Classification, Diagnosis, and Management of Neuropathic Diabetic Foot Ulcers

Abstract

Foot ulcers affect 15% of the diabetic population at some time in their lives, and precede 85% of amputations of the diabetic foot or leg. The most important risk factor for ulceration and infection of the diabetic foot appears to be peripheral neuropathy, which, when accompanied by peripheral vascular disease, is highly conducive to failure of the soft-tissue envelope of the foot. Neuropathic ulceration accompanied by impaired arterial inflow can transform a foot wound or infection into gangrene and clinical sepsis. The Wagner-Meggitt classification facilitates treatment of the diabetic foot, and Brodsky’s depth/ischemia classification system extends this to incorporate associated peripheral vascular disease. Dorsal wounds of the foot are generally associated with direct trauma or ill-fitting footwear. Plantar ulcers are typically located over bony prominences. Foot wounds with purulent drainage or necrotic tissue require sharp debridement. If this leaves a nonfunctional foot, amputation should be done. Off-loading is critical to treating diabetic foot wounds and can be accomplished with footwear lined with pressure-dissipating materials or with a total-contact cast. A Charcot deformity may require exostectomy. Numerous dressings and other preparations, skin substitutes, and negative-pressure wound therapy have enhanced the healing of treated diabetic foot wounds. Better evidence is needed before hyperbaric oxygen therapy with total body immersion can be widely applied to the diabetic patient population.

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