Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation.

doi:10.2337/DIACARE.21.5.855

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Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation.

Journal Article•DOI•

Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation.

David G. Armstrong¹, Lawrence A. Lavery, Lawrence B. Harkless•Institutions (1)

University of Texas Health Science Center at San Antonio¹

01 May 1998-Diabetes Care (DIABETES CARE)-Vol. 21, Iss: 5, pp 855-859

TL;DR: Outcomes deteriorated with increasing grade and stage of wounds when measured using the University of Texas Wound Classification System and a significant overall trend toward increased prevalence of amputations was seen.

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Abstract: OBJECTIVE To validate a wound classification instrument that includes assessment of depth, infection, and ischemia based on the eventual outcome of the wound. RESEARCH DESIGN AND METHODS We evaluated the medical records of 360 diabetic patients presenting for care of foot wounds at a multidisciplinary tertiary care foot clinic. As per protocol, all patients had a standardized evaluation to assess wound depth, sensory neuropathy, vascular insufficiency, and infection. Patients were assessed at 6 months after their initial evaluation to see whether an amputation had been performed. RESULTS There was a significant overall trend toward increased prevalence of amputations as wounds increased in both depth (χ 2 trend = 143.1, P 2 trend = 91.0, P P 2 = 31.5, odds ratio (OR) = 11.1, CI = 4.0–30.3). Patients with infection and ischemia were nearly 90 times more likely to receive a midfoot or higher amputation compared with patients in less advanced wound stages (76.5 vs. 3.5%, P 2 = 133.5, OR = 89.6, CI = 25–316). CONCLUSIONS Outcomes deteriorated with increasing grade and stage of wounds when measured using the University of Texas Wound Classification System.

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Journal Article•DOI•

Preventing Foot Ulcers in Patients With Diabetes

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Nalini Singh¹, David G. Armstrong, Benjamin A. Lipsky¹•Institutions (1)

University of Washington¹

12 Jan 2005-JAMA

TL;DR: Substantial evidence supports screening all patients with diabetes to identify those at risk for foot ulceration and recommending certain prophylactic interventions, including patient education, prescription footwear, intensive podiatric care, and evaluation for surgical interventions.

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Abstract: ContextAmong persons diagnosed as having diabetes mellitus, the prevalence of foot ulcers is 4% to 10%, the annual population-based incidence is 1.0% to 4.1%, and the lifetime incidence may be as high as 25%. These ulcers frequently become infected, cause great morbidity, engender considerable financial costs, and are the usual first step to lower extremity amputation.ObjectiveTo systematically review the evidence on the efficacy of methods advocated for preventing diabetic foot ulcers in the primary care setting.Data Sources, Study Selection, and Data ExtractionThe EBSCO, MEDLINE, and the National Guideline Clearinghouse databases were searched for articles published between January 1980 and April 2004 using database-specific keywords. Bibliographies of retrieved articles were also searched, along with the Cochrane Library and relevant Web sites. We reviewed the retrieved literature for pertinent information, paying particular attention to prospective cohort studies and randomized clinical trials.Data SynthesisPrevention of diabetic foot ulcers begins with screening for loss of protective sensation, which is best accomplished in the primary care setting with a brief history and the Semmes-Weinstein monofilament. Specialist clinics may quantify neuropathy with biothesiometry, measure plantar foot pressure, and assess lower extremity vascular status with Doppler ultrasound and ankle-brachial blood pressure indices. These measurements, in conjunction with other findings from the history and physical examination, enable clinicians to stratify patients based on risk and to determine the type of intervention. Educating patients about proper foot care and periodic foot examinations are effective interventions to prevent ulceration. Other possibly effective clinical interventions include optimizing glycemic control, smoking cessation, intensive podiatric care, debridement of calluses, and certain types of prophylactic foot surgery. The value of various types of prescription footwear for ulcer prevention is not clear.ConclusionsSubstantial evidence supports screening all patients with diabetes to identify those at risk for foot ulceration. These patients might benefit from certain prophylactic interventions, including patient education, prescription footwear, intensive podiatric care, and evaluation for surgical interventions.

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2,469 citations

Journal Article•DOI•

Challenges in the Treatment of Chronic Wounds.

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Robert G. Frykberg, Jaminelli Banks

01 Sep 2015-Advances in wound care

TL;DR: The pathophysiology of complex chronic wounds and the means and modalities currently available to achieve healing in such patients are discussed, with a focus on diabetic foot ulcers.

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Abstract: Significance: Chronic wounds include, but are not limited, to diabetic foot ulcers, venous leg ulcers, and pressure ulcers. They are a challenge to wound care professionals and consume a great deal of healthcare resources around the globe. This review discusses the pathophysiology of complex chronic wounds and the means and modalities currently available to achieve healing in such patients. Recent Advances: Although often difficult to treat, an understanding of the underlying pathophysiology and specific attention toward managing these perturbations can often lead to successful healing. Critical Issues: Overcoming the factors that contribute to delayed healing are key components of a comprehensive approach to wound care and present the primary challenges to the treatment of chronic wounds. When wounds fail to achieve sufficient healing after 4 weeks of standard care, reassessment of underlying pathology and consideration of the need for advanced therapeutic agents should be undertaken. However, selection ...

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1,321 citations

Journal Article•DOI•

2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections

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Benjamin A. Lipsky¹, Anthony R. Berendt², Paul B. Cornia¹, James C. Pile³, Edgar J G Peters⁴, David G. Armstrong⁵, H. Gunner Deery, John M. Embil⁶, Warren S. Joseph⁷, Adolf W. Karchmer⁸, Michael S. Pinzur⁹, Eric Senneville - Show less +8 more•Institutions (9)

University of Washington¹, Nuffield Orthopaedic Centre², MetroHealth³, VU University Medical Center⁴, University of Arizona⁵, University of Manitoba⁶, Memorial Hospital of South Bend⁷, Beth Israel Deaconess Medical Center⁸, Loyola University Medical Center⁹

15 Jun 2012-Clinical Infectious Diseases

TL;DR: Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs, and Employing multidisciplinary foot teams improves outcomes.

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Abstract: Foot infections are a common and serious problem in persons with diabetes Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations) This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy) Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation) Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures Employing multidisciplinary foot teams improves outcomes Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs

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1,288 citations

Cites background from "Validation of a diabetic wound clas..."

...• University of Texas (UT) ulcer classification [47]—This system has a combined matrix of 4 grades (related to the...
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...rate in wounds deeper than superficial ulcers [47]....
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Journal Article•DOI•

The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: Risk stratification based on Wound, Ischemia, and foot Infection (WIfI)

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Joseph L. Mills¹, Michael S. Conte², David G. Armstrong¹, Frank B. Pomposelli, Andres Schanzer³, Anton N. Sidawy⁴, George Andros - Show less +3 more•Institutions (4)

University of Arizona¹, University of California, San Francisco², University of Massachusetts Medical School³, George Washington University⁴

01 Jan 2014-Journal of Vascular Surgery

TL;DR: The implementation of this classification system is intended to permit more meaningful analysis of outcomes for various forms of therapy in this challenging, but heterogeneous population.

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1,006 citations

Cites background from "Validation of a diabetic wound clas..."

...Yes, cutoffs for CLI; Category 4: Resting AP <40 mm Hg; Flat or barely pulsatile ankle or forefoot PVR; TP <30 mm Hg Category 5/6: AP <60 mm Hg; flat or barely pulsatile ankle or forefoot PVR; TP <40 mm Hg No Pure ischemia model PAD classification system includes milder forms of PAD (categories 1-3); Categories 4-6 based on cutoff values for CLI; No spectrum of ischemia, does not acknowledge potential need for revascularization with <CLI cutoff depending on wound extent/infection; Not intended for patients with diabetes; Wound classes not sufficiently detailed; Omits infection as a trigger Cutoff values for CLI based on European consensus document: Ischemic rest pain >2 weeks with AP <50 mm Hg or TP <30 mm Hg ulcer and gangrene; AP <50 mmHg, TP <30 mmHg, absent pedal pulses in patient with diabetes No Pure ischemia model; No clear definitions of spectrum of hemodynamics; Minimal description of wounds; Infection omitted Yes, 3 grades; CLI cutoff Grade 1: no PAD symptoms, ABI >0.9, TBI >0.6, TcPO2 >60 mm Hg; Grade 2: PAD symptoms, ABI <0.9, AP >50 mm Hg, TP >30 mm Hg, TcPO2 30- 60 mm Hg; Grade 3: AP <50 mm Hg, TP <30 mm Hg, TcPO2 <30 mm Hg Yes, grades 1-4; see IDSA classification (Table II) Primarily intended for DFUs; Ulcer grades validated; Includes perfusion assessment, but with cutoff for CLI; Gangrene not separately categorized; Includes validated IDSA infection categories Yes 6 based on ABI <0.8 Yes, 6 wounds with frank purulence or >2 of the following (warmth, eythema, lymphangitis, edema, lymphadenopathy, pain, loss of function) considered infected Primarily intended for DFUs; Includes validated ulcer categories; PAD and infection included, but only as 6 with no grades/spectrum No No for soft tissue component; included only as osteomyelitis Orthopedic classification intended for diabetic feet; No hemodynamics; Gangrene from infection not differentiated from that due to ischemia; Osteomyelitis included; Soft tissue infection not separated from bone infection Pulse palpation only, no hemodynamics Yes, 1 ¼ no infection; 2 ¼ cellulitis; 3 ¼ osteomyelitis Intended for DFUs; Also includes neuropathy; Does not mention gangrene; No hemodynamic information; Perfusion assessment based on pulse palpation only Yes, grades 0-3; Grade 0: AP >80 mm Hg, ABI 0.9-1.2; Grade 1: AP 70-80 mm Hg, ABI 0.7-0.89, TP 55-80 mm Hg; Grade 2: AP 55-69 mm Hg, ABI 0.5-0.69, TP 30-54 mm Hg; Grade 3: AP <55 mm Hg, ABI <0.5, TP <30 mm Hg Yes, grades 0-3; Grade 0: none; Grade 1: mild. erythema 0.5-2 cm, induration, tenderness, warmth and purulence; Grade 2: moderate, erythema >2 cm, abscess, muscle tendon, joint, or bone infection; Grade 3: severe, systemic response (similar to IDSA) Detailed system intended only for DFUs; Detailed comprehensive ulcer classification system and hemodynamic categories for gradation of ischemia; Gangrene not considered separately Infection system similar to IDSA No Yes, uninfected, mild, moderate, and severe (Table II) Validated system for risk of amputation related to foot infection, but not designed to address wound depth/complexity or degree of ischemia Yes, ischemia grades 0-3; Hemodynamics with spectrum of perfusion abnormalities; No cutoff value for CLI; Grade 0: unlikely to require revascularization Yes, IDSA system (Table II) Includes PAD þ diabetes with spectrum of wounds, ischemia and infection, scaled from 0- 3; No cutoff for CLI....
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...8 are at lower risk for amputation and unlikely to require revascularization to achieve healing.(34,44,54) In these patients, wound and infection severity are the major determinants of amputation risk....
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...8), with no gradations for severity, or they mistakenly apply CLI hemodynamic criteria that were never intended to be applied to patients with DFUs.(34-49) The existing major wound classification systems (Table I) are primarily ulcer classifications, and generally do not distinguish ulcers from gangrene....
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...The diabetes prevalence was 58% in the Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL) trial,24-26 64% in the Project of Ex-Vivo Vein Graft Engineering via Transfection III (PREVENT III) trial,27 and exceeds 70% to 80% in many specialized vascular centers.28,29 Although tradition teaches that the initiating cause of foot ulceration in patients with diabetes is primarily neuropathy (loss of protective sensation and foot deformity from motor neuropathy), DFUs may be broadly categorized into three groups: purely neuropathic, purely ischemic, and neuroischemic (mixed)....
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...Based on recent studies, the prevalence of neuroischemic ulcers has steadily risen from approximately 20%-25% in the 1990s to over 50% of patients currently.23 Thus, Rutherford8 Yes, category 4/6 Category 5, minor tissue loss, nonhealing ulcer, focal gangrene with diffuse pedal ischemia Category 6, major tissue loss extending above TM level, functional foot no longer salvageable (although in practice often refers to extensive gangrene, potentially salvageable foot with significant efforts) Fontaine14 Yes, class III/IV Class IV/IV, ulcer and gangrene grouped together Class IV/IV, ulcer and gangrene grouped together PEDIS43 No Yes, grades 1-3; Grade 1: superficial full-thickness ulcer, not penetrating deeper than the dermis; Grade 2: deep ulcer, penetrating below the dermis to subcutaneous structures involving fascia, muscle or tendon; Grade 3: All subsequent layers of the foot involved including bone and/or joint (exposed bone, probing to bone) No UT34 No Yes, grades 0-3 ulcers; Grade 0: pre- or postulcerative completely epithelialized lesion; Grade 1: superficial, not involving tendon, capsule, or bone; Grade 2: penetrating to tendon/capsule; Grade 3: penetrating to bone or joint No Wagner35,36 No Grade 0: pre- or postulcerative lesion; Grade 1: partial/full thickness ulcer; Grade 2: probing to tendon or capsule; Grade 3: deep ulcer with osteitis; Grade 4: partial foot gangrene; Grade 5: whole foot gangrene Ulcer and gangrene grouped together; gangrene due to infection not differentiated from gangrene due to ischemia; also includes osteomyelitis S(AD) SAD system40 No Yes, grades 0-3 based on area and depth; Grade 0: skin intact; Grade 1: superficial, <1 cm2; Grade 2: penetrates to tendon, periosteum, joint capsule, 1-3 cm2; Grade 3: lesions in bone or joint space, >3 cm2 No Saint Elian39 No Yes, grades 1-3 based on depth; Grade 1: superficial wound disrupting entire skin; Grade 2: moderate or partial depth, down to fascia, tendon or muscle but not bone or joints; Grade 3: severe or total, wounds with bone or joint involvement, multiple categories including area, ulcer number, location and topography No IDSA42 No No No SVS Lower Extremity Threatened Limb Classification Yes, wound/clinical class 0-3 Yes, grades 0-3; Grouped by depth, location and size and magnitude of ablative/wound coverage procedure required to achieve healing Yes, grades 0-3; Grouped by extent, location and size and magnitude of ablative or wound coverage procedure required to achieve healing ABI, Ankle-brachial index; AP, ankle pressure; CLI, critical limb ischemia; DFUs, diabetic foot ulcers; IDSA, Infectious Disease Society of America; PAD, peripheral artery disease; PEDIS, perfusion, extent/size, depth/tissue loss, infection, sensation; PVR, pulse volume recording; SAD, sepsis, arteriopathy, denervation; SVS, Society for Vascular Surgery; TcPO2, transcutaneous oxygen pressure; TP, toe pressure; UT, University of Texas....
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Journal Article•DOI•

Global vascular guidelines on the management of chronic limb-threatening ischemia

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Michael S. Conte¹, Andrew W. Bradbury², Philippe Kolh³, John V. White⁴, Florian Dick⁵, Robert Fitridge⁶, Joseph L. Mills⁷, Jean-Baptiste Ricco, Kalkunte R Suresh, M. Hassan Murad⁸, Victor Aboyans, Murat Aksoy, Vlad-Adrian Alexandrescu³, David G. Armstrong⁹, Nobuyoshi Azuma¹⁰, Jill J. F. Belch¹¹, Michel Bergoeing¹², Martin Björck¹³, Nabil Chakfe, Stephen W.K. Cheng¹⁴, Joseph Dawson¹⁵, Eike Sebastian Debus¹⁶, Andrew Dueck¹⁷, Sue Duval¹⁸, Hans-Henning Eckstein¹⁹, Roberto Ferraresi, Raghvinder Gambhir²⁰, Mauro Gargiulo²¹, Patrick J. Geraghty²², Steve Goode, Bruce H. Gray²³, Wei Guo, Prem C. Gupta, Robert J. Hinchliffe²⁴, Prasad Jetty²⁵, Kimihiro Komori²⁶, Lawrence A. Lavery²⁷, Wei Liang²⁸, Robert A. Lookstein²⁹, Matthew T. Menard³⁰, Sanjay Misra⁸, Tetsuro Miyata, Greg Moneta³¹, Jose A. Munoa Prado, Alberto Munoz, Juan E. Paolini³², Manesh R. Patel³³, Frank B. Pomposelli³⁴, Richard J. Powell³⁵, Peter A Robless, Lee C. Rogers, Andres Schanzer³⁶, Peter Schneider, Spence M. Taylor⁹, Melina Vega de Ceniga, Martin Veller³⁷, Frank Vermassen³⁸, Jinsong Wang³⁹, Shenming Wang³⁹ - Show less +55 more•Institutions (39)

University of California, San Francisco¹, University of Birmingham², University of Liège³, Advocate Lutheran General Hospital⁴, Kantonsspital St. Gallen⁵, University of Adelaide⁶, Baylor College of Medicine⁷, Mayo Clinic⁸, University of Southern California⁹, Asahikawa Medical University¹⁰, University of Dundee¹¹, Pontifical Catholic University of Chile¹², Uppsala University¹³, University of Hong Kong¹⁴, Royal Adelaide Hospital¹⁵, University of Hamburg¹⁶, Sunnybrook Health Sciences Centre¹⁷, University of Minnesota¹⁸, Technische Universität München¹⁹, University of Cambridge²⁰, University of Bologna²¹, Washington University in St. Louis²², Greenville Health System²³, University of Bristol²⁴, University of Ottawa²⁵, Nagoya University²⁶, University of Texas Southwestern Medical Center²⁷, Shanghai Jiao Tong University²⁸, Icahn School of Medicine at Mount Sinai²⁹, Brigham and Women's Hospital³⁰, Oregon Health & Science University³¹, University of Buenos Aires³², Duke University³³, St. Elizabeth's Medical Center³⁴, Dartmouth College³⁵, University of Massachusetts Amherst³⁶, University of the Witwatersrand³⁷, Ghent University Hospital³⁸, Sun Yat-sen University³⁹

01 Jun 2019-Journal of Vascular Surgery

TL;DR: The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP) resulting in three stages of complexity for intervention.

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993 citations

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References

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Journal Article•DOI•

Pathways to Diabetic Limb Amputation: Basis for Prevention

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Roger E. Pecoraro¹, Gayle E. Reiber, Ernest M. Burgess•Institutions (1)

University of Washington¹

01 May 1990-Diabetes Care

TL;DR: Defining causal pathways that predispose to diabetic limb amputation suggests practical interventions that may be effective in preventing diabetic limb loss.

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Abstract: We defined the causal pathways responsible for 80 consecutive initial lower-extremity amputations to an extremity in diabetic patients at the Seattle Veterans Affairs Medical Center over a 30-mo interval from 1984 to 1987. Causal pathways, either unitary or composed of various combinations of seven potential causes (i.e., ischemia, infection, neuropathy, faulty wound healing, minor trauma, cutaneous ulceration, gangrene), were determined empirically after a synthesis by the investigators of various objective and subjective data. Estimates of the proportion of amputations that could be ascribed to each component cause were calculated. Twenty-three unique causal pathways to diabetic limb amputation were identified. Eight frequent constellations of component causes resulted in 73% of the amputations. Most pathways were composed of multiple causes, with only critical ischemia from acute arterial occlusions responsible for amputations as a singular cause. The causal sequence of minor trauma, cutaneous ulceration, and wound-healing failure applied to 72% of the amputations, often with the additional association of infection and gangrene. We specified precise criteria in the definition of causal pathway to permit estimation of the cumulative proportion of amputations due to various causes. Forty-six percent of the amputations were attributed to ischemia, 59% to infection, 61% to neuropathy, 81% to faulty wound healing, 84% to ulceration, 55% to gangrene, and 81% to initial minor trauma. An identifiable and potentially preventable pivotal event, in most cases an episode involving minor trauma that caused cutaneous injury, preceded 69 to 80 amputations. Defining causal pathways that predispose to diabetic limb amputation suggests practical interventions that may be effective in preventing diabetic limb loss.

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1,465 citations

"Validation of a diabetic wound clas..." refers background in this paper

...Furthermore, since ischemia is the only single disease process that can, by itself, necessitate an amputation (8), it comes as no surprise that the data reported in this study suggest a higher...
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...Ulceration is the most common single precursor to amputation and has been identified as a component in 85% of lower- extremity amputations (8)....
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...Additionally, infection, gangrene, and ischemia were the most common component causes of lower-extremity amputation (8)....
[...]

Journal Article•DOI•

The Diabetic Foot

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Elroy Patrick Weledji, Pius Fokam

12 Mar 2015-The journal of nursing care

TL;DR: The natural history of the diabetic foot is reviewed and the surgical impact of the Infectious Diseases Society of America clinical practice guideline- based care of diabetic foot infections is assessed.

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Abstract: Diabetic foot infections are a frequent clinical problem. About 50% of diabetic foot infections who have foot amputations die within five years. Properly managed most can be cured, but many patients needlessly undergo amputations because of improper diagnostic and therapeutic approaches. This approach along with vascular assessment help clinical decisions about which patients to hospitalize, which to send for imaging procedures or for whom to recommend surgical interventions. This paper reviewed the natural history of the diabetic foot and assessed the surgical impact of the Infectious Diseases Society of America clinical practice guideline- based care of diabetic foot infections.

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855 citations

"Validation of a diabetic wound clas..." refers background in this paper

...Forefoot wounds have generally been associated with repetitive moderate pressure from walking rather than constant exposure to pressure (as is exemplified in decubitus wounds) (45-50)....
[...]

Journal Article•DOI•

Impaired Leukocyte Function in Patients with Poorly Controlled Diabetes

[...]

John D. Bagdade, Richard K Root, Roger J. Bulger

01 Jan 1974-Diabetes

TL;DR: PMN function may be impaired during periods of poor diabetes control, as has been shown previously in ketoacidosis, and hyperglycemia or a closely related factor may contribute to the defect.

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Abstract: In order to assess the influence of poor diabetes control on function of leukocytes, polymorphonuclear leukocytes (PMN's) from patients with poorly controlled but nonketotic disease were studied before and after therapy. Before treatment, phagocytosis was significantly reduced (p < .001) and, consequently, the rate of killing the test organism (type 25 pneumococcus) was decreased (p < .01). Following antidiabetes therapy phagocytosis improved significantly; while microbicidal rates also improved, they remained less than control values (p < .01). Serum from the untreated diabetics uniformly reduced phagocytosis and microbicidal rates of control granulocytes; serum from controls improved phagocytosis by the diabetic PMN's, but restored normal microbicidal rates in only half of the patients. This transferable inhibitory effect of hyperglycemic diabetic serum on control granulocytes was abolished by dilution, and was reproduced in normal serum by the isosmotic addition of glucose. These studies suggest that (1) PMN function may be impaired during periods of poor diabetes control, as has been shown previously in ketoacidosis, and (2) hyperglycemia or a closely related factor may contribute to the defect.

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557 citations

Journal Article•DOI•

Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients.

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M L Grayson¹, Gary W. Gibbons, Karoly Balogh, E. Levin, Adolf W. Karchmer - Show less +1 more•Institutions (1)

Beth Israel Deaconess Medical Center¹

01 Mar 1995-JAMA

TL;DR: If bone is palpated on probing, specialized roentgenographic and radionuclide tests to diagnose osteomyelitis are unnecessary and should be included in the initial assessment of all diabetic patients with infected pedal ulcers.

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Abstract: Objective. —To assess a bedside technique for diagnosing osteomyelitis. Design. —We prospectively assessed infected pedal ulcers for detectable bone by probing with a sterile, blunt, stainless steel probe. We then examined the relationship between detection of bone and the presence or absence of osteomyelitis that was defined histopathologically and/or clinically. Setting. —A tertiary care center. Patients. —Seventy-five hospitalized diabetic patients with a total of 76 infected foot ulcers were studied. Results. —Osteomyelitis was diagnosed in 50 instances (66%) and was excluded in 26 instances. Bone was detected by probing in 33 of 50 ulcers with contiguous osteomyelitis; in contrast, bone was probed in only four of 26 ulcers without contiguous osteomyelitis (P Conclusions. —Palpation of bone in the depths of infected pedal ulcers in patients with diabetes is strongly correlated with the presence of underlying osteomyelitis. If bone is palpated on probing, specialized roentgenographic and radionuclide tests to diagnose osteomyelitis are unnecessary. Probing for bone should be included in the initial assessment of all diabetic patients with infected pedal ulcers. (JAMA. 1995;273:721-723)

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545 citations

"Validation of a diabetic wound clas..." refers background or methods in this paper

...For all wounds, depth was evaluated using a sterile blunt nasal probe (25)....
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...For instance, wounds that probe to bone have been associated with a high prevalence of osteomyelitis (25,29)....
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Journal Article•DOI•

Classification and treatment of chronic nonhealing wounds. Successful treatment with autologous platelet-derived wound healing factors (PDWHF).

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David R. Knighton, Kevin F. Ciresi, Vance D. Fiegel, Lorinda L. Austin, Ellen L. Butler - Show less +1 more

01 Sep 1986-Annals of Surgery

TL;DR: This is the first clinical demonstration that locally acting growth factors promote healing of chronic cutaneous ulcers by showing a direct correlation to 100% healing with initial wound size and the initiation of PDWHF therapy.

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Abstract: Previous animal data showed that platelets contain growth factors that stimulate capillary endothelial migration (angiogenesis), fibroblast proliferation and migration, and collagen synthesis. This study utilized autologous platelet-derived wound healing factors (PDWHF) to treat 49 patients with chronic nonhealing cutaneous ulcers. Patients were classified on the basis of 20 clinical and wound status parameters to generate a wound severity index. Forty-nine patients--58% diabetic (20% with renal transplants); 16% with trauma, vasculitis, etc.; 14% with decubitus ulcers; and 6% each with venous stasis or arterial insufficiency--with a total of 95 wounds had received conventional wound care for an average of 198 weeks (range: 1-1820 weeks). After informed consent was obtained, patients received autologous PDWHF. Mean 100% healing time for all patients was 10.6 weeks. There was no abnormal tissue formation, keloid, or hypertrophic scarring. A multivariant analysis showed a direct correlation to 100% healing with initial wound size and the initiation of PDWHF therapy. This is the first clinical demonstration that locally acting growth factors promote healing of chronic cutaneous ulcers.

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537 citations

"Validation of a diabetic wound clas..." refers background in this paper

...Most classification systems previously reported in the medical literature have primarily focused on the depth of the ulceration and have neglected or inconsistently included infection and peripheral arterial occlusive disease (9-16)....
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