Updated: 6/8/2021

Diabetic Foot Ulcers

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  • summary
    • Diabetic Foot Ulcers are very common lower extremity wounds that occur in diabetics with peripheral neuropathy and are responsible for 85% of lower extremity amputations.
    • Diagnosis is made clinically with presence of a plantar foot ulcer which may probe to bone. MRI studies are useful to assess for presence and extent of osteomyelitis. 
    • Treatment depends on ulcer size, ulcer thickness, ulcer location and presence of concomitant infection. 
  • Epidemiology
    • Incidence
      • approximately 12% of diabetics have foot ulcers
      • most common medical complication causing diabetics to get medical treatment
      • foot ulcers are responsible for ~85% of lower extremity amputations
    • Risk factors
      • factors associated with decreased healing potential
        • uncontrolled hyperglycemia (Hb A1C > 8.0)
        • inability to offload the affected area
        • poor circulation
        • infection
        • poor nutrition
      • factors associated with increased healing potential
        • serum albumin > 3.0 g/dL
        • total lymphocyte count > 1,500/mm3
  • Etiology 
    • Pathophysiology
      • neuropathy
        • has largest effect on diabetic foot pathology
        • sensory dysfunction leads to lack of protective sensation and is primary risk factor for ulcer development
        • autonomic dysfunction leads to drying of skin due to lack of normal glandular function
        • net effect is increased mechanical and axial stress on skin that is more prone to injury due to drying
      • angiopathy
        • lesser effect than neuropathy
        • >60% of diabetic ulcers have decreased blood flow due to peripheral vascular disease
    • Associated condition
      • infection / osteomyelitis
        • high rates of associated osteomyelitis if bone is able to be probed, or is exposed at the base of the ulcer
          • 67% of ulcers that probe to bone have osteomyelitis
      • organisms
        • usually polymicrobial
        • gram-positive
          • most common pathogens are aerobic gram positive cocci (s. aureus)
        • gram-negative
          • increased gram-negative organisms are found in chronic wounds and wounds recently treated with antibiotics
        • anaerobes
          • obligate anaerobic pathogens with ischemia or gangrene
      • deep cultures and bacterial biopsies help guide management
  • Classification
    • Wagner Classification and Treatment
      Description
      Treatment
      Grade 0
      Skin intact but bony deformities lead to "foot at risk"
      Shoe modifications with serial exams
      Grade 1
      Superficial ulcer
      Office debridement and contact casting
      Grade 2
      Deeper, full thickness extension
      Operative formal debridement and contact casting
      Grade 3
      Deep abscess formation or osteomyelitis
      Operative formal debridement and contact casting
      Grade 4
      Partial Gangrene of forefoot
      Local vs. larger amputation
      Grade 5
      Extensive Gangrene
      Amputation
    • Brodsky Depth-Ischemia Classification and Treatment
      Depth
      Classification
      Definition 
      Treatment
      0
      At risk foot, no ulceration
      Patient education, accommodative footwear, regular clinical examination
      1
      Superficial ulceration, not infected
      Off-loading with total contact cast, walking brace or special footwear
      2
      Deep ulceration, exposing tendons or joints
      Surgical debridement, wound care, off-loading, culture-specific antibiotics
      3
      Extensive ulceration or abscess
      Debridement or partial amputation, off-loading, culture-specific antibiotics
      Ischemia
      A
      Not ischemic
      B
      Ischemia without gangrene
      Non-invasive vascular testing and vascular reconstruction with angioplasty/bypass
      C
      Partial forefoot gangrene
      Vascular reconstruction and partial foot amputation
      D
      Complete gangrene
      Complete vascular evaluation and major extremity amputation
  • Presentation
    • Symptoms
      • often painless
    • Physical exam
      • depth of ulcer
        • probe for bone
      • presence of infection
        • look for cellulitis, pus
        • check for gangrene
      • assess Achilles tendon tightness
        • Silverski√∂ld test
          • improved ankle dorsiflexion with knee flexed = gastrocnemius tightness
          • equivalent ankle dorsiflexion with knee flexion and extension = Achilles tightness
      • circulation
        • assess dorsalis pedis and posterior tibialis pulses
  • Studies
    • Transcutaneous oxygen pressures (TcpO2)
      • considered Gold Standard to assess wound healing potential
      • > 30 mm Hg (or 40mmHg depending on review source cited) is a good sign of healing potential
    • ABI's and ischemic index
      • calcification in the arteries can result in inaccurate doppler flow readings
        • calcifications falsely elevate the ABI's due to decreased compliance of the calcified vessels
        • index of > 0.45 and toe pressure >45mm Hg are needed to heal amputation and >60mm Hg to heal an ulcer
  • Imaging
    • Radiographs
      • recommended views
        • AP, lateral, and oblique of foot and ankle
    • MRI
      • best for differentiating abscess from soft tissue swelling
      • difficult to differentiate infection from Charcot arthropathy on MRI
    • Bone scan
      • views
        • obtain with technetium Tc99m, gallium (Ga)67, or indium (In) 111
      • useful to differentiate between
        • soft tissue infection
        • osteomyelitis
        • Charcot arthropathy
  • Treatment
    • General
      • factors important in deciding a treatment plan include
        • angiopathic vs. neuropathic
        • deep vs. superficial
        • +/- osteomyelitis, antibiotics based on bone biopsy culture sensitivities
        • +/- pyarthrosis
    • Nonoperative
      • shoe modification
        • indications
          • prevention when signs of potential ulcers are present
        • includes deep or wide shoes, custom insoles, rocker bottom soles, etc.
        • of the available shoe only modifications, rocker sole shoes best reduce the plantar pressure on the forefoot
        • medicare will cover modifications and custom shoes/insoles yearly
      • wound care
        • indications
          • first line of treatment
        • goals of wound care and dressings
          • provide moist environment
          • absorb exudate
          • act as a barrier
          • off-load pressure at ulcer
      • total contact casting (TCC)
        • indications
          • gold standard for mechanical relief plantar ulcerations
        • contraindications
          • absolute
            • infection
          • relative
            • marginal arterial supply to affected area
            • patients unable to comply with cast care
            • patients unable to tolerate a cast (cast claustrophobia)
        • outcomes
          • if ulcer recurs, it is typically 3-4 weeks after cast removal
    • Operative
      • surgical debridement, antibiotics, contact casting +/- gastroc recession/TAL
        • indications
          • grade 3 or greater ulcers should undergo I&D with antibiotic treatment before casting
        • outcomes
          • high rates of associated osteomyelitis if bone is able to be probed, or is exposed at the base of the ulcer
      • ostectomy +/- TAL
        • indications
          • bony prominence causing internal pressure
        • technique
          • TAL indicated if tight Achilles
            • several studies have shown TAL to be effective to help heal and prevent recurrence of plantar forefoot ulcers
      • partial calcanectomy +/- TAL
        • indications
          • large heel ulcers with associated calcaneal osteomyelitis
        • outcomes
          • preserves limb length and decreases morbidity compared to higher level amputations
      • Syme amputation
        • indications
          • forefoot gangrene and a palpable posterior tibial artery pulse
      • Keller resection arthroplasty
        • indications
          • IPJ plantar neuropathic ulcer with hypomobile/stiff MTPJ that has failed total contact casting
  • Techniques
    • Total Contact Casting
      • often necessary for up to 4 months
      • TCC followed by Charcot restraint walker then custom shoe
      • pneumatic walking brace
        • alternative to TCC, same principal
        • allows better wound surveillance
        • significant deformity and/or extremely large girth often requires custom pneumatic walkers
        • patient compliance with offloading can be an issue because the pneumatic walker is removable
  • Prognosis
    • Diabetic foot ulceration is considered the most likely predictor of eventual lower extremity amputation in patients with diabetes mellitus

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(OBQ12.189) A 66-year-old male with a known history of uncontrolled Type 2 diabetes presents for follow up of a forefoot ulcer that is seen in Figure A. All of the following are strong prognostic indicators of osteomyelitis EXCEPT:

QID: 4549
FIGURES:
1

Exposed bone at ulcer site

3%

(103/3961)

2

Periarticular erosions at 1st MTP joint

11%

(454/3961)

3

Increased signal within metatarsal diaphysis on T2 weighted MRI

5%

(179/3961)

4

Increased signal within indium labeled WBC scan

3%

(116/3961)

5

Positive wound culture

78%

(3075/3961)

L 2 C

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(OBQ11.151) A 55-year-old female with longstanding type I diabetes presents for evaluation of her left foot, which is shown in Figure A. On exam, the soft tissue infection extends to the metatarsals plantarly, and there is a palpable posterior tibial artery pulse. She is otherwise medically stable, and without sepsis. Which of the following treatment options will most likely result in definitive management of her forefoot gangrene and allow the highest level of functional activity after surgery?

QID: 3574
FIGURES:
1

Transmetatarsal amputation

22%

(607/2742)

2

Below the knee amputation

7%

(194/2742)

3

Syme amputation

69%

(1901/2742)

4

Above the knee amputation

0%

(7/2742)

5

Extensive soft-tissue debridement, local wound care, and antibiotic therapy

1%

(22/2742)

L 3 C

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(OBQ10.150) A 65-year-old diabetic male presents with the foot ulcer shown in Figure A. There is no exposed bone, and no signs of infection. Pulses are palpable. What additional information should be obtained next to help guide this patient's treatment?

QID: 3238
FIGURES:
1

MRI scan with contrast

5%

(157/3116)

2

Ankle-brachial index

11%

(345/3116)

3

Results of Silfverskiold test

59%

(1833/3116)

4

Transcutaneous oxygen measurements of the toes

16%

(495/3116)

5

Hemoglobin A1C level

9%

(273/3116)

L 3 B

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(OBQ10.81) A 44-year-old male with long standing insulin dependent diabetes complains of a non-healing plantar foot ulcer. The ulcer is shown in Figure A. The second metatarsal head can be probed at the base of the wound, and he lacks plantar sensation. Laboratory work-up for infection is negative. Which of the following is the best initial treatment?

QID: 3169
FIGURES:
1

Ray resection and primary wound closure

3%

(73/2465)

2

Oral antibiotics and local wound care

2%

(38/2465)

3

Local wound care and non-weight bearing in a removable boot

23%

(569/2465)

4

Surgical debridement, dressing changes, and IV antibiotics

54%

(1323/2465)

5

Transmetatarsal amputation

18%

(455/2465)

L 4 B

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(OBQ10.261) A 44-year-old man with diabetes mellitus has a non-healing Wagner grade 1 ulcer shown in Figure A for the past 8 months. Conservative management with total contact casting has not resolved the ulcer. Physical examination reveals loss of protective sensation by Semmes-Weinstein testing, no signs of infection, positive Silfverskiold test indicating gastrocnemius contracture, and palpable pedal pulses. What is the next most appropriate step in management?

QID: 3358
FIGURES:
1

Integra artificial dermis placement followed by split thickness skin grafting

2%

(65/3213)

2

Continued total contact casting

2%

(74/3213)

3

Split thickness skin grafting to ulcer

1%

(30/3213)

4

Strayer procedure (gastrocnemius lengthening)

90%

(2885/3213)

5

Weil metatarsal decompression osteotomy

4%

(139/3213)

L 1 A

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(OBQ09.104) A 65-year-old patient with poorly controlled diabetes develops 2nd metatarsal head osteomyelitis deep to a superficial ulcer. Which of the following treatment modalities would have the highest chance of success?

QID: 2917
1

IV Vancomycin

1%

(38/2869)

2

Oral Levofloxacin

0%

(9/2869)

3

IV antibiotics based on ulcer swab culture sensitivity

2%

(48/2869)

4

IV antibiotics based on percutaneous bone biopsy culture sensitivity

94%

(2708/2869)

5

Elevation and non-weight bearing

2%

(53/2869)

L 1 C

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(OBQ09.130) A 57-year-old man taking metformin for diabetes and gabapentin for peripheral neuropathy has a superficial plantar midfoot ulcer with a clean, noninfected appearance. Total contact casting is implemented for mechanical relief. Which of the following radiographs most likely corresponds to the clinical situation described?

QID: 2943
FIGURES:
1

Figure A

0%

(8/2119)

2

Figure B

1%

(28/2119)

3

Figure C

72%

(1529/2119)

4

Figure D

8%

(163/2119)

5

Figure E

18%

(380/2119)

L 2 C

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(OBQ09.271) You are caring for a 72-year-old male with diabetes and peripheral neuropathy with a non-healing forefoot ulcer as shown in Figure A. To reduce the plantar pressure on his forefoot, which of the following shoe modifications would you suggest?

QID: 3084
FIGURES:
1

Polyethylene foam insole

8%

(186/2333)

2

Open toe sandals

0%

(3/2333)

3

Rocker sole shoes

65%

(1514/2333)

4

Custom indepth shoes

25%

(582/2333)

5

Hard postoperative shoe

2%

(40/2333)

L 3 D

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(OBQ08.253) A 55-year-old man with diabetes underwent successful casting for a neuropathic plantar foot ulcer. Within what time period after discontinuation of the cast is the ulcer most likely to recur?

QID: 639
1

2 days

0%

(9/2197)

2

1 week

5%

(110/2197)

3

1 month

54%

(1196/2197)

4

6 months

36%

(784/2197)

5

1 year

4%

(85/2197)

L 4 D

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(OBQ07.125) Which of the following variables is not predictive of poor healing of diabetic foot ulcers?

QID: 786
1

Transcutaneous oxygen pressure < 20 mmHg

2%

(49/2135)

2

Systolic blood pressure > 140 mmHg

88%

(1881/2135)

3

Ankle-brachial index < 0.45

2%

(35/2135)

4

Albumin < 3.0 g/dL

1%

(25/2135)

5

Total lymphocyte count < 1,500/mm3

6%

(136/2135)

L 1 C

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(OBQ07.90) A 45-year-old diabetic male has a Wagner type 3 heel ulcer shown in Figure A that measures 4x2cm and is recalcitrant to debridements and total contact casting for 4 months. The patient has palpable pulses, active drainage at the ulcer, and does not have protective sensation with a 5.07 Semmes-Weinstein filament. Radiograph and MRI (sagittal and axial) images are shown in Figures B-D respectively. In addition to bone culture biopsy, debridement and antibiotic therapy, what surgical intervention is most appropriate?

QID: 751
FIGURES:
1

Ankle disarticulation

4%

(98/2602)

2

Soft tissue fasciocutaneous flap coverage

7%

(177/2602)

3

Partial calcanectomy

75%

(1940/2602)

4

Below knee amputation

10%

(256/2602)

5

Soft tissue free flap coverage

4%

(114/2602)

L 2 C

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(OBQ06.224) Which of the following is least likely to predict future amputation in diabetic patients?

QID: 235
1

Diabetic foot ulceration

3%

(38/1171)

2

Loss of sensation with 5.07 Semmes-Weinstein monofillament testing

6%

(70/1171)

3

Infection

3%

(31/1171)

4

Hemoglobin A1c level of 10.7

5%

(55/1171)

5

Ankle-brachial index of 1.07

83%

(969/1171)

L 1 D

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(OBQ06.117) Which of the following is not financially covered during one calendar year for Medicare patients under the United States Therapeutic Shoe Bill?

QID: 303
1

Three pair of inserts for extra-depth shoes

23%

(246/1050)

2

Shoe wedges

6%

(68/1050)

3

Inserts for missing toes

8%

(80/1050)

4

Two pairs of custom-molded shoes

54%

(564/1050)

5

Velcro closure shoe modification

8%

(80/1050)

L 4 D

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(OBQ06.158) A 62-year-old diabetic female presents with a Wagner grade 1 foot ulcer. Upon examination of the foot, no dorsalis pedis pulse is palpable. Each of the following noninvasive vascular tests indicate a good prognosis for ulcer healing EXCEPT:

QID: 344
1

Triphasic waveforms

2%

(22/1456)

2

Ankle-brachial indices (ABI) of 0.72

27%

(397/1456)

3

Absolute toe pressure of 45 mm Hg

3%

(46/1456)

4

Transcutaneous oxygen measurements (pO2) of 15mm Hg

64%

(938/1456)

5

Presence of hair on the toes

3%

(45/1456)

L 2 D

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(OBQ06.54) Which of the following patients with type 2 diabetes mellitus is most likely to develop a foot ulcer?

QID: 165
1

54-year-old female unable to feel the presence of a 5.07 Semmes-Weinstein monofilament on the plantar aspect of the foot

78%

(835/1073)

2

63-year-old male with transcutaneous oxygen pressures (TcpO2) of 30 mm Hg

4%

(46/1073)

3

51-year-old male with ratio of ankle to brachial pressures of < 0.6

14%

(153/1073)

4

71-year-old male with serum albumin of 3.1 g/dL

0%

(5/1073)

5

60-year-old with autonomic dysfunction leads to drying of skin due to lack of normal glandular function

2%

(25/1073)

L 2 D

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(OBQ05.20) A 34-year-old patient is noted to have a lack of ankle dorsiflexion by 5 degrees with knee extension as seen in Figure A. However, the ankle dorsiflexion improves to 20 degrees with knee flexion as seen in Figure B. Which of the following diagnoses would benefit MOST from a gastrocnemius recession (Strayer procedure)?

QID: 57
FIGURES:
1

Chronic peroneal tendonitis

10%

(301/2944)

2

Freiberg's infraction

3%

(87/2944)

3

Chronic retrocalcaneal bursitis

6%

(185/2944)

4

Chronic calcaneal osteomyelitis

1%

(31/2944)

5

Chronic plantar forefoot ulcer

79%

(2318/2944)

L 2 B

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(OBQ04.84) A 37-year-old man with type-1 diabetes mellitus reports a 3-month history of a plantar foot ulcer shown in Figure A. His pulses are palpable and sensation to a 5.07 Semmes-Weinstein monofilament is absent on the entire plantar surface of the foot. There is no erythema or drainage and there is no bone encountered during probing of the ulcer. There is no fever and the white blood cell count is normal. The C-reactive protein and erythrocyte sedimentation rate are normal. What is the most appropriate next step in treatment?

QID: 1189
FIGURES:
1

Total contact casting and empiric IV antibiotics

3%

(65/1965)

2

Surgical debridement, dressing changes, and empiric IV antibiotics

3%

(62/1965)

3

Charcot restraint orthotic walker (CROW)

5%

(101/1965)

4

Surgical debridement, dressing changes, biopsy, and culture specific IV antibiotics

8%

(167/1965)

5

Total contact casting

79%

(1557/1965)

L 2 C

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