Assessment

Recommendations

Identify and Treat the Cause
1 Perform a complete history, physical examination and appropriate laboratory investigations to identify systemic factors affecting ulcer development and healing. Level of Evidence
Not Assessed
2 Conduct a detailed examination of the foot to identify local factors affecting ulcer healing. Level of Evidence
Not Assessed
3 Conduct a foot inspection and examine for decreased sensation. Correct (if possible) risk factors for ulcer formation/amputation: ♦ Vascular supply ♦ Infection ♦ Pressure (including bony deformity) Remember the mnemonic VIP Level of Evidence
Not Assessed


Address patient-centered Concerns
4 Provide individualized education to enhance Glycemic control, Adherence to treatment, Plantar pressure redistribution/daily foot inspection. (GAP) Level of Evidence
Not Assessed


Provide Local Wound Care
n/a


Provide Organizational Support
5 Include ulcer staging in protocols relating to ulcer assessment and management to facilitate treatment planning, monitoring of effectiveness, and communication among the team caring for the patient. Level of Evidence
Not Assessed
6 Diabetic foot care clinics should review ulcer classification systems and adopt one that best meets the needs of their patient population. Level of Evidence
Not Assessed
7 Establish and empower an interprofessional team to work with Persons With Diabetes (PWD). Level of Evidence
Not Assessed


Background

The diabetic foot syndrome comprises neuropathy, deformity and vascular insufficiency, which eventually lead to complications of ulceration and amputation. These complications affect approximately 15% of diabetic patients and are associated with increased morbidity and mortality and decreased quality of life. Foot ulcers are the leading cause of hospitalization in patients with diabetes and precede amputation in 85% of cases. Comprehensive assessment of the diabetic foot is necessary to institute both preventive and treatment strategies and is required for all patients presenting with ulceration.

A detailed history, complete physical examination and appropriate investigations can determine general health and identify systemic risk factors for ulcer development and factors that influence healing. These include smoking, nutritional deficiency, recurrent trauma, diabetic control, medications that can interfere with healing, malignancy, autoimmune disorders, obesity, renal failure, jaundice, and vascular insufficiency. Psychosocial status, cognitive function and functional status also affect ulcer healing. Local factors that can affect wound healing include loss of protective sensation, decreased blood supply, mechanical stress, edema, hematoma and infection. Other relevant systemic and local factors may also be present.

Ulcer staging or grading is crucial to planning treatment, monitoring effectiveness, predicting outcomes and facilitating communication among the clinical team caring for the patient. The ulcer should be assessed and categorized, using an accepted system, such as the Wagner system or the University of Texas classification.

The Wagner Classification grades diabetic ulcers as follows:
1: Superficial ulcer with partial- or full-thickness skin loss
2: Probing to tendon or capsule with soft-tissue infection
3: Deep ulcer with osteomyelitis
4: Ulcer with forefoot gangrene
5: Ulcer with gangrene involving entire foot

The University of Texas Diabetic Wound Classification System uses a matrix to divide ulcers into stages A to D and grades 1 to 3.
Stages:
A: Clean wound
B: Nonischemic infected wound
C: Ischemic noninfected wound
D: Ischemic infected wound

Grades
1: Superficial wound
2: Wound penetrating to tendon or capsule
3: Wound penetrating bone or joint.

Increasing stage is associated with increased healing time and risk of amputation. The increased detail in the University of Texas system allows improved prediction of outcome.

References

Essential Publications
1 University of Texas Diabetic Wound Classification System Quality Indicator
 Type:
Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996;35:528-531
This well-known classification system for diabetic foot infections developed to guide future surgical treatment protocols, algorithms. The classification system grades depth, ischaemia and infection.
2 University of Texas Diabetic Wound Classification System - validation Quality Indicator
 Type: RCT
Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. Diabetes care 1998;21(5):855-858.
Validation of the grading system based on retrospective analysis of medical records of 360 diabetic patients in multidisciplinary tertiary care diabetic foot clinic, illustrating that outcomes deteriorate with increasing grade and stage of wounds
3 Wagner Grading System for the Dysvascular Foot Quality Indicator
 Type: RCT
Wagner FW. The Dysvascular Foot: A system for diagnosis and treatment. Foot & Ankle 1981;2(2):64-122.
This is the well-known Wagner foot grading system, devised by Dr. Wagner, through observing progression of diabetic foot lesions. The classification system was developed to guide future surgical treatment protocols. Grading system: Grade 0 - no open lesion, Grade 1 - superficial ulcer, Grade 2 - deep ulcer, Grade 3 - absess osteitis, Grade 4 - gangrene forefoot, Grade 5 - gangrene entire foot.
4 Wagner Classification - validation Quality Indicator
 Type: Retrospective Analysis
Calhoun JH, Cantrell J, Cobos J, Lacy J, Valdex RR, Hokanson J, Mader JT. Treatment of Diabetic Foot Infections: Wagner Classification, Therapy, and Outcome. Foot & Ankle 1988;9(3):101-106.
In retrospective analysis, use of the Wagner classification system and therapy algorithms was shown to be a reasonable approach.
5 Clinical Diagnosis of Osteomyelitis Quality Indicator
 Type: Systematic review
Butalia S, Palda VA, Sargeant RJ, Detsky AS, Mourad O. Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA 2008;299(7):806-813.
This systematic review was conducted to evaluate the diagnostic accuracy of historical features, physical examination, laboratory tests, radiographic tests and magnetic resonance imagining (MRI) compared with bone biopsy (the reference standard) in patients with diabetes. Each of the following increase the odds of osteomyelitis: ulcer size greater than 2 cm2, positive “probe-to-bone” test, erythrocyte sedimentation rate of more than 70 mm/h, abnormal radiograph, and positive MRI. A normal MRI result makes osteomyelitis very unlikely. The diagnostic usefulness of combining these test results was not determined.
6 Clinical Diagnosis of Osteomyelitis – validation of probe-to-bone test Quality Indicator
 Type: Longitudinal study (1 group)
Lavery LA, . Armstrong DG, Peters EJG, Lipsky BA. Probe-to-Bone Test for Diagnosing Diabetic Foot Osteomyelitis: Reliable or relic? Diabetes Care 2007;30(2):270-4.
This is a recent evaluation of the probe to bone (PTB) test in relation to bone biopsy in 247 patients with diabetes attending a foot clinic. Although it appears that efforts were made to ensure that the decision to perform the ‘gold standard’ test, bone biopsy, was made independent of the PTB test, this is a potential source of bias. The incidence of infections was 12%. Using all wounds, the positive predictive value of the PTB test was found to be low (0.57), but the negative predictive value was high (0.98) suggesting that a negative PTB test is better at ruling out infection than detecting it in this particular population. Replication of this work in this and other populations is important.
7 Clinical Diagnosis of Osteomyelitis – description of probe-to-bone test Quality Indicator
 Type: Scale Description
Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. JAMA 1995;273(9):721-723.
In this article the probe to bone test for detecting osteomyelitis is described. Its validity was ascertained in relation to histological findings. The test had sensitivity of 66% and specificity of 85%, with positive predictive value of 89% in hospitalized patients with limb-threatening foot infections. The probe to bone test is often used clinically to diagnose osteomyelitis.
8 Assessment of the diabetic foot Quality Indicator
 Type: Longitudinal study (1 group)
Abbott CA, Carrington AL, Ashe H, Bath S, Every LC, Griffiths J, Hann AW, Hussein A, Jackson N, Johnson KE, Ryder CH, Torkington R, Van Ross ER, Whalley AM, Widdows P, Williamson S, Boulton AJ; North-West Diabetes Foot Care Study. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med. 2002 May;19(5):377-84.
This study examines the incidence of, and risk factors for, diabetic foot ulceration. The results demonstrated that over 2% of diabetic patients develop new foot ulcers, and that neuropathy disability score, 10 g monofilament and palpation of foot pulses should be used as screening tools.


Enablers for practice

Coming Soon...