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 login to view 5 more bullets factors associated with increased healing potential login to view 2 more bullets modifiable risk factors for prevention of amputation login to view 2 more bullets Etiology Pathophysiology neuropathy login to view 4 more bullets angiopathy login to view 2 more bullets Associated condition infection / osteomyelitis login to view 2 more bullets organisms login to view 7 more bullets deep cultures and bacterial biopsies help guide management and remain gold standard for diagnosis 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 login to view 1 more bullet presence of infection login to view 2 more bullets assess Achilles tendon tightness login to view 3 more bullets circulation login to view 1 more bullet 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 login to view 2 more bullets Imaging Radiographs recommended views login to view 1 more bullet MRI best for differentiating abscess from soft tissue swelling difficult to differentiate infection from Charcot arthropathy on MRI Bone scan views login to view 1 more bullet useful to differentiate between login to view 3 more bullets Treatment General factors important in deciding a treatment plan include login to view 4 more bullets Nonoperative shoe modification login to view 5 more bullets wound care login to view 7 more bullets total contact casting (TCC) login to view 11 more bullets negative pressure wound therapy login to view 1 more bullet Operative Flexor tendon tenotomy login to view 4 more bullets surgical debridement, antibiotics, contact casting +/- gastroc recession/TAL login to view 5 more bullets ostectomy +/- TAL login to view 5 more bullets partial calcanectomy +/- TAL login to view 4 more bullets Syme amputation login to view 2 more bullets Keller resection arthroplasty login to view 2 more bullets Techniques Total Contact Casting often necessary for up to 4 months TCC followed by Charcot restraint walker then custom shoe pneumatic walking brace login to view 4 more bullets Prognosis Diabetic foot ulceration is considered the most likely predictor of eventual lower extremity amputation in patients with diabetes mellitus