Diabetic Ulcers Workup
- Author: Vincent Lopez Rowe, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP more...
Patient workup for diabetic ulcers includes blood tests, pulse-volume recording, ultrasonography, ankle-brachial index, radiography, computed tomography, magnetic resonance imaging, bone scans, and angiography.
A complete blood count should be done. Leukocytosis may signal plantar abscess or other associated infection. Wound healing is impaired by anemia. In the face of underlying arterial insufficiency, anemia may precipitate rest pain.
Assessment of serum glucose, glycohemoglobin, and creatinine levels helps to determine the adequacy of acute and chronic glycemic control and the status of renal function.
Blood testing should also include hemoglobin A1C assessment because a normal value is a surrogate marker for wound healing.
Pulse-volume recording (PVR), or plethysmography, uses pneumatic cuffs encircling the thighs, calves, ankles, feet, and, occasionally, toes to sense segmental volume changes with each pulse beat. The resulting tracings provide useful information about the hemodynamic effects of the arterial disease at each level. In severe disease, tracings at the transmetatarsal level may become nearly flat. In mild disease, particularly involving the aortoiliac segment, PVR tracings may appear normal at rest and become abnormal only after the patient walks until symptoms occur.
PVR is noninvasive and rapid and, therefore, may be repeated frequently to help assess the overall hemodynamic response to medical or surgical treatment. Ordinarily, if pedal pulses are satisfactory, arterial evaluation PVR provides no useful information.
Duplex ultrasonography can provide images of arterial segments that help localize the extent of disease, and simultaneous Doppler measurement of flow velocity can help estimate the degree of stenosis. Duplex scanning is quite useful in visualizing aneurysms, particularly of the aorta or popliteal segments. Use of this technique probably is best left to the discretion of the vascular specialist.
A handheld Doppler scanner may be used to assess arterial signals, to localize arteries to facilitate palpation of pulses, or to determine the loss of Doppler signal as a proximal blood pressure cuff is inflated (as in measurement of systolic pressure in extremity arteries).
Laser Doppler studies also have been used but may not be reliable.
The systolic pressure in the dorsalis pedis or posterior artery divided by the upper extremity systolic pressure is called the ankle-brachial index (ABI) and is an indication of severity of arterial compromise. Normal ABI averages 1.0. An ABI less than 0.9 suggests atherosclerotic disease, with a sensitivity of approximately 95%. In general, an ABI below 0.3 suggests a poor chance for healing of distal ischemic ulcerations. Unfortunately, the ABI often is falsely elevated (and thus may be unreliable) if the underlying arteries are heavily calcified, a finding common in diabetic persons.
See recommendations for the workup of patients with atherosclerotic disease of the extremities in the Medscape Reference article Infrainguinal Occlusive Disease.
Plain radiographic studies of the diabetic foot may demonstrate demineralization and Charcot joint and occasionally may suggest the presence of osteomyelitis. Plain radiographs are not routinely obtained in the workup of peripheral arterial occlusive disease. This is because arterial calcification seen on plain radiographs is not a specific indicator of severe atherosclerotic disease. Calcification of the arterial media is not diagnostic of atherosclerosis, and even calcification of the arterial intima, which is diagnostic of atherosclerotic disease, does not necessarily imply hemodynamically significant stenosis.
Computed Tomography and Magnetic Resonance Imaging
Although an experienced clinician usually can diagnose a plantar abscess by physical examination alone, computed tomography (CT) scanning or magnetic resonance imaging (MRI) is indicated if a plantar abscess is suspected but not clear on physical examination.
Bone scans are of questionable use because of a sizable percentage of false-positive and false-negative results. A recent study suggests Technetium-99m-labeled ciprofloxacin is a somewhat useful marker for osteomyelitis.
If vascular or endovascular surgical treatment is contemplated, angiography is needed to delineate the extent and significance of atherosclerotic disease. Major risks associated with conventional contrast-injection angiography are related to the puncture and to the use of contrast agents. See also Infrainguinal Occlusive Disease.
Typically, a catheter is inserted retrograde via a femoral puncture, and contrast is power-injected into the infrarenal aorta. Films are taken as the contrast is followed down to both feet. In certain cases, as with aortic occlusion, a femoral approach to the aorta may not be possible. In this case, the interventionalist (interventional cardiologist, vascular surgeon, or interventional radiologist) may use an alternative entry point, such as via the brachial or axillary artery. The arterial catheter is usually passed through a 5F sheath that is 1.6 mm in diameter. This is a sizable hole in the femoral artery, which may be only 6-10 mm in diameter. After the catheter is removed, gentle pressure must be applied to the puncture site for approximately 30 minutes. In most cases, the physician performing the angiogram may elect to use a small device to aid in closing the puncture site (“closure device”). Successful deployment of these devices eliminates the need for prolonged pressure application.
Risks associated with catheter insertion include hemorrhage, pseudoaneurysm formation, and clotting or dislodgement of an intimal flap, which may acutely occlude the artery at or near the entry site. Use of percutaneous closure devices on the puncture sites has significantly reduced site complication rates.
Angiographic contrast material is nephrotoxic. The risk of precipitating acute renal failure is highest in patients with underlying renal insufficiency and those with diabetes. Patients with both of these risk factors have a 30% rate of acute renal failure following contrast angiography. Hence, an acceptable serum creatinine level must be confirmed prior to elective angiography. Avoid contrast angiography (if possible) for patients with any significant degree of renal impairment. If contrast angiography is absolutely required despite renal impairment, use a minimal volume of contrast material. In addition, providing adequate hydration prior to, during, and after the procedure is essential. Oral administration of the antioxidant acetylcysteine (Mucomyst) the night prior to and then just before angiography may be protective of renal function for patients at risk of contrast-induced nephropathy.
To prevent the possibility of fatal lactic acidosis, patients with diabetes who are taking metformin (Glucophage) must not take this medication immediately following contrast angiography. Patients may resume taking the medication when normal renal function is confirmed 1-2 days after contrast exposure.
Alternatives to Conventional Angiography
Magnetic resonance angiography
Magnetic resonance angiography (MRA) is an alternative for patients who are allergic to iodinated contrast material. MRA is not innocuous. Gadolinium chelates, the contrast agents used in MRA, have been linked recently to 3 potentially serious side effects in patients with renal insufficiency: acute renal injury, pseudohypocalcemia, and nephrogenic systemic fibrosis. MRA is contraindicated in patients with implanted hardware such as a hip prostheses or pacemakers.
The resolution provided by MRA may be inadequate for the vascular surgeon in planning reconstructive procedures, particularly in the smaller infrapopliteal arteries, although MRA technology and contrast agents continue to improve.
Multidetector CT angiography
Multidetector CT (MDCT) angiography avoids arterial puncture. By using precisely timed intravenous contrast injection, multidetector (16 or 64 channel) CT scanners can generate angiographic images of excellent resolution and at a relatively high acquisition speed. MDCT angiography carries the contrast-related risks described above.
Carbon dioxide angiography
Carbon dioxide angiography is an alternative for patients with renal insufficiency; however, it is not widely available and requires some iodinated contrast material in addition to the carbon dioxide gas in order to provide useful images.
Transcutaneous Tissue Oxygen Studies
Transcutaneous tissue oxygen studies are reserved for borderline situations in which the advisability of arterial bypass surgery may be unclear.
Amin N, Doupis J. Diabetic foot disease: From the evaluation of the "foot at risk" to the novel diabetic ulcer treatment modalities. World J Diabetes. 2016 Apr 10. 7 (7):153-64. [Medline]. [Full Text].
Naves CC. The Diabetic Foot: A Historical Overview and Gaps in Current Treatment. Adv Wound Care (New Rochelle). 2016 May 1. 5 (5):191-197. [Medline]. [Full Text].
Gentile AT, Berman SS, Reinke KR, Demas CP, Ihnat DH, Hughes JD, et al. A regional pedal ischemia scoring system for decision analysis in patients with heel ulceration. Am J Surg. 1998 Aug. 176(2):109-14. [Medline].
Beckert S, Witte M, Wicke C, Konigsrainer A, Coerper S. A new wound-based severity score for diabetic foot ulcers: A prospective analysis of 1,000 patients. Diabetes Care. 2006 May. 29(5):988-92. [Medline].
Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care. 2001 Jan. 24(1):84-8. [Medline].
Robson MC, Hill DP, Woodske ME, Steed DL. Wound healing trajectories as predictors of effectiveness of therapeutic agents. Arch Surg. 2000 Jul. 135(7):773-7. [Medline].
Tomic-Canic M, Brem H. Gene array technology and pathogenesis of chronic wounds. Am J Surg. 2004 Jul. 188(1A Suppl):67-72. [Medline].
Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med. 2004 Jul 1. 351(1):48-55. [Medline].
Arora S, Pomposelli F, LoGerfo FW, Veves A. Cutaneous microcirculation in the neuropathic diabetic foot improves significantly but not completely after successful lower extremity revascularization. J Vasc Surg. 2002 Mar. 35(3):501-5. [Medline].
Boulton AJ. Pressure and the diabetic foot: clinical science and offloading techniques. Am J Surg. 2004 May. 187(5A):17S-24S. [Medline].
Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet. 2003 May 3. 361(9368):1545-51. [Medline].
Naemi R, Chatzistergos P, Sundar L, Chockalingam N, Ramachandran A. Differences in the mechanical characteristics of plantar soft tissue between ulcerated and non-ulcerated foot. J Diabetes Complications. 2016 Jun 8. [Medline].
Marshall MC Jr. Diabetes in African Americans. Postgrad Med J. 2005 Dec. 81(962):734-40. [Medline]. [Full Text].
Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Reiber GE, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999 Mar. 22(3):382-7. [Medline].
Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg. 1998 Aug. 176(2A Suppl):5S-10S. [Medline].
Galkowska H, Olszewski WL, Wojewodzka U, Rosinski G, Karnafel W. Neurogenic factors in the impaired healing of diabetic foot ulcers. J Surg Res. 2006 Aug. 134(2):252-8. [Medline].
Chammas NK, Hill RL, Edmonds ME. Increased Mortality in Diabetic Foot Ulcer Patients: The Significance of Ulcer Type. J Diabetes Res. 2016. 2016:2879809. [Medline]. [Full Text].
Mayfield JA, Sugarman JR. The use of the Semmes-Weinstein monofilament and other threshold tests for preventing foot ulceration and amputation in persons with diabetes. J Fam Pract. 2000 Nov. 49(11 Suppl):S17-29. [Medline].
Teodorescu VJ, Chen C, Morrissey N, Faries PL, Marin ML, Hollier LH. Detailed protocol of ischemia and the use of noninvasive vascular laboratory testing in diabetic foot ulcers. Am J Surg. 2004 May. 187(5A):75S-80S. [Medline].
Christman AL, Selvin E, Margolis DJ, Lazarus GS, Garza LA. Hemoglobin a1c predicts healing rate in diabetic wounds. J Invest Dermatol. 2011 Oct. 131(10):2121-7. [Medline]. [Full Text].
Dutta P, Bhansali A, Mittal BR, Singh B, Masoodi SR. Instant 99mTc-ciprofloxacin scintigraphy for the diagnosis of osteomyelitis in the diabetic foot. Foot Ankle Int. 2006 Sep. 27(9):716-22. [Medline].
Edmonds M, Foster A. The use of antibiotics in the diabetic foot. Am J Surg. 2004 May. 187(5A):25S-28S. [Medline].
O'Meara SM, Cullum NA, Majid M, Sheldon TA. Systematic review of antimicrobial agents used for chronic wounds. Br J Surg. 2001 Jan. 88(1):4-21. [Medline].
Brem H, Balledux J, Bloom T, Kerstein MD, Hollier L. Healing of diabetic foot ulcers and pressure ulcers with human skin equivalent: a new paradigm in wound healing. Arch Surg. 2000 Jun. 135(6):627-34. [Medline].
Beuker BJ, van Deursen RW, Price P, Manning EA, van Baal JG, Harding KG. Plantar pressure in off-loading devices used in diabetic ulcer treatment. Wound Repair Regen. 2005 Nov-Dec. 13(6):537-42. [Medline].
Hilton JR, Williams DT, Beuker B, Miller DR, Harding KG. Wound dressings in diabetic foot disease. Clin Infect Dis. 2004 Aug 1. 39 Suppl 2:S100-3. [Medline].
Veves A, Falanga V, Armstrong DG, Sabolinski ML. Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. Diabetes Care. 2001 Feb. 24(2):290-5. [Medline].
Bennett SP, Griffiths GD, Schor AM, Leese GP, Schor SL. Growth factors in the treatment of diabetic foot ulcers. Br J Surg. 2003 Feb. 90(2):133-46. [Medline].
Guzman-Gardearzabal E, Leyva-Bohorquez G, Salas-Colín S, Paz-Janeiro JL, Alvarado-Ruiz R, García-Salazar R. Treatment of chronic ulcers in the lower extremities with topical becaplermin gel .01%: a multicenter open-label study. Adv Ther. 2000 Jul-Aug. 17(4):184-9. [Medline].
Platelet-derived growth factor for diabetic ulcers. Med Lett Drugs Ther. 1998 Jul 17. 40(1031):73-4. [Medline].
Jirkovska A, Boucek P, Woskova V, Bartos V, Skibova J. Identification of patients at risk for diabetic foot: a comparison of standardized noninvasive testing with routine practice at community diabetes clinics. J Diabetes Complications. 2001 Mar-Apr. 15(2):63-8. [Medline].
Muha J. Local wound care in diabetic foot complications. Aggressive risk management and ulcer treatment to avoid amputation. Postgrad Med. 1999 Jul. 106(1):97-102. [Medline].
Pinzur MS, Slovenkai MP, Trepman E, Shields NN. Guidelines for diabetic foot care: recommendations endorsed by the Diabetes Committee of the American Orthopaedic Foot and Ankle Society. Foot Ankle Int. 2005 Jan. 26(1):113-9. [Medline].
Edmonds M. Diabetic foot ulcers: practical treatment recommendations. Drugs. 2006. 66(7):913-29. [Medline].
Bello YM, Phillips TJ. Recent advances in wound healing. JAMA. 2000 Feb 9. 283(6):716-8. [Medline].
Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S, et al. Diabetic foot disorders. A clinical practice guideline. For the American College of Foot and Ankle Surgeons and the American College of Foot and Ankle Orthopedics and Medicine. J Foot Ankle Surg. 2000. Suppl:1-60. [Medline].
Margolis DJ, Kantor J, Santanna J, Strom BL, Berlin JA. Risk factors for delayed healing of neuropathic diabetic foot ulcers: a pooled analysis. Arch Dermatol. 2000 Dec. 136(12):1531-5. [Medline].
Brem H, Sheehan P, Rosenberg HJ, Schneider JS, Boulton AJ. Evidence-based protocol for diabetic foot ulcers. Plast Reconstr Surg. 2006 Jun. 117(7 Suppl):193S-209S; discussion 210S-211S. [Medline].
Evans D, Land L. Topical negative pressure for treating chronic wounds: a systematic review. Br J Plast Surg. 2001 Apr. 54(3):238-42. [Medline].
Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, et al. Diagnosis and treatment of diabetic foot infections. Plast Reconstr Surg. 2006 Jun. 117(7 Suppl):212S-238S. [Medline].
Wieman TJ, Mercke YK, Cerrito PB, Taber SW. Resection of the metatarsal head for diabetic foot ulcers. Am J Surg. 1998 Nov. 176(5):436-41. [Medline].
Faries PL, Teodorescu VJ, Morrissey NJ, Hollier LH, Marin ML. The role of surgical revascularization in the management of diabetic foot wounds. Am J Surg. 2004 May. 187(5A):34S-37S. [Medline].
Marston WA, Davies SW, Armstrong B, Farber MA, Mendes RC, Fulton JJ, et al. Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization. J Vasc Surg. 2006 Jul. 44(1):108-114. [Medline].
Ehrenreich M, Ruszczak Z. Update on tissue-engineered biological dressings. Tissue Eng. 2006 Sep. 12(9):2407-24. [Medline].
Streit M, Braathen LR. Apligraf--a living human skin equivalent for the treatment of chronic wounds. Int J Artif Organs. 2000 Dec. 23(12):831-3. [Medline].
Demiri E, Foroglou P, Dionyssiou D, Antoniou A, Kakas P, Pavlidis L, et al. Our experience with the lateral supramalleolar island flap for reconstruction of the distal leg and foot: a review of 20 cases. Scand J Plast Reconstr Surg Hand Surg. 2006. 40(2):106-10. [Medline].
Strauss MB. Hyperbaric oxygen as an intervention for managing wound hypoxia: its role and usefulness in diabetic foot wounds. Foot Ankle Int. 2005 Jan. 26(1):15-8. [Medline].
Roeckl-Wiedmann I, Bennett M, Kranke P. Systematic review of hyperbaric oxygen in the management of chronic wounds. Br J Surg. 2005 Jan. 92(1):24-32. [Medline].
Löndahl M, Katzman P, Nilsson A, Hammarlund C. Hyperbaric oxygen therapy facilitates healing of chronic foot ulcers in patients with diabetes. Diabetes Care. 2010 May. 33(5):998-1003. [Medline]. [Full Text].
Kranke P, Bennett MH, Martyn-St James M, Schnabel A, Debus SE. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2012 Apr 18. 4:CD004123. [Medline].
Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005 Jan 12. 293(2):217-28. [Medline].
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993 Sep 30. 329(14):977-86. [Medline].
Hiatt WR, Money SR, Brass EP. Long-term safety of cilostazol in patients with peripheral artery disease: the CASTLE study (Cilostazol: A Study in Long-term Effects). J Vasc Surg. 2008 Feb. 47(2):330-336. [Medline].
[Guideline] Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004 Oct 1. 39(7):885-910. [Medline].
Game FL, Apelqvist J, Attinger C, Hartemann A, Hinchliffe RJ, et al. Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review. Diabetes Metab Res Rev. 2015 Sep 7. [Medline].
van Netten JJ, Price PE, Lavery LA, Monteiro-Soares M, Rasmussen A, et al. Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev. 2015 Sep 5. [Medline].
Bus SA, van Deursen RW, Armstrong DG, Lewis J, Caravaggi CF, et al. Footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in patients with diabetes: a systematic review. Diabetes Metab Res Rev. 2015 Sep 5. [Medline].
|This seaweed extract contains guluronic and mannuronic acids that provide tensile strength and calcium and sodium alginates, which confer an absorptive capacity. Some of these can leave fibers in the wound if they are not thoroughly irrigated. These are secured with secondary coverage.||These are highly absorbent and useful for wounds having copious exudate. Alginate rope is particularly useful to pack exudative wound cavities or sinus tracts.|
|An absorptive textile fiber pad, also available as a ribbon for packing of deep wounds. This material is covered with a secondary dressing. The hydrofiber combines with wound exudate to produce a hydrophilic gel. Aquacel-Ag contains 1.2% ionic silver that has strong antimicrobial properties against many organisms, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus.||These are absorbent dressings used for exudative wounds.|
|Debriding agents||Hypergel (hypertonic saline gel)
Accuzyme (papain urea)
|Various products provide some degree of chemical or enzymatic debridement.||These are useful for necrotic wounds as an adjunct to surgical debridement.|
|Polyurethane foam has some absorptive capacity.||These are useful for cleaning granulating wounds having minimal exudate.|
Duoderm CGF Extra Thin
|These are made of microgranular suspension of natural or synthetic polymers, such as gelatin or pectin, in an adhesive matrix. The granules change from a semihydrated state to a gel as the wound exudate is absorbed.||They are useful for dry necrotic wounds, wounds having minimal exudate, and clean granulating wounds.|
|These are water-based or glycerin-based semipermeable hydrophilic polymers; cooling properties may decrease wound pain. These gels can lose or absorb water depending upon the state of hydration of the wound. They are secured with secondary covering.||These are useful for dry, sloughy, necrotic wounds (eschar).|
|These are various materials designed to remove easily without damaging underlying skin.||These are useful for acute minor wounds, such as skin tears, or as a final dressing for chronic wounds that have nearly healed.|
|These are highly conformable acrylic adhesive film having no absorptive capacity and little hydrating ability, and they may be vapor permeable or perforated.||These are useful for clean dry wounds having minimal exudate, and they also are used to secure an underlying absorptive material. They are used for protection of high-friction areas and areas that are difficult to bandage such as heels (also used to secure IV catheters).|