Diabetic Foot Ulcer

dr. IGAB Krisna Wibawa, SpB (K) V

 Introduction

Diabetes has reached epidemic proportions

worldwide

The International Diabetes Federation (IDF)

estimates 425 million people living with DM
worldwide in 2017, estimated to rise to 628
million by 2045

Abdissa, D., Adugna, T., Gerema, U., & Dereje, D. (2020). Patients with DFU have a greater than twofold increase in mortality compared with
nonulcerated diabetic patients. Journal of Diabetes Research, 2020.
 Introduction

Diabetic foot disease (DFD) is one of the diabetic

complications associated with major morbidity,
mortality, and reduced quality of life and is the most
serious complication of diabetes mellitus.

Patient come to the hospital usually have a or extensive

gangrene or necrotic. This is because inadequate initial
screening. If the patient presents with claudication, the
prognosis may be better after endovascular surgery

Abdissa, D., Adugna, T., Gerema, U., & Dereje, D. (2020). Patients with DFU have a greater than twofold increase in mortality compared with
nonulcerated diabetic patients. Journal of Diabetes Research, 2020.
 Introduction

This condition is associated with

Neurological alterations and peripheral
arterial disease (PAD).
A person with DM is estimated to have a
risk of about 25% of developing the DFU
condition during his/her lifetime.

Abdissa, D., Adugna, T., Gerema, U., & Dereje, D. (2020). Patients with DFU have a greater than twofold increase in mortality compared with
nonulcerated diabetic patients. Journal of Diabetes Research, 2020.
 RISK FACTORS Diabetic Foot

• Poor glycemic control

• Previous lower extremity amputation
• History of a foot ulcer
• Anatomic foot deformity
• Peripheral vascular disease
• Diabetic nephropathy in those on dialysis
• Smoking
• Dislipidemia

Cardoso, H. C., Zara, A. L. D. S. A., Rosa, S. D. S. R. F., Rocha, G. A., Rocha, J. V. C., Araújo, M. C. E. De, Quinzani, P. D. F., Barbosa, Y. P., &
Mrué, F. (2019). Risk Factors and Diagnosis of Diabetic Foot Ulceration in Users of the Brazilian Public Health System. Journal of Diabetes
Research, 2019. https://doi.org/10.1155/2019/5319892
 PATHOPHYSIOLOGY - Neuropathy
• In people with neuropathy, minor trauma (eg, from ill-fitting
shoes or an acute mechanical or thermal injury) can precipitate
ulceration of the foot.

• Loss of protective sensation (LOPS), foot deformities, and limited

joint mobility can result in abnormal biomechanical loading of
the foot. This produces high mechanical stress in some areas, the
response to which is usually thickened skin (callus).

• The callus then leads to a further increase in the loading of the foot, often with
subcutaneous haemorrhage and eventually skin ulceration. Whatever the primary
cause of ulceration, continued walking on the insensitive foot impairs healing of
the ulcer

Aumiller, W. D., & Dollahite, H. A. (2015). Pathogenesis and management of diabetic foot ulcers. Journal of the American Academy of Physician
Assistants, 28(5), 28–34.
PATHOPHYSIOLOGY - Neuropathy
Loss Of Pain Sensation

Unnoticed Trauma ( Thermal,

Chemical, Mechanical)

Tissue necrosis & damage

Progression of lesion unchecked beneath callus

Development of cavities filled

Callous Formation with serous fluid

Erupt into surface

Result in Ulcer Formation

Pheripheral arterial disease (PAD)

• PAD, generally caused by atherosclerosis, is present in up to 50% of patients

with a diabetic foot ulcer.
• PAD is an important risk factor for impaired wound healing and lower
extremity amputation.
• A small percentage of foot ulcers in patients with severe PAD are purely
ischaemic; these are usually painful and may follow minor trauma.

• The majority of foot ulcers, however, are either purely

neuropathic or neuro-ischaemic, that is, caused by combined
neuropathy and ischaemia. In patients with neuro-ischaemic
ulcers, symptoms may be absent because of the neuropathy,
despite severe pedal ischaemia.

Aumiller, W. D., & Dollahite, H. A. (2015). Pathogenesis and management of diabetic foot ulcers. Journal of the American Academy of Physician
Assistants, 28(5), 28–34.
Clinical Presentation

• AHA Guidelines defines the presentation of PAD by four categories: asymptomatic, claudication,
critical limb ischemia, and acute limb ischemia (ALI).
• Patients who are asymptomatic do not have typical claudication symptoms.
• Claudication is defined as fatigue, discomfort, or pain in the lower extremities, typically the calves,
which is reproducibly brought on by exercise and relieved by rest.
• Critical limb ischemia is defined by chronic ischemic rest pain, nocturnal recumbent pain, or ischemic
skin lesions that may include ulcers or frank gangrene. Symptoms typically are present for at least 2
weeks.
• ALI refers to patients with a sudden decrease in limb perfusion causing an immediate threat to limb
viability. Presentation can occur up to 2 weeks from the onset of symptoms. ALI may present with the
“6 Ps” of pain, paralysis, paresthesia, pulselessness, poikilothermia, and pallor.
PATHOPHYSIOLOGY - Vasculopathy

Macroangiopathy Microangiopathy

Artherosclerosis of large Increased thickness of

arteries basement membrane and
endothelial Proliferaton

Capilary damage
 Wagner Ulcer Classification System

Aumiller, W. D., & Dollahite, H. A. (2015). Pathogenesis and management of diabetic foot ulcers. Journal of the American Academy of Physician
Assistants, 28(5), 28–34.
WIFI
Classification
Physical examination
Vascular Status
 Examination of Arterial Disease

Inspection
-PAOD: muscle atrophy, hair loss, nail thickening, -Skin
discoloration, brittle skin, edema, ulcers, wounds

Palpation
Description: normal, reduced, absent

Auscultation
Bruit : turbulent flow

Rutherford’s Vascular Surgery, 7th ed. 2010. Saunders Elsevier. London. Chapter 13. Vol 1
ABI
• Normal value  ABI 0.9 to 1.29
• Intermittent claudication  ABI 0.5 to 0.9
• Pain at rest  ABI below 0.4
• Impending gangrene  ABI below 0.3
• Sensitivity of ABI in detecting PAD ranges from 80% to 95%
• Specificity ranges from 95% to 100%
MANAGEMENT

Ulcer debridement removes necrotic tissue,

foreign material such as bacteria, and
hyperkeratosis that may surround the wound

Perform urgent surgical intervention is

necessary in most cases of deep abscesses,
compartment syndrome and virtually all
necrotizing soft tissue infections
Schaper, N. C., van Netten, J. J., Apelqvist, J., Bus, S. A., Hinchliffe, R. J., & Lipsky, B. A. (2020). Practical Guidelines on the prevention and
management of diabetic foot disease (IWGDF 2019 update). Diabetes/Metabolism Research and Reviews, 36(S1), 1–10.
https://doi.org/10.1002/dmrr.3266
Longitudinal view of compartments of the foot
Surgery

• Longitudinal skin incisions

respecting the specific
compartments 
• durable, weight-bearing, and
often nonpainful plantar
surface
• If required, this incision can
also be modified to include
amputation.

11/14/2021 21
 Wound Debridement

• Wound bed preparation is the most important

concept in current wound care practice:
Restoring an altered chronic wound to an acute
wound that progresses naturally towards
healing.

Wound Bed Preparation

Debridement Exudate Management Control of bacteria burden

•
UAW Product Presentation
Debridement

Surgical
Bistouri at the OR
Osmotic Sharp
Hyperosmolar Scalpel, progressive at
solutions the patient’s bed

Methods of
Autolytic
Biologic debridement Natural, requires
Maggots
moisture

Mechanical Enzymatic
Hydrojet Exogenous enzymes

• Chronic wounds generally require repeated

debridement; different methods can be combined or
used in sequential or alternate ways
 Definition UAW
• UAW is a Low Frequency Contact Ultrasonic
Debridement method
• Direct contact between moving sonotrode tip, liquid
and wound surface is needed to make use of
cavitation effects

EWMA debridement document (2013)

The act of removing necrotic material, eschar,

devitalised tissue, infected tissue, hyperkeratosis,
slough, pus, haematomas, foreign bodies, debris, bone
fragments or any other type of bioburden from a
wound with the objective to promote wound healing

Strohal R, Apelquist J., Dissemond J, et al. EWMA Document : Debridement. J Wound Care. 2013: 22
(Suppl.1):2S1-S 52
4
The Range

Instrument Accessories

Irrigation Fluid

Hoof
Instrument cabel

Double Ball Footswitch

Generator
Disposable irrigation
Spatula tubing

UAW Product Presentation

Handpieces

• Three differently shaped sonotrode tips

Ball shaped Hoof shaped Spatula shaped

No sharp edges to Plain surface to clean To clean narrow
gently clean wound wound surfaces wounds, i.e. between
pockets toes

UAW Product Presentation

The sonotrode oscillates 25.000 times
Functionality
per second back and forth.

Due the the backward movement,

cavitation bubbles arise in the irrigation
solution.

When the sonotrode move forth again,

the cavitation bubbles implode and
create a powerful streaming with
detaches debris and biofilm from the
wound bed.
2
7
 Skin and wound Refashioning of the
cleansing Debridement
wound edge
 Cleanse the wound  Removal of necrotic  Remove necrotic,
bed to remove tissue, slough, crusty and or over
devitalized tissue biofilm at every hanging wound
debris and biofilm dressing change edges that may be
harbouring biofilm
 Cleanse the
periwound skin to  Ensure the skin edge
remove dead skin align with the wound
scales and callus, bed to facilitate
and to epithelial
decontaminate it advancement and
contraction

Wound Bed Preparation : Prontosan and Sonoca

• Selectivity of UAW
 Removes: Necrotic, fibrinous tissue, eschar, pus,
dirt
 Preserves: Healthy freshly granulated tissue

Before Debridement
Wound covered with fibrinous
layer

After UAW Debridement

Fibrin is removed, wound cleaned,
healthy tissue not damaged, little
UAW Product Presentation
bleeding

Source: Herberger, UKE Hamburg, GER

Key Benefit of UAW

Time and Cost Saving

1 Only local anesthetics

2 No extensive operative settings

3 Access to difficult to reach areas

4 As effective as sharp debridement

5 Stimulated fibroblast proliferation

• *Herberger K et al: Efficacy, tolerability and patient benefit of ultrasound-assisted wound

treatment versus surgical debridement: a randomized clinical study. 2011
** Suchkova V. et al: Ultrasound enhancement of fibrinolysis at frequencies of 27 to 100 kHz.;
Ultrasound Med Biol. 2002 Mar;28(3):377-82.
 Examples

• Examples of effective UAW debridement

UAW After debridement

Before debridement

Sources: ATZ Stern, Bocholt and Herberger,

UKE Hamburg, GER
Before debridement After debridement

UAW Product Presentation

 Examples

• Indications for Ultrasound-Assisted Wound-Debridement

Ulcus cruris

Diabetic Foot
Sources: ATZ Stern, Bocholt, hospital Idar-Oberstein, Güntsch, Schwerin

UAW Product Presentation

 How to use UAW

• Perform treatment in a room that can be easily wipe-disinfected and

contains only few fixtures. No bedside treatment
• Always wear protective clothing during UAW treatment
• Start the treatment with a power setting of 40% and increase or
decrease the power – depending on the desired effect on the
wound as well as patient tolerance.
• For patients with low pain tolerance, apply a local anesthetic, 30-45
minutes prior to treatment
• Constantly move the hand pieces during treatment.
• There should always be sufficient irrigation fluid on the wound
surface
Endovascular
 Vascular grafts or bypasses indicated in patients with peripheral
arterial disease. Adequate peripheral circulation is key to fighting
infection and promoting wound healing
 Endovascular repair techniques have shown high success in patients
with claudication. Comprehensive arteriographic studies help clinicians
identify flow-limiting lesions and determine the repair procedure.
 Revascularization surgery should be undertaken as soon as possible to
avoid losing healthy limb tissue and reduce the risk of foot amputation.
 • P/ 63th
• luka pada kaki kanan sejak ± 2 bulan yang lalu
Case 1 • Post debridement + amputasi digiti 3-5 pedis D (8/10/2021)
• Riwayat DM, HT
 • P/ 63th
• luka pada kaki kanan sejak ± 2 bulan yang lalu
Case 1 • Post debridement + amputasi digiti 3-5 pedis D (8/10/2021)
• Riwayat DM, HT
 • P/ 63th
• luka pada kaki kanan sejak ± 2 bulan yang lalu
Case 1 • Post debridement + amputasi digiti 3-5 pedis D (8/10/2021)
• Riwayat DM, HT
 • P/ 63th
• luka pada kaki kanan sejak ± 2 bulan yang lalu
Case 1 • Post debridement + amputasi digiti 3-5 pedis D (8/10/2021)
• Riwayat DM, HT
 • L/ 61 thn
• nyeri dan terasa pegal pada kaki kiri sejak 3 minggu. Nyeri
Case 2 dirasakan terutama saat berjalan dan berkurang dengan
istirahat
• Riwayat DM
 • L/ 61 thn
• nyeri dan terasa pegal pada kaki kiri sejak 3 minggu. Nyeri
Case 2 dirasakan terutama saat berjalan dan berkurang dengan
istirahat
• Riwayat DM
 • L/ 61 thn
• nyeri dan terasa pegal pada kaki kiri sejak 3 minggu. Nyeri
Case 2 dirasakan terutama saat berjalan dan berkurang dengan
istirahat
• Riwayat DM
 • L/69 thn
• Riwayat DM (+) sejak 20 tahun
Case 3 • Riwayat debridement kompleks + amputasi digiti 3,4 Pedis D
(30/7/21)
• Riwayat debridement + necrotomy Pedis dextra (13/8/21)
 • L/69 thn
• Riwayat DM (+) sejak 20 tahun
Case 3 • Riwayat debridement kompleks + amputasi digiti 3,4 Pedis D
(30/7/21)
• Riwayat debridement + necrotomy Pedis dextra (13/8/21)
 • L/69 thn
• Riwayat DM (+) sejak 20 tahun
Case 3 • Riwayat debridement kompleks + amputasi digiti 3,4 Pedis D
(30/7/21)
• Riwayat debridement + necrotomy Pedis dextra (13/8/21)
 • L/69 thn
Case 4 • Riwayat DM (+) sejak 20 tahun
• Riwayat debridement kompleks + amputasi digiti 3,4
Pedis D (30/7/21)
 • L/69 thn
Case 4 • Post debridement + necrotomy Pedis dextra (13/8/21)
 • L/69 thn
Case 4 • post Debridement + STSG (okt 2021)
 • L/60 thn
Case 5 • Keluhan Nyeri pda tungkai kiri
• Riwayat DM
 • L/60 thn
Case 5 • Keluhan Nyeri pda tungkai kiri
• Riwayat DM
 • L/60 thn
Case 5 • Keluhan Nyeri pda tungkai kiri
• Riwayat DM
 • L/45 thn
Case 6 • Keluhan Claudicatio Intermittent
• Riwayat DM
 • L/45 thn
Case 6 • Keluhan Claudicatio Intermittent
• Riwayat DM
 • L/45 thn
Case 6 • Keluhan Claudicatio Intermittent
• Riwayat DM
 Prevent foot ulcers

1.Identifying the at-risk foot.

2.Regularly inspecting and examining the at-risk
foot.
3.Educating the patient, family, and health care
professionals.
4.Ensuring routine wearing of appropriate footwear.
5.Treating risk factors for ulceration.
Conclusion
• Prevention of diabetic foot ulceration is critical in
order to reduce the associated high morbidity and
mortality rates, and the danger of amputation.

• It is essential to identify the “foot at risk,” through

careful inspection and physical examination of the foot
followed by neuropathy and vascular tests.

• Screening with a good physical examination of vascular status,

followed by appropriate treatment can reduce complications
of leg amputation
 References

• Abdissa, D., Adugna, T., Gerema, U., & Dereje, D. (2020). Patients with DFU have a
greater than twofold increase in mortality compared with nonulcerated diabetic
patients. Journal of Diabetes Research, 2020.
• Aumiller, W. D., & Dollahite, H. A. (2015). Pathogenesis and management of diabetic
foot ulcers. Journal of the American Academy of Physician Assistants, 28(5), 28–34.
https://doi.org/10.1097/01.JAA.0000464276.44117.b1
• Cardoso, H. C., Zara, A. L. D. S. A., Rosa, S. D. S. R. F., Rocha, G. A., Rocha, J. V. C., Araújo,
M. C. E. De, Quinzani, P. D. F., Barbosa, Y. P., & Mrué, F. (2019). Risk Factors and
Diagnosis of Diabetic Foot Ulceration in Users of the Brazilian Public Health System.
Journal of Diabetes Research, 2019. https://doi.org/10.1155/2019/5319892
• Everett, E., & Mathioudakis, N. (2018). Update on management of diabetic foot ulcers.
Annals of the New York Academy of Sciences, 1411(1), 153–165.
https://doi.org/10.1111/nyas.13569
• Schaper, N. C., van Netten, J. J., Apelqvist, J., Bus, S. A., Hinchliffe, R. J., & Lipsky, B. A.
(2020). Practical Guidelines on the prevention and management of diabetic foot
disease (IWGDF 2019 update). Diabetes/Metabolism Research and Reviews, 36(S1), 1–
10. https://doi.org/10.1002/dmrr.3266
MATUR SUKSMA