Hidup Berkwalitas dengan Diabetes:

Upaya Pencegahan Kaki Diabetes

 JUMLAH PENDERITA ( Peserta ASKES)
Penyakit Kronis th 2010

No Diagnosa Jumlah
1 Gagal Ginjal 11.875
2 Hipertensi 629.315
3 Diabetes Melitus 420.743
4 Kanker 132.810
5 Penyakit Jantung 247.203
6 Stroke 117.356
7 Asthma 105.689
8 Osteoporosis 15.084
9 Penyakit Kronis lain 220.151

JUMLAH
JUMLAH PESERTA
PESERTA ASKES
ASKES :: 16.561.376
16.561.376 JIWA
JIWA
USIA 40 TAHUN
11/21/17 USIA 40 TAHUN :
: 9.507.098 JIWA
9.507.098 JIWA
nf (57.41
(57.41 %)
%) 2
 Komplikasi kronis diabetes
Mikroangiopati Makroangiopati
Retinopati Stroke
Diabetik

Nefropati
Penyakit
Diabetic Kardiovaskular

Neuropati
Diabetik Kaki Diabetik

1
UK Prospective Diabetes Study Group.
Diabetes Res 1990; 13:111. 2
Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99S102. .
 Diabetic Complications

60 54 Microangiopathy >> Macroangiopathy

Retinopathy
50 Neuropathy
Proteinuria
40 Dialysis
33.4
Foot Ulcer
30 26.5 Amputation
Angina

20 MCI
10.9 Heart Failure
8.7 7.4 Stroke
10 5.3 5.3
2.7 PAD
0.5 1.3
0
IDMPS Indonesia
 Fakta-fakta
1. 4-10 % penderita diabetes akan mengalami ulkus
pada kaki
2. Risiko untuk mengalami kaki diabetes 25 %
3. Insidens luka pada kaki 2-7 % pertahun
4. Resiko amputasi kaki > 15 kali dari non diabetes
5. 80 % amputasi didahului oleh ulkus
6. 85% amputasi kaki diabetes dapat dicegah dengan
edukasi
 Risk Factors

11/21/17 Kyoto Foot Meeting 2010 6

 Penyebab Terjadinya Luka pada Kaki

Gangguan 11/21/17 11/21/17 11/21/1 Gangguan Kalus infeksi

syaraf 7 pembuluh
darah

Reiber GE, Vileikyte, Boyko EJ et al. Causal pathways for incident lowerextremity ulcers in patients with from two settings.
Slide 7
Diabetes Care 1999: 157-162
 Karakteristik Pasien Kaki Diabetes
di
Rawat Inap Penyakit Dalam RSCM

Karakteristik Pasien (n: 114)

Laki-laki : perempuan 70:77
Usia 60.18 + 8.48 tahun

Lama diabetes 9.94 + 6.09 tahun

Lama Luka 26.8 + 14.97 hari
Kadar Hb A1c: 9,38 + 2,06%
Lama Rawat 29.2 + 12.86 hari

Yunir, August 2011 February 2013

 Grade Luka
Wagner Classification
60
53
50
40
Number of Patients

40 38

30

20
11
10
5
0
0 0
Grade Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Angka Amputasi di RSCM
Umumnya disertai dengan infeksi

5; 11.63%

3; 6.98%

Improved
5; 11.63%
MinorMembaik
Amputation
19; 44.19% MajorAmputasi minor
Amputation Amputasi:
Died Amputasi mayor
Escaped
37%
Meninggal
11; 25.58%
Self request Pulang paksa
discharge

n = 43 patients

Em Yunir, Kyoto Foot Meeting 2012

 Pathophysiology of diabetic foot
Diabetes Mellitus

Neuropathy Trauma Vascular Disease

MOTOR SENSORY AUTONOMIC MICROVASCULAR MACROVASCULAR

Weakness
Atrophy Anhidrosis dry Structural Structural
skin capillary BM atherosclerosis
Deformity Loss of thickening
Abnormal Protective Occlusive
Stress Sensation narrowing
Functional AV
High Plantar
Shunting
Pressure Sympathetic
Ischemia
Callus Tone
Formation

Structural
Deformity Impaired Response to
Infection Ischemia
Cheiroarthropat
hy
Amputation Diabetic Foot Ulcer Amputation
Slide 12
Diabetic Foot Disorders: A Clinical Practice Guideline (2006 Revision)
 Neuropati perifer Intrinsic Factors

Atonom Motorik Sensorik

Decreased Sweating Loss of protective

Changes muscletone sensation

Dry Skin Deformities Decreased pain
threshold
Decreased Elasticity Lack of temperature
sensation and
Fissure / Callus
proprioception

Ulcer

Thermal Trauma Ill fitting

in bajaj Shoes
Slide 13
1. Akibat kelainan bentuk(Deformitas)

Pasca amputasi/operasi
Kelainan bentuk
 Deformitas

Hammer toes
Pes Cavus
Halux valgus Claw toes
Luka akibat kelainan bentuk kaki
diabetes
Luka akibat gangguan syaraf perasa

akibat sepatu sempit

 Akibat Kulit tidak sensitif

Jalan di aspal panas Korban seragem

 Perubahan tekanan pada telapak kaki dapat
menyebabkan kalus - luka

Distribusi tekanan pada telapak kaki

G-7: This picture has been made three or four days before the death. Hand distal phalanx
Kelainan bentuk penyebab luka
are bare-skined and the patient is now totally blind. No surgery.
Fig. 12.

3.3.2 CASE H: The patient suffers a toes deviation. Big toe infraductus and total claw
of the second toe. This patient is old, diabetic with a kidney insufficiency. Hes only
treated by a podiatrist. He has very painful angiopathic wounds

H-1: On May 13th 2004. First

H-2: On May the 27th 2004. H-3: Actisorb Ag+ application
corrective Hapla Band TO and
Fifteen days later. used all the treatment long.
one inter-digital felt TO.

Luka akibat gesekan dengan sepatu

in contact with the ground, and a Swing Phase (40%), when the foot is free f
stance phase is further divided into a contact phase (10%), a midstance phase
Perubahan
propulsive phase (10%)beban berat
(See Figure badan
3). Since saat
pathology berjalan
develops most when
touching the ground, FLEB concentrates on the stance phase of gait.

Fig. 3. The Stance Phase of Gait

Because the tendo Achilles is medially inserted on the calcaneus, it places th

inverted position when the stance phase of gait begins and so the heel strikes th
Terjadinya luka pada telapak kaki dengan kalus

-2 faktor yang berpengaruh :

- gaya gesekan
- gaya tekanan
1 toe rigid: it is due to hardening of the first MTT phalange joint with loss of dorsiflexion,
resulting in excessive weight forces on the plantar surface and callus formation.
Joint stiffness: The limitation of joint movement is produced by the glycosylation of
collagen and thickening of periarticular structures (tendons, ligaments, joint capsule, etc.)
Kelainan biomekanik penyebab luka
which favors deformities and plantar pressures, upsetting the biomechanics of the foot
during walking by limiting plantar flexion and promoting equinus foot.

Lapisan lemak
pelindung

Fig. 3. The different deformities of at risk diabetic foot. The three different stages of
changes in the architecture of the foot which causes hammer toes and contraction of the
plantar fat pad (look arrow). Above: normal foot. Middle: beginning of deformation.
Bottom: Complete deformation. (Modified from Levin & ONeal 2008. Right images
courtesy from Ramos F, MD)
Kelainan Kuku
 Gangguan Makrosirkulasi
Plaque
Athero- Rupture/
Fatty Fibrous sclerotic Fissure & Myocardial
Normal Streak Plaque Plaque Thrombosis Infarction

Ischemic
Stroke

Critical
Leg
Clinically Silent
Ischemia
Angina,TIA`s,
Angina, TIA`s, PAD
PAD
Cardiovascul
ar Death
Increasing Age
Pembuluh darah tersumbat
Faktor penyebab gangguan pembuluh darah
kaki

Diabetes
Merokok
Hipertensi
Dislipidemia

INTER-SOCIETY CONSENSUS FOR THE MANAGEMENT OF PERIPHERAL ARTERIAL DISEASE (TASC II)
Penanganan sumbatan ada pembuluh darah

Percutaneous Trans Angyoplasty Stenting

 Tanda-Tanda Infeksi pada Kaki

Bengkak
Kemerahan pada kulit >0.5 -cm1
disekitar luka
Nyeri lokal
Kulit sekitar luka terasa hangat
Terdapat nanah atau cairan dari luka
Demam, menggigil

IWGDF grade (IDSA classification)

Lipsky BA. Diabetes Metab Res Rev 2012; 28(Suppl 1): 16378
traumatize the feet with maximum pressure exerted on different points caused by the tight
fit, as shown in Fig 7. In our experience, neuropathy was the first component cause (present
in 100% of patients with ulcers), and the ischemia was a component cause in 35% of ulcers.

Pemilihan sepatu yang salah

Another independent component of the triad is the difficulty of healing the ulcer that is
related with alterations in the immune response, decreased blood flow to the wound area,
cellular components of the inflammatory system, abnormal expression of growth factors,
cytokines and their receptors that are involved in the healing process; it is usually the
combination of the various components that leads to chronic ulceration and amputation.

Fig. 7. Diabetic patient with neuropathy, callus and claw toes using inappropriate shoes that
cause repetitive trauma, thus forming the fracture of the callus and infecting the skin. The
final result is a wound that later evolves to an infected ulcer. Sufficient cause is complete.
(Courtesy of Aguilar F & Tern JM 2011)

3. Clinical presentation
About 50% of patients with foot ulcers due to DM present clinical signs of infection. By
definition, infection is characterized by the presence of purulent secretions or at least two of
the classic signs of inflammation (erythema, hyperemia, edema, or swelling and pain) but
5 Cornerstones of Foot Management

Foot
examinatio
n
Classificati
Treatment
on risk
before ulcer
factors

Appropriate
footwear Education
 Program pencegahan
Jangan lakukan
1. Berjalan tanpa alas kaki
2. Memakai sepatu yang sempit
3. Memakai kaos kaki yang sempit dengan lipatan
pada ujung kaki
4. Membiarkan kulit menjadi kering dan bersisisk
5. Penggunaan bahan kimia atau benda tajam untuk
menghilangkan mata ikan
6. Merokok
7. Penggunaan cincin pada jari kaki
8. Mengunakan sepatu dengan tumit tinggi atau ujung sepatu
runcing ke depan
 Program Pencegahan
Lakukanlah
1. Pemeriksaan kaki setiap hari
2. Selalu memakai alas kaki
3. Periksa sepatu sebelum dipakai
4. Gunakan alas kaki yang pas
5.Belilah sepatu pada sore hari
6. Gunakan selalu kaos kaki katun
7. Cuci kaki dengan sabun lembut, keringkan
8. Gunting kuku secara mendatar
9. Kontrol kaki secara teratur ke petugas kesehatan
10. Gunakan lotion pelembab kulit secara teratur
 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