A New Wound-Based Severity Score for Diabetic Foot Ulcers : A prospective analysis of 1,000 patients Beckert,  Maria Witte,  Corinna Wicke,  Alfred Königsrainer,  Stephan Coerper  Diabetes Care. May 2006.Vol.29 R1 문송미

Background

Diabetic foot Risk for foot ulcerations :15% Recur risk : 70% of healed ulcers within 5 yrs Risk factor 1) Peripheral neuropathy 2) Peripheral vascular disease 3) Abnormal plantar pressure load 4) Infection

DM foot classification system Meggit –Wagner classification

DM foot classification system The University of Texas system

DM foot classification system Classification system by Treece et al.

Object

To establish a new wound-based clinical scoring system for diabetic foot ulcers To anticipate chances for healing and risk of amputation

Research and method

Research group December 1997 and April 2004 1,000 consecutive patients DM pts.( the criteria of WHO ) Followed-up for 365 days or until healing or amputation if earlier Excluded less than two visits during the observation period

Diabetic foot ulcer scoring system According to a severity Score rang : O to 4 Parameters 1) Palpable pedal pulses 2) Probing to bone 3) Ulcer location (foot or toe ulcer) 4) The presence of multiple ulcers The aim of scoring system - Prediction of clinical outcome defined as probability of healing and risk for amputation

Wounds Wound depth - Grade 1 : dermis - Grade 2 : subcutaneous - Grade 3 : fascia - Grade 4 : muscle - Grade 5 : bone Single or multiple ulcerations on the same foot Healing : as complete epithelization

Amputation - Minor : toe or forefoot amputation - Major : below or above knee amputation Soft tissue infection - Purulent discharge - Two other local signs : warmth, erythema, edema, lymphangitis, lymphadenopathy or pain

Local wound therapy Wound care - Sharp debridement - Local surgical procedures : limited bone resections - Moist wound therapy - Pressure off loading

Diabetic ulcer severity score(DUSS) 1 Pedal pulses present absent Bone involvement no probing to bone probing to bone Site of ulceration toe foot Number of ulcerations single multiple

Result

Table1. Baseline dermographic details

Figure 1. Probability of healing according to the DUSS

Univariate analysis of parameters reducing chance for healing 1) Nonpalpable pedal pulses (P<0.0009) 2) Probing to bone (P<0.0019) 3) Multiple ulcerations (P<0.00001) 4) Foot ulceration(P<0.00001) - Local soft tissue infection (P<0.5324)

Table2. Multivariate analysis of parameters reducing chance for healing

Table3. Subgroup analysis with respect to ulcer severity score

Discussion

Nylon monofilament test

Usual location of ulcer

The influencing factor of ulcer healing Location of ulcer Consequenent off loading Recurrent soft tissue infection Immediate and adequate therapy

The result of DUSS Increasing in the DUSS by one score point  reduced the chance for healing by 35% Adequate local surgery and minor amputation prevent major amputation

The using of DUSS Easy diagnostic tool for anticipating probability of healing, hospital admission and local surgery Daily clinical practice Suitable easily applied in estimating putative health care costs Not setting up the subsequent wound care according to DUSS

Conclusion

DUSS Wound based score Not investigation disease based parameters Predicting clinical outcome The communication index between health care providers