By Lee C. Rogers, DPM

Note to the Reader: These articles summarize the "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes," authored by Robert J. Snyder et al., published as a supplement to Ostomy Wound Management in April 2010.

Published as a supplement to the April 2010 issue of Ostomy Wound Management was a pivotal reference paper titled, "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes."¹ The authors are a recognized group of leading experts in the field who convened the consensus panel.

The world's population with diabetes will increase from 171 million to 366 million by 2025.² In the U.S., there are an estimated 24 million people with diabetes. Up to 25% of those with diabetes will develop a foot ulcer in their lifetimes.³ That translates roughly to 1-2% of the diabetic patients per year.

Diabetic foot ulcers (DFU) and lower extremity amputations (LEA) are a costly problem. In 2007, it was estimated that $30 billion was spent for the care of those two conditions.⁴

The recommendations from the consensus panel are important because they help to update the standard of care based on a review of 111 studies. The recommendations are divided into three categories: Assessment, Treatment, Advanced Therapies.

In this issue we will look at recommendations on assessment of the diabetic foot ulcer.

The team approach to assessment and management of the DFU is recognized as the standard of care. No physician "is an island", and the co-morbidities within the diabetic foot cross multiple physician disciplines. A thorough history should be performed. Since wound healing delays can occur with anemia, renal insufficiency, and uncontrolled blood sugar, a CBC and HbA1c should be performed at baseline. If osteomyelitis is suspected, erythrocyte sedimentation rate (ESR) and (CRP) should be ordered.

The patient's nutritional status should be assessed by history and serum pre-albumin. Historical concerns are unintentional weight loss, chronic alcohol use, and problems chewing or swallowing. Smoking is a risk factor for peripheral arterial disease (PAD) and delays wound healing. One should remember the four A's of smoking cessation: Ask about smoking, Advise to quit, offer Assistance, Arrange follow-up.

Neurologic screening should consist of 10 gram monofilament and 128-Hz tuning fork tests. Vascular evaluation is more complicated. There is no single test that can completely evaluate vascular health. Palpation of pulses or ante brachial index (ABI) cannot be relied upon in this population. The absence of pulses is a good indicator of poor flow, but the presence of pulses cannot rule out arterial insufficiency. The toe brachial index (TBI) is less susceptible to false readings due to diabetic arterial calcification. Skin perfusion pressure (SPP) measures capillary pressure in the skin and is very sensitive at uncovering vascular disease in diabetics as well as predicting wound healing. Transcutaneous oximetry (TCPO2) can validate referral for hyperbaric oxygen. Vascular imaging tests should be performed by an appropriate specialist if there is reasonable suspicion of underlying vascular disease.

The foot examination should include assessment of dermatologic changes, musculoskeletal deformities, and ulcer evaluation. Dermatologic changes can show inflammation by thermometry or thermography. Also, it can reveal ischemia by the presence of purpura, fat atrophy, loss of hair growth, or taut skin. The podiatrist is a key member of the team for understanding the biomechanical abnormalities that lead to ulceration. Range of motion of the ankle and first metatarsophalangeal joints should be assessed for restriction in dorsi-flexion. Inspect for deformities associated with Charcot joint disease.

Radiography is useful to help uncover osteomyelitis or deformities. The foot should be x-rayed at baseline and it is appropriate to perform bilateral x-rays for comparison.

The wound assessment and documentation includes size, depth, shape, probing, undermining, condition of the wound bed, and condition of the periwound area. One should use a standard wound classification scheme. The consensus panel recommends use of the University of Texas Classification.⁵

Infection is devastating to the diabetic foot and its evaluation is primarily clinical. Heat, redness, pain, and swelling are the classic symptoms. The diabetic neuropathic patient does not always exhibit all those signs, so one should be aware of secondary signs like exudate, delayed healing, discolored granulation tissue, and malodor. Culture should only be taken if the clinician suspects infection.