Diabetic Foot Ulcers

  • Andrew J. M. Boulton
  • Frank Bowling

The Wagner system describes the diabetic foot ulcer as a full thickness wound extending to tendons or deeper subcutaneous tissue but without bony involvement or osteomyelitis [1]. The university of Texas system refers to levels of ischemia [2] and infection while the SAD system [3] attends to size, area, depth, arteriopathy and any neuropathic involvement. The breadth of classification system in use reflects the complexity and range of signs/symptoms associated with diabetic foot ulceration, with a lower limb lost to amputation every 30 seconds [4]. Recent research has estimated that more than 50% of diabetic foot ulcers will recur within 3 years suggesting that the professionals involved in treatment are fighting a difficult battle especially when it is considered that the lifetime risk for developing such an ulcer is calculated to be in the region of 15–25% [5].


Diabetic Peripheral Neuropathy Vacuum Assisted Closure Total Contact Cast Necrotic Wound Charcot Neuroarthropathy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Wagner FW. The dysvascular foot: A system for diagnosis and treatment. Foot Ankle 1981;2:64–122.PubMedGoogle Scholar
  2. 2.
    Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic foot wound classification system: contribution of depth infection and vascular disease to the risk of amputation. Diabetes Care 1998;21:855–859.CrossRefPubMedGoogle Scholar
  3. 3.
    Treece KA, MacFarlane RM, Pound P, Game FL, Jeffcoate WJ. Validation of a system of foot ulcer classification in Diabetes Mellitus. Diabet. Med. 2004;21:987–991.CrossRefPubMedGoogle Scholar
  4. 4.
    International Diabetes Federation time to act: Diabetes and foot care. Brussels: International Diabetes Federation, 2005.Google Scholar
  5. 5.
    Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217–228.CrossRefPubMedGoogle Scholar
  6. 6.
    Gordois A, Scuffham P, Shearer A, Oglesby A, Tobian JA. The health care costs of Diabetic Peripheral Neuropathy, in the US. Diabetes Care 2003;26:1790–1795.CrossRefPubMedGoogle Scholar
  7. 7.
    Gordois A, Scuffham P, Shearer A, Oglesby A. The healthcare costs of Diabetic Peripheral Neuropathy, in the UK. Diabet. Foot 2003;6:62–73.Google Scholar
  8. 8.
    Vileikyte L. Stress on wound healing. Clinics in Dermatology 2007;25:49–55.CrossRefPubMedGoogle Scholar
  9. 9.
    Boulton AJM. The Diabetic Foot. Diabet. Med. 2006;34:87–90.Google Scholar
  10. 10.
    Lobmann R, Ambrosch A, Waldmann K, Schultz G, Lehnert H, Schiweck S. Expression Matrix-metalloproteinases and inhibitors in the wounds of diabetic and non-diabetic patients. Diabetologia 2002;45:1011–1016.CrossRefPubMedGoogle Scholar
  11. 11.
    Thomas S. Sterile maggots and the preparation of the wound bed. In: Cherry GW, Harding KG, Ryan TJ (eds). Wound bed preparation. Proceedings of a symposium sponsored by the European Tissue Repair Society, 2000 Nov 24–25; Oxford UK. International Congress and Symposium Series 250. Royal Society of Medicine Press Limited, 2001:59–66.Google Scholar
  12. 12.
    Bowling FL, Salgami E, Boulton AJM. Larval therapy a novel treatment in eliminating MRSA from diabetic foot wounds. Diabetes Care 2007;30:370–371.CrossRefPubMedGoogle Scholar
  13. 13.
    Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 1990;3:513–521.CrossRefGoogle Scholar
  14. 14.
    Mc Manon MM, Bistrian BR. Host defences and susceptibility to infection in patients with diabetes mellitus. Infect. Dis. Clin. North Am. 1995;9:1–10.Google Scholar
  15. 15.
    Marhoffer W, Stein M, Schleinkofer L, Federlin K. Evidence of ex vivo and in vitro impaired neutrophil oxidative burst and phagocytic capacity in type 1 diabetes mellitus. Diabet. Res. Clin. Pract. 1993;193:183–188.CrossRefGoogle Scholar
  16. 16.
    Wetzler C, Kampfer H, Stallmeyer B, Pfeilschifter J, Frank S. Large and sustained induction of chemokines during impaired wound healing in the genetically diabetic mouse: prolonged persistence of neutrophilils and macrophages during the late phase of repair. J. Invest. Dermatol. 2006;11520:245–253.Google Scholar
  17. 17.
    Bridges RM, Deitch EA. Diabetic foot infections. Pathophysiology and treatment. Surg. Clin. North Am. 1994;74:537–545.PubMedGoogle Scholar
  18. 18.
    Roghmann MC, Siddiqui A, Plaisance K, Standiford H. MRSA colonization and the risk of bacteraemia in hospitalized patients with chronic ulcers. J. Hosp. Infect. 2001;47:98–103.CrossRefPubMedGoogle Scholar
  19. 19.
    O'Meara S, Nelson EA, Golder S, Dalton JE, Craig D, Iglesias C. Systematic review of methods to diagnose infection in foot ulcers in diabetes. Diabet. Med. 2006;23(4):341–347.CrossRefPubMedGoogle Scholar
  20. 20.
    Lipsky BA. A report from the international consensus on diagnosing and treatment the diabetic foot. Diabet./Metab. Res. Rev. 2004;20(Suppl. 7):586–577.Google Scholar
  21. 21.
    McMahaon MM, Bistrian BR. Host defences and susceptibility to infection in patients with diabetes mellitus. Infect. Dis. Clin. North Am. 1995;9:1–10.Google Scholar
  22. 22.
    International Working Group on the Diabetic Foot. International consensus on the diabetic foot. European Association for the Study of Diabetes. CD ROM 2003, May.Google Scholar
  23. 23.
    Chantelau E, Tanudjaja T, Altenhofer F, Ersanli Z, Lacigova S, Metzeger C. Antibiotic treatment for uncomplicated neuropathic forefoot ulcers in diabetes. Diabet. Med. 1996;13:156–159.CrossRefPubMedGoogle Scholar
  24. 24.
    Cunha BA. Antibiotic selection for diabetic foot infections: a review. J. Foot Ankle Surg. 2000;39:253–257.CrossRefPubMedGoogle Scholar
  25. 25.
    Venkatesan P, Lawn S, Macfarlane R, Fletcher EM, Finch RG, Jeffcoate WJ. Conservative management of osteomyelitis in the feet of diabetic patients. Diabet. Med. 1997;14:487–490.CrossRefPubMedGoogle Scholar
  26. 26.
    Jeffcoate W, Lipsky B. Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin. Infect. Dis. 2004;39:S115–S122.CrossRefPubMedGoogle Scholar
  27. 27.
    Bradley M, Cullum N, Nelson EA, Petticrew M, Sheldon T, Torgeson D. Systematic reviews of wound care management. Health Technol. Assess. 1999;3:1–35.PubMedGoogle Scholar
  28. 28.
    Cullum C, Majid M, O'Meara S, Shelocn T. Use of dressings: is there an evidence base? In: Boulton AJM, Connor H, Cavanagh PR (eds). The foot in diabetes, 3rd edn, Chichester: Wiley; 2000:153–163.Google Scholar
  29. 29.
    Armstrong DG, Lavery LA, Wu S, Boulton AJM. Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. Diabetes Care. 2005;28(3):551–554.CrossRefPubMedGoogle Scholar
  30. 30.
    Armstrong DG, Findlow AH, Cybil SC, Boulton AJM. Absorbable antibiotic-impregnated calcium sulphate pellets in the management of diabetic foot infections. Diabet. Med. 2001;18:937–948.CrossRefGoogle Scholar
  31. 31.
    Kelly CM, Wilkins RM, Gitelis S, Hartjen C, Watson JT, Kim PT. The use of a surgical grade calcium sulfate as a bone graft substitute: results of a multi-centre trial. Clin. Orthop. Relat. 2001;382:42–50.CrossRefGoogle Scholar
  32. 32.
    Petruskeukius J, Nielsen S, Faalunis S, Fnudsen PR, Cvergaards NC. Effects of osteoset, a bone craft substitute on bone healing in humans. Acta Orthop. Scand. 2002;5:575.Google Scholar
  33. 33.
    Armstrong DG, Lavery LA, Nixon BP, Boulton AJM. It is not what you put on, but what you take off: techniques for debriding and offloading the diabetic foot wound. Clin. Infect. Dis. 2004;39:S92–S99.CrossRefPubMedGoogle Scholar
  34. 34.
    Brand PW. The diabetic foot. In: Ellenberg M, Rifkin H (eds), Diabetes mellitus, theory and practice, 3rd edn., Medical examination publishing: New York; 1983:803–828.Google Scholar
  35. 35.
    Mueller MJ, Diamond JM, Sinacore DR. Total contact casting in treatment of diabetic planter ulcers. Controlled clinical trial. Diabetes Care 1989;12:384–388.CrossRefPubMedGoogle Scholar
  36. 36.
    Armstrong DG, Lavery LA, Kinbriel HR, Nixon BP, Boulton AJM. Activity patterns of patients with diabetic foot ulceration. Diabetic foot ulceration. Diabetes Care 2003;26:1–4.CrossRefGoogle Scholar
  37. 37.
    Tentolouris N, Jude EB, Smirnoff I, Knowles EA, Boulton AJM, Methicillin Resistant Staphylococcus aureus: an increasing problem in the diabetic foot clinic. Diabet. Med. 1999;16:767–771.CrossRefPubMedGoogle Scholar
  38. 38.
    Kellogg EW III, Yost MG, Barthakurn, Kreveger AP. Superoxide involvement in the bacteriocidal effects of negative air ions on staphylococcus albus. Nature 1979;4:281–400.Google Scholar
  39. 39.
    Vernon CJ. Long term experience of the Dentron Biogun in verruca pedis, mosaic verruca and hand warts. J. Pod. Med. 2000;65:4–8.Google Scholar
  40. 40.
    Dang CN, Anwar R, Thomas G, Prasad YDM, Boulton AJM, Malik R. The Biogun: A novel way of eradicating MRSA colonization in diabetic foot ulcers. Diabetes Care 2006;29:1176–1177.CrossRefPubMedGoogle Scholar
  41. 41.
    Armstrong DG, Attinger CE, Boulton AJM, Frykberg RG. Guidlines regarding negative wound therapy (NWPT) in the diabetic foot. Ostomy. Wound Manage. 2004;50(4b Suppl.):35–27s.Google Scholar
  42. 42.
    Working Group on The Diabetic Foot. Diabetes Monitor 2007 volume 19:21–27.Google Scholar
  43. 43.
    Jude EB, Selby PL, Burgess J, Lilleystone P, Mawer EB, Page Sridcnohce M, Foster AV, Edmonds ME, Bolton AJM. Bisphosphonates in the treatment of Charcot neuroarthropathy. Diabetologia 2001;44(11):2032.CrossRefPubMedGoogle Scholar
  44. 44.
    Pitocco D, Rudtolov V, Caputos, Mancin L, Collina MC, Manto A, Caradonna P, Chirlanda G. Six-month treatment with alendronate in acute Charcot neuroarthropathy. Diabetes Care 2005;5:1214–1215.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Andrew J. M. Boulton
    • 1
  • Frank Bowling
    • 1
  1. 1.Universities of ManchesterMiamiUSA

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