How are ulcers classified

Apart from their classification to plain neurotrophic, plain ischaemic and neuroischaemic ulcers, as mentioned earlier, there are two classification systems for the severity of the ulcers. Traditionally, classification by Meggitt-Wagner was considered as the 'classification of choice'. Relatively recently, however, a new classification system was proposed by the University of Texas in the USA, which is considered to be superior. Its main advantage is that it takes into consideration the presence of infection and ischaemia in the more superficial ulcers, two factors that are related to outcome and survival. Furthermore, this newer classification scheme was evaluated in a prospective study and was found to predict outcome (Tables 17.3 and 17.4).

Table 17.3. The Meggitt-Wagner ulcer classification system

Degree Description of ulcer

0 Completely healed ulcer

1 Superficial ulcer in the epidermis that is not extended in the chorion

2 Ulcer that extends in the subcutaneous tissue or even beyond it (tendons, fascia, synovium) without, however, abscesses or osteomyelitis

3 Deep ulcer with osteomyelitis or formation of abscess

4 Gangrene localized in the toes or the forefoot

5 Extensive gangrene

CASE STUDY 2

A 68 year old woman with a chronic neurotrophic ulcer in the 3rd metatarsal head for six months, comes to the diabetic foot clinic for re-evaluation. She has an ulcer 2 x 3 cm in diameter and 1 cm in depth. It is foul smelling and the surface is dirty, with accompanying cellulitis extending 3 cm around it. She denies any pain and receives no antibiotics. Her temperature is normal and she

Table 17.4. The University of Texas ulcer classification system

Stage 0

Ulcer completely healed

With infection With ischaemia

Superficial ulcer, without involvement of tendons, synovial membranes or bone With infection With ischaemia

With infection With infection

Ulcer with involvement of tendons or synovial membranes

With infection With ischaemia With infection

Ulcer with involvement of joints or bone

With infection With ischaemia With infection and ischaemia and ischaemia and ischaemia and ischaemia wears special therapeutic shoes for decompression of the ulcer area. How should this patient be managed?

It is obvious that the ulcer has been complicated by an infection. In this case, thorough debridement and curettage of the ulcer base is indicated, followed by culture of the deep tissues inside it (this is preferable to obtaining culture by swabbing the ulcer surface) with fast dispatch of the specimens to the laboratory for identification of the inciting aerobic and/or anaerobic pathogens. When clinical signs of infection are present, empirical initiation of antibiotic treatment is indicated, while awaiting the results of the culture. However, when the ulcer shows no signs of infection, no culture should be sent and, most importantly, no antibiotics should be prescribed.

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