOR DIABETIC FOOT ULCER
 Grade 0 - Skin intact, no foot deformity
 Grade 1 - Superficial ulcer

 Grade 2 - Deep ulcer

 Grade 3 - Deep ulcer with infection

 Grade 4 - Limited necrosis

 Grade 5 - Necrosis of the entire foot

 Diabetic foot deformity due to motor neuropathy  pressure
points at specific bone prominences (A), patient cannot feel
because of sensory neuropathy & loss of protective sensation.
 Ulceration increased pressure: hammer toes/ claw toes (B)
 Metatarsal head perforans ulcer (C)
 Midfoot collapse or Charcot’s foot (D)
FOOT DEFORMITY

Navicular-Cuneiform (lisfranc)

Talonavicular (Chopart)

Bayonet deformity
talo-calcaneal
tibiotalar joint
9/8/2018 13
 ARTERIAL ULCERS
RESULT OF REDUCED BLOOD SUPPLY DUE TO:
 Emboli
 leads to infarction
&ischemia

 Atherosclerosis (accumulation of plaque)

- narrows lumen of artery
- diminished arterial blood supply
- decreased delivery of O2 & nutrients
- leads to tissue hypoxia and necrosis
 ARTERIAL ISCHEMIA ASSESSMENT

History of:
 Cold feet
 Intermittent claudication - pain in
leg/buttock with walking
 Rest pain - in toes & forefoot
 Pain aggravated by elevation &
relieved by dependency
 Smoking, diabetes, hypertension,
hyperlipidemia, CAD, age
 VASCULAR ASSESSMENT
Inspection:
 Colour – pale
 Dependent rubor- with -
 Elevation pallor
 Decreased capillary refill time
(>15 sec.)
 Atrophy of subcutaneous fatty
tissue
 Shiny, thin, tightly drawn skin
 Loss of hair on foot and toes
 Thick, yellow, brittle nails
 VASCULAR ASSESSMENT

 Palpation: Dorsalis pedis

Cool to touch

Absence of pedal
pulses

Blanch test
Posterior tibial
 ABI
 ABI Arterial
Insufficiency
0,9 – 1,2 None
 ABI = 0.8
0,8 – 0,9 Mild
0,6 – 0,8 Moderate  Blood flow in ankle is 80%
< 0,6 Severe of that in the arm

 ABI < 0,9  Vascular

consult
 re-establishment of an adequate
vascular supply is indicated if
feasible
 VASCULAR ASSESSMENT
Vascular Lab:
 Toe pressures more
accurate
 <25 mmHg represent
severe occlusion
 >30 mmHg needed for
healing to occur
 >45 mmHg in people
with diabetes
 Arteriography (diagnosis of
by-passable conditions-
surgery)
 Transcutaneous oxygen
pressures ->30%
ARTERIAL ULCER CHARACTERISTICS

Caused by Trauma

Usually very painful

Circular or punched out appearance

Painful if leg elevated

On distal areas of foot-toe tip, between digits,

over bony prominences

Wound bed - necrotic tissue or pale

granulation base

Little exudate, dry & necrotic

Surrounding tissue pale or mottled

SO, HOW DO WE MANAGE DFU?
DETERMINE POTENTIAL FOR HEALING
 Assess Patient and Wound for:
Blood Supply
 Important for wounds of lower extremities

 If inadequate:
 moist interactive wound healing is
contraindicated use topical antiseptics
 Vascular referral to determine if
re-vascularization possible
Diabetic Foot-Protocol
Diabetic Foot
routine
24-48 hrs
Uncomplicated Complicated
Emergency
Minor/moderate
Major
Screening Specialised Clinic
ABPI
Neuropathy Diabetic Control Infection
Education Fluids Culture/swabs
Identify High Risk insulin Antibiotics
Debride/drain

Neuropathy Ischaemic
Off load Duplex Wound Care
Rest Angiogram
Protect

Endovascular Reconstruction Amputation

DIABETIC FOOT TEAMS
 Reduce amputations
 Save money
BUT
 Need planning
 Regular review and audit

 Need single team for each area

 Common protocols
 Must be commisioned as a single service
OPTIMAL THERAPY FOR DIABETIC FOOT

Integration of Wound Care

Control of glucose metabolism

Antibiotic Therapy

Debridement

Reconstructive Foot Surgery

Vascular Reconstruction
ANTIBIOTIC THERAPY

Aristidis et al. The Diabetic Foot. 2nd Ed. 2006

DEBRIDEMENT

 Debridement of  Pre-revascularization
nonviable and debridement is indicated
uninfected tissue is in a septic foot with and
performed only after the without ischemic signs
revascularization (Level II)
procedure. (Level II)  Edema and infection can
lead to digital arterial
thrombosis

National Ireland guideline for wound management 2009.

European Wound Management Association
Modern Dressing
 EVIDENCE BASED IN ARTERIAL ULCER
 All patients with ulcers  assessed for arterial disease.(Level I)
 Pedal pulses
 Ankle brachial index
 Referral to a vascular specialist:
 Patients with absent or reduced pulses or ABI ≤ 0.9 and
 Patients with an ulcer and rest pain or gangrene . (Level
I)
 Patients with risk factors for atherosclerosis who have ulcers
should be carefully evaluated. (Level I)
 In the presence of an arterial ulceration, the natural history is one of
disease progression and eventual limb loss (Level I)
 Treatment options are revascularization or amputation
 Adjuvant therapies may improve healing but do not correct the
underlying vascular disease
 LONG TERM MAINTENANCE IN ARTERIAL
ULCER
 Education
 Risk factor reduction (Level I)
 Smoking cessation
 Control of
 diabetes
 hyperlipidemia
 hypertension
 elevated homocysteine levels
 Exercise to increase arterial blood flow (Level I)
 Anti-coagulation therapy (Level II)
 Aspirin, Clopidogrel, Ticlodipine, LMWH
WHY DIABETICS ARE DIFFERENT ?
 RULE OF “15”

 Diabetic foot ulcer precipitate 85% of amputation

 15% of diabetes patients will have foot ulcer in
lifetime
 15% of foot ulcers are followed by osteomyelitis
 15% of foot ulcers will end with foot amputation

Clinical Care of Diabetic Foot,

2005
 RULE OF “50”

 50% of amputations are major amputations

 50% of patients will have 2nd amputations in ≤5y

 50% of patients will die in ≤ 5y

 50% of patients with diabetic ulcer will have PAD

Clinical Care of Diabetic Foot,

2005
 THE PRIMARY GOALS OF
REVASCULARIZATION

 Relieve ischemic pain

 Heal (neuro) ischemic ulcers

 Prevent limb loss

 Improve patient function & quality of life &

prolong survival
 WHAT KIND OF
REVASCULARIZATION?

 Open or Endovascular ?
 Arterial lesion based ?

 Targeted ulcer related arterial lesion ?

 OPEN OR ENDOVASCULAR?

 The determination of the best method of

revascularization is based upon the balance
between risk of a specific intervention and
the degree and durability of the improvement
that can be expected from this intervention
 USG STRATEGY

 Femoro-popliteal or SFA lesion

(less common)

 Below the knee  90%

 Anterior tibia artery
 Posterior tibia artery
 Peroneal artery (this is the artery that in most cases
remains patent & the last of the three crural artery
to occlude
CTA STRATEGY
DIAGNOSTIC
ARTERIOGRAPHY
OUR EXPERIENCES
SFA ANGIOPLASTY
OUR EXPERIENCES
BTK ANGIOPLASTY
OUR EXPERIENCES
BTK ANGIOPLASTY
OUR EXPERIENCES
BTK ANGIOPLASTY
 OPEN SURGERY
FEMORAL POPLITEAL BYPASS FEMORAL TIBIAL BYPASS
VASCULAR RECONSTRUCTION
Open Surgery
 OTHER PROBLEMS

 Nowadays, despite progress in

revascularization, we are facing new complex
problems:
 Mixed diseases (DM, CHD, PAOD, renal failure,
etc)
 Very old or very young patients
Assessment of the risk of amputation:
The WIFI classification
ASK YOUR SELF
INFECTION? NEUROPHATY?
NEUROISCHAEMIC ?
Mr A, Male, 66 yo
DFU
Mrs. Y, 43 yo
Left DFU, Diabetic Type 2
Mrs.N, 41 yo
Right DFU, Chronic Kidney Failure on HD,
Diabetic Type 2
Mr.Z, 68 yo
Bilateral DFU with ascending infection,
Sepsis, CAD, Acute Kidney Injury
MR. S, 49 YO ABI :
1:1.2
 Left DFU, Post Debridement + NPWT
 Diabetic type 2, CKD stage IV, Hipertension
AFTER NPWT
MRS S, 54 YO
RIGHT CALCANEAL DFU
METABOLIC ENCEPHALOPATY
ABI
1/1.13
POST DEBRIDEMENT
MRS H, 63 YO,
BILATERAL DFU, DIABETIC GANGREN, SEPSIS EC
PNEUMONIA, HCAP
ABI :
1.08/1.00
CHOPART AMPUTATION
MR. D, 42 YO, DIABETIC TYPE 2
Before Skin Graft

After Skin Graft

MR S 56YO, LEFT DFU, OSTEOMYELITIS
HEAD METATARSAL, DIABETIC TYPE 2

•
AFTER NPWT
MR. B , 52YO
INTRA OP
POST OP
MR. RS 54Y.O
DFU + GANGRENE 2ND AND 3 RD DIGIT OF THE RIGHT FOOT
+PAD
FI : GR 2, I: GR 2, W: GR 2
RISK OF AMPUTATION : HIGH
BENEFIT OF REVASC : HIGH
LAB : WBC : 18.800
BLOOD GLUCOSE : 377
Mr. H, 69 y.o
Aortoilliac disease + left DFU (post
choppart amputation) Lab : WBC : 8.950 , BG : 149
 Severe stenosis of distal
aorta until left femoral
artery

FI : gr 2
I : gr2
W : gr 2
Risk of Amputation : High
Benefit of revasc : High
AFTER ANGIOPLASTY
 Mr.HJ, 52 yrs male, heavy smoker, DM 5 yrs
Rest pain & blackening of right foot x 3 months
R\L lower limb pulses absent
ABI R - 0 , L – 0.2
 Management
Underwent emergency Aorto-bifemoral bypass
and right trans-tarsal amputation
 Outcome

Post Op ABI left 1.1

Right stump healed well

Mr. BHT 72 y.o
Gangrene of the left leg and foot +Total
occlusion of distal aorta + sepsis
Lab : WBC : 18.200, Alb : 2.2, BG
: 210
TOTAL OCCLUSION OF DISTAL
ABDOMINAL AORTA

FI : gr 3
I : gr 3
W : gr 3

Risk of amputation : High

Benefit of revasc : High
Above Knee Amputation
Pass away  COD : Prolong sepsis
 SUMMARY

 Diabetic foot problems in Indonesia:

 High infection incidence
 Younger patients

 Poor metabolic control of blood glucose level &

albumin
 Longer length of stay
 SUMMARY

 The management of the diabetic foot is

challenging and requires a multidisciplinary
approach.
 Once ulceration  aggressive management.

 Identification of high risk patients requires

screening (regular).
 Patient education should be part of this
process.
Thank You for Your Attention