Clinical Examination And Screening Techniques To Identify The Patient At Risk Of Foot Ulceration

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It is well-known that prevention remains the best means of averting the potentially devastating results of diabetic foot complications. It has been estimated that up to 80% of diabetic foot ulcers are preventable (70). Accordingly, routine clinical examination to identify those patients at risk for ulceration has been advocated (71). This involves a simple but thorough history and clinical examination consisting of a basic examination of the foot to include vascular, neurological, dermatological, and mus-culoskeletal examination.

Clinical evaluation of a patient with diabetes should begin with a thorough history to determine if a patient has a history of previous ulceration or amputation. A past history of ulceration or amputation increases the risk for future ulceration, infection, and amputation. Up to 60% of patients with diabetes with a history of a foot ulcer will develop another ulcer within a year following wound healing (72). Three possible explanations for this have been proposed.

1. The risk factors that were necessary to cause the previous ulceration are in most cases still present;

2. The skin and soft tissue on the site of earlier ulceration may not have the same properties after healing has occurred in this area as compared with before the ulcer was present. Therefore, the skin and soft tissue might be altered and more prone to subsequent breakdown; and

3. Areas of previous amputation may leave a residual deformity that by themselves are areas of increased pressure that might be prone to ulceration. Additionally, any previous surgical interventions might alter pedal biomechanics, resulting in imbalances where areas of high pressure develop, which may subsequently ulcerate.

Other aspects of the history should include a history of symptoms of neuropathy. For example, numbness, tingling, burning, hypersensitivity, cold sensations, or any other altered sensations in the feet or legs should be noted. Painful symptoms, such as sharp shooting or aching pains should also be noted. Obviously, it should be emphasized that the absence of neuropathic symptoms is not to be equated with the absence of neuropathy and that a large number of patients develop neuropathic ulceration without ever having or noticing any symptoms.

The clinical examination begins with the vascular assessment. Peripheral vascular disease is the cause in approximately 25% of foot ulcers and might contribute to the inability of an ulcer to heal (73). Vascular assessment includes a brief history for the existence of claudication. Clinical examination for the palpation of all lower extremity pulses and the presence or absence of hair should be carried out. The skin should be inspected for texture, turgor, color, and temperature. The absence of hair growth and skin atrophy are clues to impaired circulation. The absence of palpable foot pulses or

Skin Inspections For Ischemia
Fig. 5. The 5.07 Semmes-Weinstein Monofilament. The filaments is flexed when 10 gr of pressure is applied on the skin. Failure to feel a 5.07 strongly indicates that the patient is at risk of developing foot ulceration.

the existence of a nonhealing ulceration should prompt noninvasive vascular examination along with consultation with a vascular surgeon.

The next step in the clinical examination involves neurological testing to evaluate for the presence of neuropathy. The perception of pain, touch, and vibration can be easily tested using simple standard equipment, such as a pin prick, cotton or wool, and a tuning fork. The main feature the clinician should look for is a sensory level below which all the earlier mentioned modalities are reduced. The examination should be completed by testing the ability of the patient to feel a 5.07 Semmes-Weinstein monofilament (SWM) at the very least at the pulp of toes 1, 3, and 5 as well as the corresponding metatarsophalangeal joints (Fig. 5). Additional sites include two sites on the plantar aspect of the midfoot, one site on the plantar aspect of the heel, and one on the dorsum of the midfoot. Inability to feel the 5.07 SWM and/or the presence of a sensory level can identify 99% of all patients with diabetes who are at risk of foot ulceration (74,75). These are simple, quick techniques with inexpensive equipment and should be performed at least once a year in all patients with diabetes. Patients with a sensory level or abnormality Semmes-Weinstien monofilament testing may be at risk of ulceration and should be provided preventive care (70,75,76).

Vibration pressure threshold (VPT) is another effective technique to identify patients at risk of ulceration. VPT is commonly measured with a hand-held biothesiometer device that applies voltage in the range of 0-50 Volts (V). The test is performed by placing the vibrating stylus on the pulp of the great toe or the malleolus. Failure to detect a value of 25 V is considered indicative of a foot at risk for ulceration (28). When compared with SWM testing, the sensitivity of VPT approaches only 79% and it requires more sophisticated and expensive equipment. Accordingly, it cannot be recommended as the technique of choice (74,75).

Clinical examination concludes with a thorough musculoskeletal examination to appreciate and understand the overall structure and dynamics of the foot being evaluated. An inspection for the presence of foot deformities and limitation of joint mobility is carried out. Both these entities increase foot pressures that lead to ulceration. Osseous prominences can be observed secondary to Charcot neuroarthropathy, motor neuropathy, and common foot deformities, such as hallux abductovalgus, hallux limitus/rigidus, and hammertoes. In addition, the examiner should look for callus formation. In the past, the presence of calluses was speculated to be a protective mechanism with debridement of these lesions not recommended. However, it is now well-known that most calluses are actually focal areas of increased pressure and can serve as sites of potential ulceration (77). Any areas of erythema secondary to shoe wear irritation should be protected with padding or appropriate accommodative shoe wear dispensed to alleviate the pressure.

Diabetic Foot Ulcer Classification

There have been numerous classification schemes proposed for describing diabetic foot ulcers. The most commonly used and most often referred to is the Wagner system (78). The Wagner system classifies diabetic foot ulcers into five distinct grades, based on anatomical location and depth. Wagner grade 0 describes a pre- or postulcerative lesion. Grade 0 ulcerations are healed sites of ulcerations although risk factors for ulcer development, such as calluses and foot deformities are present. Wagner grade 1 ulcerations are superficial, full thickness ulcers with penetration past the epidermis. Grade 1 lesions are often indicative of the presence of peripheral sensory neuropathy, and usually another risk factor for ulceration. Continued weight-bearing on grade 1 ulcerations will result in progression past the dermis with involvement of deeper structures, such as tendons, ligaments, joint capsules, and neurovascular structures. These are grade 2 ulcerations. Grade 2 lesions do not probe to bone and osteomyelitis is not present. Wagner grade 3 ulcerations are characterized by the presence of deep infection with or without bone involvement and are usually the result of grade 2 ulcerations, which have worsened because of inadequate or lack of effective treatment. Other factors include lesions with rapidly forming tissue necrosis or puncture wounds. Wagner grade 4 ulcers present with partial gangrene of the foot. Grade 4 ulcers typically are associated with peripheral vascular disease. Infection is also present and necessitates aggressive management by a limb salvage team in order to limit tissue loss. Partial amputation in patients with these ulcerations is not uncommon. Grade 5 ulcers are characterized by extensive necrosis and gangrene of the foot, which is usually best addressed with aggressive treatment and amputation.

The Wagner classification system for diabetic foot ulcers is popular, but has its drawbacks. The first three grades provide an understanding as to the depth. However, there is no indication as to the status of the patients perfusion or the presence of infection. The patient's perfusion status and the presence of infection are key points in ulcer evaluation. Grades 4 and 5 ulcerations are severe, hence that aggressive debridement and minor or major amputation are often necessary. Essentially, these conditions are so severe that the aggressive treatment necessary means that the conditions are only very temporary. That and the fact that they are not as common are reasons that grades 4 and 5 are rarely used. Because of these shortcomings, other classification systems have been proposed including one described by Lavery, et al. (79) that aims to be more inclusive of all types of neuropathic foot lesions in addition to providing predictors of outcomes and response to therapy. This classification system mirrors the Wagner classification, but instead incorporates the presence or absence of infection and/or ischemia within each grade (80). This classification scheme has the added benefit of correlating expected outcomes with increasing stage and grade. The factors determining increasing grade are depth and presence or absence of infection and ischemia. These newer classifications are more inclusive, but more difficult to remember and use in the clinical setting. Because of this, efforts have been made to devise a new system. For purposes of describing ulcerations by clinicians of various specialties who may not be aware of complex ulcer classifications, it is easier to just remember the three factors important in accurately describing foot ulcerations: depth, presence or absence of infection, and the patient's vascular status. These three factors will allow a clinician to effectively articulate the status of a patient with an ulceration.

Treatment Principles of Foot Ulceration

Treatment of diabetic foot ulcers varies greatly depending on the severity of the ulceration as well as the presence of ischemia. However, basic key points of treatment for full thickness ulcers are effective debridement, offloading of pressure, treatment of infection, and local wound care. In addition, a greater understanding of the pathophysiology of wound healing has led to advanced wound care products demonstrating promise in accelerating wound healing.


The goal of wound debridement is the complete removal of all necrotic, dysvascu-lar, and nonviable tissue in order to achieve a red, granular wound bed. Sharp surgical debridement using sharp instruments, such as a scalpel blade is ideal (81) (Fig. 6). Using this technique all nonviable tissue are removed until a healthy bleeding ulcer bed is produced with saucerization of the wound edges. Ulcerations with redundant hyper-keratotic rim should be aggressively debrided to remove this hyperkeratotic tissue. This will help to reduce pressure on the wound when the patient ambulates. It will also facilitate better visualization of the wound for a more thorough evaluation. The bacterial

Foot Ulcer Debridement
Fig. 6. A grade 2 ulcer after surgical debridement. Adequate debridement is achieved when all exuberant callous tissue and necrotic tissue have been removed and a clean granular base is revealed.

load at the ulcer site can also be reduced by debriding an ulceration aggressively. This procedure can be performed in the office setting except in the rare cases when extensive debridement is required or sensation to the foot is not intact and the use of the operating room might be required. In addition, in the event that ischemia is suspected, aggressive debridement should be delayed until vascular examination and revascular-ization are achieved.

Other debridement techniques are also available, but none has gained universal acceptance. Autolytic debridement refers the body's own mechanism of removing devitalized tissue. This process is primarily undertaken by macrophages, which release proteolytic enzymes to degrade nonviable tissue (82). However, this method requires adequate arterial perfusion as well as wound hydration and can be slow and tedious. It often involves the use of occlusive dressings left in place for 2-3 days. Enzymatic debridement involves the use of topical agents with the ability to degrade necrotic tissue using proteolytic enzymes. These agents are typically applied to a wound under an occlusive dressing. Indications for use are limited and are generally, indicated to slowly soften large eschars or debride decubitus ulcerations in sensate limbs. Drawbacks to this form of debridement include the lengthy process and considerable expense of these agents (83). Finally, mechanical debridement gently loosens and removes slough from the wound bed. The simplest form of this technique is the commonly applied wet-to-dry saline gauze. The moist gauze dries on the wound. Upon removal of the dried gauze, the adhered tissue will be removed with the dressing. The material that is removed is very superficial tissue. Where this is an inexpensive and relatively easy technique, it can remove both viable and nonviable tissue and cause pain in the sensate foot. Caution must be exerted in using this type of dressing to a wound with a granulating base that only requires epithelialization to close. This type of dressing might remove epithelial tissue with each dressing change and therefore, should not be used in this situation as opposed to a adherent dressing, which is more ideal.

Pressure Offloading

Reduction of pressures is essential in the healing of plantar foot ulcers. As discussed previously, ulcerations occur in high pressure areas of the insensate foot. There are a number of methods used for the reduction of foot pressures, with varying success rates. The most popular methods include total contact casting, half shoes, short leg walkers, and felted foam dressings.

Total contact casting has been considered the most effective means of offloading diabetic foot ulcers as measured by wound healing rate (84). Described by Paul Brand, total contact casting involves the use of a well-molded minimally padded plaster cast to distribute pressures evenly to the entire limb. It allows for patient mobility during treatment and has been found to help control edema linked to impairment of healing (85) while maintaining the forced patient compliance because of the inability to remove the apparatus. Disadvantages include the considerable skill and time required for application, the possibility of secondary skin lesions because of cast irritation, and the inability to assess the wound daily. Patients also complain of the total contact cast making sleeping and showering difficult.

Because of the considerable disadvantages associated with the total contact cast, few clinicians use it as the technique of choice in regular clinical practice. Instead, commercially available off the shelf devices, such as the half shoe and prefabricated short leg walker are more commonly used. Both these devices are relatively inexpensive, easy to use, and readily accepted by the patient. However, pressure reduction is significantly less compared with total contact casting and patient compliance cannot be assured because of the removable nature of the devices (86).

Felted foam dressings are accommodative offloading devices fashioned from a felt-foam pad with an aperture corresponding to the ulceration for customized pressure relief. The pad is attached to the patients skin with a pliable adhesive, preventing migration of the pad, and thereby ensuring a degree of patient compliance (Fig. 7). Wound care and wound assessment can be performed through the aperture or window that is created for access to the wound. The felted foam is often used in conjunction with a surgical shoe or half-shoe and must be changed every 10-14 days to ensure integrity of the dressing. Felted foam dressings in combination with a surgical shoe or half-shoe were found to be more effective in pressure reduction when compared with a short leg walker or a half-shoe alone (87).

Wagner Type Foot Ulcer
Fig. 7. The felted foam dressing is an effective pressure offloading modality for patients with Wagner 1 and 2 foot ulcers. The felted foam can stay in place for 1 week whereas wound care and wound assessment can be performed through the aperture portion.

Treatment of Infection

Bacteria colonize ulcerations and these ulcerations may serve as a portal of entry resulting in the development of an infection. Diagnosis of infection is primarily based on clinical appearance, relying on clinical signs such as erythema, edema, pain, tenderness, and warmth. Care must be taken to diagnose and treat infections sufficiently as mild cellulitis can rapidly progress to a limb threatening infection if left untreated. Indeed the spectrum of infections might range from the local cellulites to severe, limb threatening deep abscesses with osteomyelitis. Additional clinical information may be obtained with cultures, radiographs, and more advanced imaging techniques. When clinical infection of an ulcer is suspected, cultures of the wound will aid in directing subsequent antibiotic therapy. Empirical antibiotic therapy should be started for cases of infection, with revision of therapy pending culture results.

Radiographical imaging of the infected foot can demonstrate increased density and thickening of the subcutaneous fat along with blurring of the usually visible fat planes (88). Presence of osseous changes, such as periosteal reaction, cortical bone destruction, and focal osteopenia might suggest a diagnosis of osteomyelitis. However, these

Table 1

Selected Antibiotic Regimens for Initial Empiric Therapy of Foot Infections in Patients With Diabetes Mellitusa

Infection Antimicrobial regimen6

Non Limb threatening Cephalexin 500 mg p.o. q 6 hour Clindamycin 300 mg p.o. q 8 hour Amoxicillin-clavulanate (875/125 mg) one q 12 hour Dicloxacillin 500 mg p.o. q 6 hour Levofloxacin 500-750 mg p.o. q day Limb threatening Ceftriaxonec 1 gm iv daily + clindamycin 450-600 mg iv q 8 hour Ciprofloxacin 400 mg iv q 12 hour + clindamycin 450-600 mg iv q 8 hour

Ampicillin/sulbactam 3 g iv q 6 hour Ticarcillin/clavulanate 3.1 g iv q 4-6 hour Piperacillin/tazobactam 3.375 g iv q 4 hour or 4.5 g iv q 6 hour Fluoroquinolone^ iv + metronidazole 500 mg iv q 6 hour Life threatening Imipenem cilastatin 500 mg iv q 6 hour

Piperacillin/tazobactam 4.5 g iv q 6 hour + gentamicine 1.5 mg/kg iv q 8 hour

Vancomycin 1 g iv q 12 hour + gentamicin + metronidazole aFrom ref. 89.

6Doses for patients with normal renal function. cAn alternative is cefotaxime 2 g iv q 8 hour.

^Fluoroquinolone with increased activity against gram positive cocci, for example, levofloxacin 500-750 mg iv q day.

eCan be given as single daily dose 5.1 mg/kg per day. p. o., orally; q, every.

changes only become evident after osteomyelitis has been present for 10-14 days and require up to 50% bone loss before becoming recognizable (89). Advanced imaging techniques, such as magnetic resonance imaging and computed tomography may aid in the accurate diagnosis of osteomyelitis as well as demonstrate abscess formations.

Treatment of infection involves debridement of all necrotic tissue with aggressive, adequate drainage along with antibiotic therapy. Antibiotic selection should take into account the likely causative organisms, whereas bearing in mind the potential toxicity of the agents. In the diabetic foot, the bacteria most likely responsible for minor, non-limb threatening infections such as a cellulitis are Staphylococcus and Streptococci. Whereas more severe, deeper, and limb-threatening infections are generally the consequence of a polymicrobial infection (90). Empirical antibiotic selection should be based on the suspected bacterial pathogens along with modifications to address anticipated resistant pathogens that might have been present during earlier episodes of infection. Antibiotic selection should minimize toxicity and be cost effective. Broad spectrum antimicrobial therapy should be initiated empirically with reassessment following the results of culture data. The main antibiotic regimens for initial empiric therapy that are used in our unit is shown in Table 1 (91).

The duration of antimicrobial therapy for severe soft tissue infections of the foot is based on response to the antibiotics and wound care. Two weeks of therapy is the usual guideline, however, recalcitrant infections might require longer courses. Even if the ulcer has not fully healed, antibiotics can be discontinued when evidence of infection has resolved. Continuation of antibiotics beyond this duration has not demonstrated any effect on wound healing (92,93).

Wound Care

The effective use of dressings is essential to ensure the optimal management of diabetic foot ulcers. In recent years, the concept of a clean, moist, wound-healing environment has been widely accepted. Benefits to this approach include prevention of tissue dehydration and cell death, acceleration of angiogenesis, and facilitating the interaction of growth factors with the target cells (94). In addition, patients have reported less discomfort with moist wound dressings. The notion that a moist wound environment increases the risk of developing an infection appears to be unfounded. There are a multitude of wound care products available in the market that promote moist wound healing, however, wet-to-dry normal saline gauze remains the standard of care.

Advanced Wound Care Products

Advanced wound care products have been developed in response to an improved understanding of the impaired wound healing integral in the diabetic foot ulcer. A greater understanding of wound pathophysiology with deficiencies, such as decreased growth factors production and altered cellular inactivity have led to the development of products that address these deficiencies. These include recombinant platelet-derived growth factor and biological skin substitutes.

Recombinant human PDGF-BB (becaplermin) is the only growth factor to date approved by the US Food and Drug Administration for the treatment of diabetic foot ulcers. PDGF-B is a potent mitogen and chemotactic agent for connective tissue and stromal cells and may act to increase the wound vascularization by stimulating endothelial cell proliferation, movement, and tube formation. Levels of PDGF have been shown to be lower in chronic wounds (95). Becaplermin as it is known, is formulated as a gel to help maintain proper moisture balance. It was found to increase both the incidence of complete wound closure and decreased the time to achieve complete wound healing (96).

Biological skin substitutes, also known as living skin equivalents (LSE), are commercially available. The LSEs are produced through tissue-engineering technology. Available for epidermal, dermal, and composite (epidermal and dermal) wounds, LSEs offer distinct advantages compared with traditional skin grafting as their use is nonin-vasive, does not require anesthesia, can be performed in an outpatient setting, and avoids potential donor site complications, such as infection and scarring (97). Two LSEs were approved for use in diabetic foot ulcers, Dermagraft (Advanced Tissue Sciences Inc, La Jolla, CA) and Apligraf (Novartis Pharmaceutical Corp., Basel). Dermagraft consists of neonatal dermal fibroblasts cultured in vitro onto a bioabsorbable polyglactin mesh, producing a living, metabolically active tissue containing the normal dermal matrix proteins and cytokines. Dermagraft has been shown to incorporate quickly into the wound with good vascularization and with no adverse side-effects (98,99). In a prospective randomized multicenter study, Dermagraft-treated ulcers were shown to compare favorably with more complete and rapid healing. Along with the added benefit of a reduction in the ulcer recurrence rate compared with conventional therapy (100). Dermagraft has since been discontinued.

Apligraf is considered a composite graft, containing both epidermal and dermal components. The outer layer consists of allogenic human keratinocytes constructed with an inner dermal layer consisting of human fibroblasts on type 1 collagen dispersed in a protein matrix. Apligraf histologically resembles human skin, but it does not contain structures, such as blood vessels, hair follicles, or sweat glands. Interestingly, Apligraf acts like human skin, producing all the cytokines and growth factors produced by normal skin during the wound healing process (101). In diabetic foot ulcers, Apligraf was shown to significantly increase the wound healing rate as well as decreasing the median time to complete wound closure (102,103). Ulcer recurrence rate was similar in both Apligraf-treated ulcers and standard treatment groups (103).

The exact mechanism of action of Dermagraft and Apligraf is not completely understood. It is believed that improved wound healing is because of filling of the wound with extracellular matrix proteins and with the subsequent induction, and expression of growth factors and cytokines necessary for wound healing. Additionally, the matrix components might further facilitate the recruitment of cells to the wound to enhance wound healing.

Although, advanced wound care products can increase the rate of complete wound healing, they carry the disadvantage of being very expensive, to the extent that their use is prohibited in some societies with limited resources. However, even in prosperous societies their use is not recommended in all patients as they carry a heavy economic cost. Therefore, they are not considered a first line agent. The current consensus is that they should be utilized only in cases that are likely to fail standard care. The identification of such patients is therefore very important as it can help individual patients heal their ulcers, whereas at the same time do not impose an economical burden on the society.

Observing the changes in wound area during a 4-week period, whereas intensive standard care is administered, is the best currently available method to identify the patients who do not respond to standard care and are more likely to benefit by advanced care wound products (Fig. 8). The wound area is calculated by measuring the maximal width and length of the ulcer. Patients who fail to reduce the wound area by 50% during this period are unlikely to achieve complete wound closure in the next few months and should be selected for additional advanced treatment (104). Therefore, patients who exceed the 50% reduction should be expected to heal in a reasonable period of time and should continue to receive standard care. However, in those patients where ulcer area reduction slows to less than 50%, their progress must be monitored carefully as a change in their wound care may need to be considered.

Treatment by Ulcer Severity

Treatment of the diabetic foot ulcer requires a thorough assessment of factors such as size, depth, location, and presence/absence of infection or ischemia. The location of the ulcer is a clue to the etiology of the wound and offloading measures necessary to minimize motion at the ulcer site. Size will help in determining the length of time required for wound healing. Depth is very important in determining the proximity of adjacent structures. The presence of infection should be addressed with appropriate antibiotic therapy or surgical incision and drainage when required. Ischemic ulcers demand revascularization techniques in order for wound healing to proceed.

Fig. 8. Mean percent ulcer area reduction during the first 4 weeks of a prospective study that followed up a large number of patients for a 12-week period. Patients who completely healed their ulcer during the 12-week period of the study are characterized as Healers and those who failed to heal their ulcer as nonhealers. The ulcer area was measured by multiplying the length by the width of the ulcer. During the first 4 weeks of the study, the Healers had a mean percent ulcer area reduction of 82% (95% CI 70-94) significantly higher to that of the nonhealers who had a 25% reduction (95% CI 15-35, p < 0.001). The midpoint between the percentage area reduction from baseline at 4 weeks in patients healed against those not healed at 12 weeks was 53%. Subjects with an ulcer area reduction above the 4-week median had a 12-week healing rate of 58%, whereas those less than that had a healing rate of only 9% (p < 0.01). Thus, patients who fail to reduce their ulcer area half over a 4-week period should be considered as to be unlikely to heal and the use of advanced wound care products may be justifiable (from ref. 100).

Fig. 8. Mean percent ulcer area reduction during the first 4 weeks of a prospective study that followed up a large number of patients for a 12-week period. Patients who completely healed their ulcer during the 12-week period of the study are characterized as Healers and those who failed to heal their ulcer as nonhealers. The ulcer area was measured by multiplying the length by the width of the ulcer. During the first 4 weeks of the study, the Healers had a mean percent ulcer area reduction of 82% (95% CI 70-94) significantly higher to that of the nonhealers who had a 25% reduction (95% CI 15-35, p < 0.001). The midpoint between the percentage area reduction from baseline at 4 weeks in patients healed against those not healed at 12 weeks was 53%. Subjects with an ulcer area reduction above the 4-week median had a 12-week healing rate of 58%, whereas those less than that had a healing rate of only 9% (p < 0.01). Thus, patients who fail to reduce their ulcer area half over a 4-week period should be considered as to be unlikely to heal and the use of advanced wound care products may be justifiable (from ref. 100).

The treatment of ulcers based on grade, as delineated by the Wagner classification, will be presented here. It is important to note that as a general rule, Wagner grades 0 and 1 and the vast majority of grade 2 ulcers are largely managed on an outpatient basis whereas Wagner grades 3, 4, and 5 might require hospitalization. Table 2 describes the management of specific Wagner classified foot ulcers based on treatment rendered and medical personnel involved.

Wagner Grade 0

As mentioned earlier, all patients identified as being at risk of developing foot ulceration should be classified as grade 0. The management of the grade 0 foot consists primarily of patient education and regular foot care in an effort to prevent the development of foot ulceration. The patients should be informed of the risks associated with the neuropathic foot along with the early signs and symptoms of infection. In addition, the need of regular foot care by a specialist and the avoidance of certain dangerous self-care interventions should be emphasized. Daily inspection of the foot by the patient or a member of his close environment is critical. Diabetic literature with simple and easily understood guidelines is available worldwide by various sources and all patients should have access to this information.

Regular visits for podiatric care should be part of the patients healthcare management. Clinical inspection of the feet should be performed with evaluation of vascular perfusion to the foot. Hyperkeratotic lesions, such as corns and calluses should be

Table 2

Principles of Treatment and Medical Personnel Involved in Diabetic Foot Ulcers Based on the Wagner Classification

Table 2

Principles of Treatment and Medical Personnel Involved in Diabetic Foot Ulcers Based on the Wagner Classification

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  • tom
    What is a wagner pressure ulcer?
    9 years ago

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