Diabetic Foot

Amputation
Long Case 3
Oleh: dr. Ingrid Melinda
Pembimbing: dr. I Putu Alit Pawana, Sp. KFR-K
Kaki Diabetik
 Berdasarkan data di RS Cipto Mangunkusumo tahun 2011, persentase
komplikasi DM yang paling tinggi yaitu neuropathy sebesar 54% yang
meningkatkan kejadian ulkus kaki diabetes, infeksi dan bahkan
keharusan untuk amputasi kaki, sedangkan persentase untuk ulkus kaki
diabetes sebesar 8,7% dan amputasi akibat diabetes sebesar 1,30%
(Infodatin, 2014).

Individu dengan DM memiliki resiko 15%-25% terjadi ulkus kaki diabetik

Pendahuluan selama hidup mereka dengan angka rekurensi sebesar 50%-70% dalam 5
tahun kemudian (Boulton AJ, 2005).

Ulkus yang timbul sering menunjukkan penyembuhan yang suboptimal

ketika penyakit yang mendasari dan penyebab tidak di terapi dengan
baik dan pasien tidak menerima penanganan yang komprehensif.
Patofisiologi

(Frykberg et al., 2006)

 Neuropathy
• Prediktor utama untuk terjadi ulkus.
• Pada pemeriksaan fisik didapatkan gambaran claw toes, kulit kering
dan berkurangnya reflex (Noor S, 2014; Alavi et al, 2014).

Peripheral Arterial disease (PAD)

• Kontributor penting terjadinya ulkus kaki diabetes.
Diagnosis • PAD didapatkan pada >50% pasien dengan ulkus diabetikum
(Prompers et al, 2008).
• Penilaian status vaskular meliputi anamnesa dan pemeriksaan fisik,
termasuk riwayat PAD sebelumnya, claudikasio intermitten, atau
rest pain (pada pasien dengan DM seringkali tidak ada karena
neuropati).
• Pemeriksaan untuk tanda klinis harus mencakup inspeksi: palor,
rubor, penurunan suhu kulit, rambut rontok, kulit mengkilat dan
atrofi serta palpasi arteri dorsalis pedis dan arteri tibialis posterior.
Klasifikasi

Wagner-
Meggit

Depth
Ischemic

University
of Texas

Charcot
Foot
 • Obat hipoglikemik oral
Medikamentosa • Insulin
• Antibiotik

Manajemen Pembedahan
• Debridement secara agresif
kaki diabetik • Amputasi

• Edukasi
• Physical Therapy
Rehabilitatif
• Modalitas
• orthesa
Amputasi Ekstremitas
Bawah
 Amputasi ekstremitas bawah → 75%-93% gangguan
vaskular
 Diabetes → duapertiga dari seluruh amputasi
ekstremitas bawah
 Jumlah amputasi bawah lutut → urutan ke-2 (27,6%)
setelah atas lutut
 Terdiri 3 level panjang stump: short (<20%), medium
(20%-50%), long (51%-90%) transtibial amputation

(Walsh, 2010)

11
  Myodesis :
 Otot dan fascia dijahit langsung ke tulang → stump lebih
stabil
 Kontraindikasi pada gangguan vaskular o.k. suplai darah ke
tulang terganggu

PENDAHULUA
 Myoplasty :
N  otot-otot yang berlawanan pada stump dijahit satu sama lain
serta ke periosteum pada ujung potongan tulang dengan
tegangan minimal
 Waktu op lebih singkat
 Indikasi gangguan vaskular

(Uustal, Baerga, & Joki, 2015)

12
 Manajemen
pre- Perawatan
prosthesis pasca
dan pre- operasi
operatif
REHABILITASI
AMPUTASI
Fitting Follow up
prosthesis jangka
dan latihan panjang

13
Case Report
  Patient Identity
 Name : Mr. K
 Age : 45 y.o.
Database 

Address
Religion
: Tambakrejo Buntu 39
: Moslem
(December  Occupation : Sales

12th 2019) 

Ethnic : Javanese
Marital status : Married
 Referred from PM&R Outpatient Clinic Soewandhi Hospital with
post amputation Below Knee.

15
  Chief Complaint: Ingin membuat kaki palsu.
 History of Present Illness:
 Patient post amputee at 13th November 2019 at
Soewandhi Hospital
History Of  At April 2017, patient got burnt from presto stove
Present Illness at his outer ankle. The wound got deeper and
wider, until his big toes, 2nd and 3rd toes. The skin
(December blackened especially at his 1st-3rd fingers, and at
12th 2019) August 2017, it were amputated.
 The amputation wound is dried in about 3 months,
and he can still walk afterwards and go to work as
‘usual’ even his left foot felt like ‘clubbing’. There’s
no pain felt, only tired when he walk for around 30
minutes.

16
 Early 2019, he felt more and more difficult to walk because of
his foot shape. He went to hospital, and were told that his ankle
joint becoming one. He then requested to be amputated at 13th
November, at Soewandhi hospital.
 Now his wound already dried, and the stitches has been
removed fully at 10th December. He also already referred to
PM&R OPC at Soewandhi hospital to do exercise weekly.
 There is no sensation that his lower foot is present, but he
sometimes felt pain in the tip of lower left foot that is already
amputated.
 Patient now can use double axillary crutches to help him doing
daily activities. He never fall down when using crutches.
 No complaints in defecation and micturition, and also eat and
drink.

17
  History of Diabetes Mellitus since 2006, but not
routinely controlled. At that time he just given
Metformin and Glibenclamide from general
History of Past practicioner clinic.
Illness  He routinely control to internist since around
august 2019, he then got Lantus, 1 x 10 IU
injected before sleep.

18
  History of hypertension is denied.
 History of coronary disease: there is no
complain about chest pain, but he never
History of Past checked about it before.
Illness  History of tumor or malignancy is denied.
 Patient had amputee in big toes, and 2nd-3rd
left toes of left foot at April 2017 because of
Diabetes.

19
  His father passed away 7 years ago, he got
history of uncontrolled diabetes and
hypertension. He got sudden death after he
History of complains about chest pain.
Familial  His mother passed away 5 years ago, when she
Disease can’t be waken up from sleep. She also got
history of diabetes mellitus.
 His uncle also got amputated because of
diabetic foot.
  Previously the patient work in cooking utensils, like
presto pan, that he modified by himself, for this past 4
years. After got amputated, the patient cannot do his
job as sales, who walking around to selling things. He
also felt easily tired when walk for a while.
 He spend most of his time in at home by sitting and
History of watching tv and sometimes help her sister in the
kitchen.
Socioeconomy
 Patient not yet married, living with his 2 siblings who
already married and got 2 nieces.
 Patients can wear their own clothes, toileting,
showering by himself but still struggling when walking,
going up stairs or defending themselves without a
handle.

21
  General State: He complaint about his left
amputated leg.
 Cardiopulmonary System: There was no shortness of
breath during doing daily activities. There was no
palpitation and orthopnea.
 Gastrointestinal system: Bowel, bladder, and sexual
Review of problem were denied.
System  Nervous system: there was no complaint of smelling,
blurred vision, mastication difficulty, facial
weakness, disartria, dizziness, vertigo, deafness, and
turning head and neck.
 Integumentum system: there was no nodule nor
pigmentation.

22
  General Status
 Compos mentis. Independent ambulation with
double axillary crutches. Right handed domination.
 Body Weight: 70 kg, Height: 160 cm  BMI: 27,3
kg/m² (Obese gr. I)
Physical  Blood Pressure: 140/90 mmHg
Examination  Heart Rate: 84x/m, regular,
 Respiratory Rate : 20x/m

23
 Head
 Anemic (-/-), Icteric (-/-), Cyanosis (-/-), Dyspneu (-/-)
 Neck
 Enlargement of lymph nodes (-)
 Thorax
 Cor: S1 S2 Single Murmur (-) Gallop (-)
 Right heart margin: Sternal Line Dextra
 Left heart margin: ICS V MCL Sinistra
 Pulmo: Vesicular/ Vesicular, Rh -/-, Wh -/-
 Abdomen
 Flat, Soefl, Bowel Sound (+) normal, Meteorismus (-), Liver/
Spleen Unpalpable
 Extremity
 Warm, Dry, Red Acral, Edema (-/-)

24
 NECK ROM MMT
Flexion F (0-450) 5
Extension F (0-450) 5
Lateral bending F/F (0-450) 5/5
Musculosceletal Rotation F/F (0-600) 5/5
Status TRUNK ROM MMT
Flexion F (0-800) 5
Extension F (0-300) 5
Lateral bending F/F (0-350) 5/5
Rotation F/F (0-450) 5/5

25
SHOULDE ROM
MMT WRIST ROM MMT
R
Flexion F/F (0-1800) 5/5 Flexion F/F (0-800) 5/5
Extension F/F (0-600) 5/5 Extension F/F (0-700) 5/5 FINGERS ROM MMT
Abduction F/F (0-1800) 5/5 Ulnar F/F (0-300) 5/5
deviation Flexion
Adduction F/F (0-450) 5/5 Radial F/F (0-200) 5/5 MCP F/F (0-900) 5/5
Internal F/F (0-700) 5/5 deviation
rotation PIP F/F (0-1000) 5/5

External F/F (0-900) 5/5 THUMB ROM MMT DIP F/F (0-900) 5/5
Rotation Flexion Extension F/F (0-300) 5/5
ELBOW ROM MMT
MCP F/F (0-500) 5/5 Abduction F/F (0-200) 5/5
Flexion F/F (0-1500) 5/5
IP F/F (0-900) 5/5 Adduction F/F (200-0) 5/5
Extension F/F (1500-0) 5/5
Supination F/F (0-900) 5/5 Extension F/F (0-200) 5/5
Pronation F/F (0-900) 5/5 Abduction F/F (0-700) 5/5
Adduction F/F (700-0) 5/5
Opposition F/F 5/5
26
 ANKLE ROM MMT
Dorsoflexion F/tde (0-20o) 5/tde
HIP ROM MMT
Plantarflexion F/tde (0-500) 5/tde
Flexion F/F (0-1200) 5/5
Extension F/F (0-300) 5/5 TOES ROM MMT
Abduction F/F (0-450) 5/5
Flexion
Adduction F/F (0-300) 5/5
Internal F/F (0-350) 5/5 MTP F/tde (0-250) 5/tde
rotation IP F/tde (0-250) 5/tde
External F/F (0-450) 5/5
rotation Extension F/tde (0-800) 5/tde

KNEE ROM MMT BIG TOES ROM MMT

Flexion F/F (0-1250) 5/5 Flexion

Extension F/F (1350-0) 5/5 MTP F/tde (0-300) 5/tde

IP F/tde (0-500) 5/tde
Extension F/tde (0-800) 5/tde
27
  N. Cranialis I-XII : Normal
 Physiological Reflex :
 BPR ++/++ KPR ++/++
 TPR ++/++ APR ++/tde
Neurological  Pathological Reflex :
Status  Babinski -/tde, Chaddock -/tde
 Hoffman -/-; Tromner -/-
 Sensory:
 Propioceptive : Normal/ Normal
 Exteroceptive :

28
Exteroceptive
(remaining
sensory)
100% 100%
90%
100%
90% 90%

29
  Inspection:
 Amputation Level : Below Knee Sinistra
Local Status  Stump Shape : Conico – cylindrical
Region of  Wound : (-)
Amputation  Redness : (-)
 Edema : (-)
 Dog Ear : (-)

30
  Palpation:
 Warmth : (-)
 Sensory : Sensory Deficit 10%
Local Status  Neuroma : (-)
Region of  Myoplasty : (+)
 Stump pain
Amputation : (-)
 Phantom sensation : (-)
 Phantom pain : (-)
 Telescoping sens. : (-)

31
  Palpation:
 Stump Length : 53%
Local Status  Stump Diameter : 34 cm
Region of  Proximal artery pulsation : good
 VMO atrophy : (-)
Amputation  Hip flexion contracture : (-)

32
  Additional
Examination:  Count test : 19
 Sitting Balance  Chest Expansion
 Static : Good  T2: 2 cm
Local Status  Dynamic : Good  T4: 2,5 cm
 Standing Balance  T6: 2 cm
Region of
One Leg  Ankle Brachial
Amputation  Static : poor Index Dextra: 1,07
 Dynamic : Poor  6MWT
 Hopping : -  VO2 Max = 9,66
 METS = 2,76

33
  Feeding = 10
 Grooming =5
 Bathing =5
 Dressing = 10
 Bowels = 10
Barthel index  Bladder = 10
 Toilet use = 10
 Transfer = 15
 Mobility =5
 Stairs =5
Total = 85 (independent)

36
Pre-
amputation
foot condition
  Body Structure:
 S580 Structure of Endocrine Glands (Diabetes Mellitus type II)
 S750 Structure of Lower Extremity (Below knee amputee sinistra)
 Body Function:
 B265 Touch Function (Sensory Deficits in both foot).
 B 440 Respiratory function (Decreased count test and chest expansion)
 B555 Endocrine Gland Function (Diabetes Mellitus type II)
 B 729 Function of joint and bone (left below knee amputation)

Problem List  B 770 Gait Pattern Function (left below knee amputation)
 Activity Limitation:
 D415 Maintaining Body Position
 D450 Walking
 D455 Moving around
 Participation Restriction:
 D859 Work and employment, other specified and unspecified (Can’t do work)
 Environmental Factor: -

39
  Left Below Knee Amputation e.c Diabetic
Clinical Foot + Polineuropathy DM + Obese gr. I +
Diagnosis Decrease of Endurance + Impaired
Balance

40
 Health Condition:
• (Z89.512) Left Below Knee Amputation
• (E11) Diabetes Mellitus type II (uncontrolled)

Body Functions and

Structures:
• S580 Structure of Endocrine Glands
Activities:
ICF • S750 Structure of Lower Extremity
• B265 Touch Function
• D415 Maintaining Body Position
• D450 Walking
Participation:
• D859 Work and

Diagnosis
• B 440 Respiratory function Participation
• D455 Moving around
• B555 Endocrine Gland Function
• B 729 Function of joint and bone
• B 770 Gait Pattern Function

External Factors: Personal Factors:

Health Service Sedentary lifestyle

41
 1. Surgical : -
2. Medical : -
3. Rehabilitation Medicine:
 P. Dx : Consult to the Nutritionist, Review X-Ray + Lab results
 P. Tx :
 Short Term Goal :
 Shaping stump

Planning 

Maintaining joint flexibility
Block glucose regulation
 Increase sensibility
 Maintaining muscle power
 Improve balance
 Intermediate Goal
 To use below knee prosthesis
 Long Term Goal :
 Improve Quality of Life.

42
 Therapeutic exercise :
 Active breathing exercise with deep breathing
 Chest expansion exercise
 AROM exercise upper and lower extremity dextra/ sinistra.
 Strengthening muscles of Lower extremity dextra/ Sinistra
 Balance training with One leg standing exercise in Parallel bar
 Sensory re-sensitization.
 Post prandial aerobic exercise:
 F = 3 – 5x/ week
 I = 40-60% HR reserve + HR rest
 T = 30 minutes
 T = arm crank.
 Shaping stump with figure of 8.

43
 Protesa:
 Below knee prothesa SACH foot exoskeleton shank quadrilateral socket

 Planning Monitoring:
 Clinical findings, vital sign, ROM, MMT, blood glucose, shape stump,
wound in the non – affected foot.

 Education:
 HE : Explain about patient’s condition.
 HEP :
 Continue exercise at home.
 Shaping stump.
 Post prandial exercise with mineral water bottle 300 cc.
 Decrease body weight
 Save our sole (SOS) in the non – affected foot.
 Use insulin routinely as prescribed.
 Routinely control to Internal medicine and Cardiovascular department.

44
 S: Chief complaint: kadang masih terasa tidak stabil
• Patient felt imbalance when he tries to stand up in one leg
• When he wants to walk for a long distance, he sometimes must
catch his breath first before continue his work
• Patient still do exercise at home, sometimes he do at soewandhi
Progress note hospital too
• Patient still wish to get a new prosthetic, but he didn’t have money
(13th January
O:
2020)
• BB: 65 kg, TB: 160cm.
• Blood pressure: 140/100. Heart rate: 100x/min.
• Count test: 22, Chest Expansion: 3/3/2.5
• Ankle Brachial Index Dextra: 1,07
• 6MWT : VO2 Max = 9,98 , METS = 2,8

47
 Additional
Inspection: Palpation:
Examination:
• Amputation • Warmth : (-) • Sitting Balance
Level : Below • Sensory : Sensory • Static: Good
Knee Sinistra Deficit 10% • Dynamic: Good
Local status of • Stump Shape : • Neuroma : (-) • Standing Balance
the Conico –
cylindrical
• Myoplasty : (+)
• Stump pain : (-)
One Leg
• Static: poor
amputation • Wound : (-)
• Redness
• Phantom • Dynamic: Poor
: (-) sensation : (-) • Hopping: -
• Edema : (-) • Phantom pain :
• Dog Ear : (-) (-)
• Telescoping
sensation : (-)
A: Left Below Knee Amputation e.c Diabetic Foot + Polineuropathy DM + Obese
gr. I

P:
• PDx:-
• PTx:
• Therapeutic exercise :
• Active breathing exercise with deep breathing
• Chest expansion exercise
• AROM exercise upper and lower extremity dextra/ sinistra.
• Strengthening muscles of Lower extremity dextra/ Sinistra
• Balance training with One leg standing exercise in Parallel bar
• Sensory re-sensitization.
• Post prandial aerobic exercise:
• F = 3 – 5x/ week
• I = 40-60% HR reserve + HR rest
• T = 30 minutes
• T = arm crank.
• Shaping stump with figure of 8.

50
 Protesa:
 Below knee prothesa SACH foot exoskeleton shank quadrilateral
socket

 Planning Monitoring:
 Clinical findings, vital sign, ROM, MMT, blood glucose, shape
stump, wound in the non – affected foot.

 Education:
 HE : Explain about patient’s condition.
 HEP :
 Continue exercise at home.
 Shaping stump.
 Post prandial exercise with mineral water bottle 300 cc.
 Decrease body weight
 Save our sole (SOS) in the non – affected foot.
 Use insulin routinely as prescribed.
 Routinely control to Internal medicine and Cardiovascular department.
 S:
• Chief complaint: none
• Patient got tripped 3 days ago, his amputee got hit with the floor. There’s
wound at his amputation, but he treated it well with betadine every day.
• He still gets his insulin shot daily at night, and he always bandage his stump.
• Patient spent most of his time doing houseworks, helping his older sister
Progress note making pecel + peyek
• He sometimes forgot to do the exercise.
(25th March • Patient still wish to get a new prosthetic, but he didn’t have money

2020) O:
- BB: 67 kg, TB: 160cm.
- Blood pressure: 130/80. Heart rate: 85x/min.
- Count test: 22, Chest Expansion: 3/3/3
- Ankle Brachial Index Dextra: 1,07
- VO2 Max: 10, METS : 2,85
- TUG test : 31 seconds
 Additional
Inspection: Palpation:
Examination:
• Amputation Level: • Warmth : (-) • Sitting Balance
Below Knee • Sensory : Sensory • Static : Good
Sinistra Deficit 10% • Dynamic : Good
Local status of • Stump Shape : • Neuroma : (-) • Standing Balance
the Conico –
cylindrical
• Myoplasty : (+)
• Stump pain : (-)
One Leg
• Static : poor
amputation • Wound : (-)
• Redness : (-)
• Phantom • Dynamic : Poor
sensation : (-) • Hopping: -
• Edema : (-) • Phantom pain :
• Dog Ear : (-) (-)
• Telescoping
sensation : (-)
A: Left Below Knee Amputation e.c Diabetic Foot + Polineuropathy DM +
Obese gr. I
P:
• PDx:-
• PTx:
• Therapeutic exercise :
• Active breathing exercise with deep breathing
• Chest expansion exercise
• AROM exercise upper and lower extremity dextra/ sinistra.
• Strengthening muscles of Lower extremity dextra/ Sinistra
• Balance training with One leg standing exercise in Parallel bar
• Sensory re-sensitization.
• Post prandial aerobic exercise:
• F = 3 – 5x/ week
• I = 40-60% HR reserve + HR rest
• T = 30 minutes
• T = arm crank.
• Shaping stump with figure of 8.

55
 Protesa: Below knee prothesa SACH foot exoskeleton shank
quadrilateral socket (waiting for the fund)
 Planning Monitoring: Clinical findings, vital sign, ROM, MMT,
blood glucose, shape stump, wound in the non – affected foot.
 Education:
 HE : Explain about patient’s condition.
 HEP:
 Continue exercise at home especially for strengthening his lower
extremities.
 Shaping stump.
 Post prandial exercise with mineral water bottle 300 cc.
 Decrease body weight and motivate patient to reduce sedentary
lifestyle
 Save our sole (SOS) in the non – affected foot.
 Use insulin routinely as prescribed.
 Routinely control to Internal medicine and Cardiovascular department.
  Reported patient 45 years old, male, referred from Rehabilitation
Clinic at Soewandhi Hospital with diagnose Post below knee
amputation.
 The chief complain of patient was ingin membuat kaki palsu,
after underwent left below knee amputation surgery 1 month ago.
He underwent amputation because has a clubbed foot that
worsened and make him difficult to walk. He has diabetic mellitus
Summary type 2 and have history of amputation of his 1st until 3rd toes of
left foot at 1 year ago.
 The condition of patient when he first came to PMR outpatient
clinic was still weak on the lower extremity at both sides, his
balance was impaired, and his endurance was decrease because
never do an exercise or housework after surgery.
 We diagnose patient with Left Below Knee Amputation e.c
Diabetic Foot + Polineuropathy DM + Obese gr. I.
 The management of physical medicine therapy on the outpatient clinic,
firstly we educate the patient how to shaping stump, maintaining
muscle power by strengthen the lower extremities muscle on both
sides, maintaining joint flexibility by doing ROM exercise. We also gave
balance training to improve his balance, and active breathing exercise,
chest expansion and not to forget the post prandial aerobic exercise to
improve his cardiovascular endurance and to maintain glucose
regulation. We educate the patient how to use crutches in the good
way.
 Based on progress, show that with rehabilitation program and education
the symptoms of disease decrease and recovery could be achieved,
but in slower progress because patient often forgot to do exercise.
 The prognosis of this patient was uncertain because his condition always
affected by his blood sugar, he must control his blood sugar routinely to
internist and cardiologist to support his exercise program so he can do
properly, patient must care and aware to keep cleanliness his right foot
and stump and also an important thing was support from her family
physically and psychologically.
 Progression on count test, TUG, VO2 Max, METS
Count test TUG VO2 Max METS
12th December 2019 15th January 2020 18th April 2020
34
33
32 32
31
30
28
26
24
22 22
20 20
18
16
14
12 12
10 9.66 9.98 10
8
6
4
2.76 2.8 2.85
2
0
Documentatio
n
Thank you