if possible and probable amputation
surgeon, rehabilitation therapy
debrided at these visits. Shoes and socks should be evaluated to determine if they are adequate. Extra-depth diabetic shoes and custom-molded inserts both serve to protect osseous prominences and also effectively reduce plantar foot pressures (105). High foot pressures often present on the plantar aspect of the forefoot can also be reduced with the use of padded socks (106).
A Grade 1 ulceration is defined as one that has penetrated beyond the epidermis. The presence of sensory neuropathy and at least one other risk factor is common. The ulcer should be evaluated for size, depth, location, and any signs of infection. The presence of drainage, as well as the type of drainage should be noted. The treatment of a Wagner grade 1 ulcer includes debridement of all nonviable tissue, local wound care, offloading of pressures, and antibiotic therapy if infection is poresent. Sharp debride-ment of the ulcer should be performed as previously discussed in this chapter. Following debridement, the foot must be off-loaded to minimize pressure and motion at the site of ulceration although, the patient continues to ambulate. Patients must also be counseled to limit ambulation and to use crutches if necessary. The authors commonly use the felted foam dressing for offloading. This method is easy to perform, relatively inexpensive, and reproducible. Wound care can be performed through a window in the felted foam dressing.
Ulcerations that recur might warrant surgical correction of any underlying structural deformity. Surgical procedures, such as digital arthroplasties, metatarsal osteotomies, metatarsal head resections, and mid- and hindfoot exostectomies, have all proved useful in the prevention of recurrent ulcerations (107-111).
Grade 2 is a full thickness ulcer that penetrates beyond the dermis with involvement of deeper structures, such as tendons, ligaments, or joint capsules. The management of such ulcers is usually based on an outpatient basis although hospitalization can be considered in deep wounds that expose tendons and complications such as peripheral vascular disease, and infection is suspected.
Outpatient care for the full thickness ulcer that has anon-infected granulating basis is similar to the grade 1 ulceration described earlier. Broad spectrum antibiotics might be added in case infection is suspected and dressing changes might be performed more often in cases of heavy exudates. Advanced wound care products may be considered for patients who are not exhibiting a satisfactory progress using the previously described criteria. Patients with grade 2 ulcerations treated as outpatients if necessary must be directed to aggressively offload the foot using crutches. With deeper structures in such close proximity, optimal patient compliance is necessary to avoid furthermore complications, such as cellulitis, abscess formation, and osteomyelitis.
Involvement of deep structures to the base of the ulcer should be managed with aggressive debridement, complete bed rest, empiric use of broad-spectrum antibiotics, and occasionally hospitalization (112). The foot may require surgical debridement in order to remove all necrotic and nonviable tissue that may impede granulation tissue. Debridement should be carried out until there is evidence of healthy, red, granulation tissue to the base. Additionally, all sinus tracts should be explored and drained. Intraoperative deep cultures should be taken for identification of the pathogen responsible for infection.
In the event that vascular insufficiency is suspected, incision and drainage of the infected foot should not be delayed. Adequate drainage of the infected foot is paramount to limb salvage. Delaying of surgical drainage may lead to furthermore tissue loss as well as potential limb loss (113). Instead, vascular consultation should be initiated as soon as possible, even if it occurs after surgical drainage.
Grade 3 ulcerations are characterized by the presence of deep infection with bone involvement and abscess collections. Grade 3 ulcers are usually the result of grade 2 ulcers that fail to respond, aggressive bacterial infections, or puncture wounds, resulting in direct inoculation of bone. Because of the depth of these ulcers and the presence of purulent collections and bone infection, these ulcers require hospitalization with adequate drainage of all infection and debridement of all infected bone. Prolonged antibiotic therapy might be required.
Adequate drainage of infection is key in managing grade 3 ulcerations. All sinus tracts must be explored and all necrotic and nonviable tissue debrided. In cases of severe infection, open amputations of digits or rays might be required to prevent the spread of infection. Once the infection has cleared and granulation of the wound bed observed, thought can be given to coverage of the wound. In instances where soft tissue coverage is adequate, delayed primary closure can be undertaken. However, more often than not in these extensive wounds, significant soft tissue defects might be present, requiring osseous remodeling in addition to tissue flaps or skin grafts to provide wound coverage (114). No single technique can be applied universally as each case is unique. Instead, a flexible approach will maximize limb salvage.
Grade 4 ulcerations demonstrate partial foot gangrene. These ulcers are usually complicated by ischemia, osteomyelitis, and sepsis. A team approach is required in order to minimize the extent of tissue loss and prevent amputation. Consultations with vascular surgeons, podiatrists, infectious disease specialists, and plastic surgeons are essential for limb salvage. The primary goal in the management of these ulcers is to limit the extent of tissue loss.
Gangrenous changes can result from minor trauma in the face of severe arterial insufficiency or when overwhelming infection results in occlusion of digital arterial branches (11,115). Initial treatment of gangrene secondary to severe arterial insufficiency should begin with vascular assessment and when possible should be followed by revasculariza-tion (113). In severe infections resulting in local ischemia, aggressive drainage along with appropriate antibiotic therapy should be instituted to limit tissue loss.
Grade 5 ulcerations demonstrate extensive necrosis of the entire foot as a direct result of arterial insufficiency. Primary amputation is the only treatment for extensive gangrene. However, vascular assessment and revascularization should always be attempted to allow for amputation at the most distal level of the foot.
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