best practice guidelines: wound management in diabetic foot ulcers

ASSESSING DFUsFIGURE 7: Areas at risk for DFU (adaptedfrom 7 )Corrective foot surgery to offload pressureareas may be considered where structuraldeformities cannot be accommodated bytherapeutic footwear.CLASSIFICATION OF DFUsClassification systems grade ulcers accordingto the presence and extent of various physicalcharacteristics, such as size, depth, appearanceand location. They can help in the planningand monitoring of treatment and in predictingoutcome 17,58 , and also for research and audit.Classification systems should be used consistentlyacross the healthcare team and berecorded appropriately in the patient’s records.However, it is the assessment of the woundthat informs management.Table 3 summarises the key features of thesystems most commonly used for DFUs.FIGURE 8: Charcot foot.Top — Charcot foot with plantarulcer. Middle — Charcot footwith sepsis. Bottom — ChronicCharcot footCharcot joint is a form of neuroarthropathythat occurs most often in the foot and in peoplewith diabetes 57 . Nerve damage from diabetescauses decreased sensation, muscle atrophyand subsequent joint instability, which is madeworse by walking on an insensitive joint. In theacute stage there is inflammation and bonereabsorption, which weakens the bone. In laterstages, the arch falls and the foot may developa ‘rocker bottom’ appearance (Figure 8). Earlytreatment, particularly offloading pressure,can help stop bone destruction and promotehealing.TABLE 3: Key features of common wound classification systems for DFUsClassificationsystemWagnerUniversity ofTexas(Armstrong)PEDISSINBADKey points Pros/cons ReferencesAssesses ulcer depth along with presenceof gangrene and loss of perfusion using sixgrades (0-5)Assesses ulcer depth, presence of infectionand presence of signs of lower-extremityischaemia using a matrix of four gradescombined with four stagesAssesses Perfusion, Extent (size), Depth(tissue loss), Infection and Sensation (neuropathy)using four grades (1-4)Assesses Site, Ischaemia, Neuropathy, Bacterialinfection and DepthUses a scoring system to help predictoutcomes and enable comparisons betweendifferent settings and countriesWell established 58Does not fully address infection and ischaemiaWell established 58Describes the presence of infection and ischaemiabetter than Wagner and may help in predicting theoutcome of the DFUDeveloped by IWGDFUser-friendly (clear definitions, few categories) forpractitioners with a lower level of experience withdiabetic foot managementWagner 1981 59Lavery et al 1996 60Armstrong et al1998 52Lipsky et al 2012 46Simplified version of the S(AD)SAD classification Ince et al 2008 63system 61Includes ulcer site as data suggests this might bean important determinant of outcome 6238 BEST PRACTICEBEST PRACTICEGUIDELINESGUIDELINES:FOR SKINWOUNDAND WOUNDMANAGEMENTCARE ININEPIDERMOLYSISDIABETIC FOOTBULLOSAULCERS