Diabetic Foot/ foot ulcer

FACTORS ASSOCIATED WITH FOOT ULCER

1. Previous ulcer/amputation

2. Neuropathy Sensorimotor

3. Trauma Poor footwearWalking barefootFalls / accidents

Objects inside shoes4. Biomechanics Limited joint mobility

Bony prominencesFoot deforminencesCallus

5. Peripheral vascular disease

6. Socio-economic status Low social positionPoor access to healthcareNon-compliance/neglectPoor education

Different stages in the development of a plantar ulcer caused by mechanical stress

Pathophysiology of foot ulceration

• Neuropathy (sensory, motor and autonomic) is the most important cause diabetic ulcers.

• In addition to purely neuropatic and purely ischemic ulcerations, there is a mixed group of-ischemic ulcers.

Mediasclerosis of the artery leading to incompressible arural vessel

Pre-ganggrenous fourth toe due to ischemia

(Minor) gangrene of the fourth toe (Major) gangrene of the forefoot

69- year old male with a history of a resection of the second through fourth toe with subplantar absecess underwent angiography

Angiography showed short segment occlusion of the superficial femoral artery and multiple crural occlusions

Purcutaneous transluminal angioplasty (PTA) of the distal superficial femoral artery was permed

Wound healing after successful PTA

Charateristics of atherosclerosis in diabetic patients as opposed to non-diabetic patient

More commonAffects younger individualsNo sex differenceFaster progressMultisegmentalMore distal (aorto-iliac arteries less frequently involved)

Peripheral Arterial Disease(PDA)

• Prevalensi PDA diukur dengan Ankle Brachial Index (ABI) :

–Ukur tekanan sistole a.dorsalis pedis (ADP) dan a. brachialis (AB) dgn alat doppler

–Hitung rasio ADP dgn AB

• AB dibanding angiografi : 95% sensitif, 100% spesifik

• Kriteria diagnosa PDA dg AB :

– Normal 1.0 – 1,3

– Obstruksi ringan 0,7 – 0,9

– Obstruksi sedang 0,4 – 0,69

– Obstruksi berat < 0,4

– Sukar dikompresi bila > 1,3

Stages, according to Fontaine :

Stages 1 : Occlusive arterial disease without clinical symptoms

Stages 2 : intermittent claudication

Stages 3 : ischemic rest pain

Stages 4 : Ulceration/gangren

Subplantar abscess and a deep calcaneal lesion

1) Angiography showed multiple crural occlusions

2) Because of the non-healing defect a popliteal-pedal by pass from the infragenual popliteal artery to the pedal artery was performed

Secondarily healed defect after succesful reconstructive revascularitation

Non-invasive evaluation and an estimate of probability of healing

75 years pld male with deep foot infection and osteomyelitis

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