La moral y los valores vistos por los niños y adolescentes

Figure 1: Pathways to Diabetic Foot Ulceration

Source: Pathophysiology of Foot Ulceration. Consensus Document, International Working Group on the Diabetic Foot, Amsterdam 2007.

peripheral arterial disease, and increasing wound depth and it also appears that the progressive cumulative effect of these co morbidities contributes to a greater likelihood of a diabetic foot ulcer leading to a lower-limb amputation. ⁸⁴

Various systems have been developed to classify diabetic foot ulcers for daily practise. This include the well-established and widely used Wagner wound classification system and the University of Texas (UT) diabetic wound classification system; both provide descriptions of ulcers to varying degrees and are easy to use among health care providers; both can provide a guide to planning treatment strategies. ⁸⁴ The Meggit/Wagner classification is probably the best known and the most frequently used; ⁸⁵ it assesses ulcer depth and the presence of osteomyelitis or gangrene using grades 0 - 5 as shown in table 4 below.

The University of Texas Diabetic Wound Classification is the first combined bi-dimensional classification published in 1996 by Lavery, Armstrong, and Harkless. ⁸⁴ It assesses ulcer depth, the presence of wound infection, and the presence of clinical signs of lower-extremity ischemia. This system uses a matrix of grade on the horizontal axis and stage on the vertical axis. The grades of the University of Texas system are as shown in table 5 below. Within each wound grade there are four stages:

- Stage A: clean wounds,

- Stage B: non-ischemic infected wounds - Stage C: ischemic noninfected wounds and - Stage D: ischemic infected wounds

An infected ischemic ulcer that penetrates to tendon (grade 2, stage D, or, simply, grade 2D of the UT system) alternatively will be grade 2 of the Wagner system. A labelling of grade 2 of the Wagner system thus will not alert other members of the foot care team of the presence of infection and ischemia, which can prolong wound healing and increase the risk of lower-limb amputation. Thus, the addition of stage to grade improves the descriptive and predictive power of a wound classification system, especially for ulcers within the same grade. The University of Texas system, which combines grade and stage, is therefore, more descriptive and shows a greater association with increased risk of amputation and prediction of ulcer healing when compared with the Wagner system.

Thus, the University of Texas system is thought to be a better predictor of clinical outcome. ⁸⁵

Other known classification systems are Brodsky’s, Gibbon's, Frykberg's and Coleman's, Forrest's, Knighton's, the Van Acker/Peter classification (VA/P), and the Ten - Level Seattle Wound Classification System. ⁸⁵ In 2003 the International working group on the diabetic foot (IWDGF) introduced its classification system (PEDIS), which was particularly developed to facilitate communication in the field of

research. ⁸⁶ On this basis, five categories were identified, which were considered the most relevant items for research projects in diabetic foot ulcers namely: Perfusion, Extent/size of wound, Depth/ tissue loss, Infection, and Sensation. For each category a grading system is provided, that describes the severity within each category.

This is outlined in table 6.

Table 4: The Wagner system of ulcer classification

Grade of ulcer Description of ulcer 0

1

2

3

4

 pre- or post-ulcerative lesion

 Superficial ulcer (limited to the dermis)

 Deep ulcer (transdermal) with exposed tendon, bone or joint, without osteomyelitis or abscess

 Deep ulcer with abscess formation or osteomyelitis

 Localized Gangrene confined to toes or forefoot

5  Extensive (whole foot) Gangrene

Table 5: The University of Texas System of Ulcer Classification ⁸⁴

GRADES

STAGES 0 I II III

A Pre- or

post- ulcerative lesion completely epithealised

Superficial wound, not

involving tendon, capsule or bone

Wound penetrating to tendon or capsule

Wound penetrating to bone or joint

B Infection Infection Infection Infection

C Ischaemia Ischaemia ischaemia Ischaemia

D Infection and

ischaemia

Infection and

ischaemia

Infection and

ischaemia

Infection and

ischaemia

Table 6: PEDIS system of wound classification ⁸⁶ Perfusion:

Grade 1: no symptoms or signs of PAD in the affected foot

Grade 2: Symptoms or signs of PAD, but not of Critical Limb Ischemia (CLI)

Grade 3: Critical Limb Ischemia, as defined by:

 Systolic ankle blood pressure < 50 mmHg or

 Systolic toe blood pressure < 30 mmHg or

 TcPO2 < 30 mmHg Extent/size

Wound size (measured in square centimetres) should be determined after debridement, if possible. The outer border of the ulcer should be measured from the intact skin surrounding the ulcer.

Depth and tissue loss

Grade 1: Superficial full thickness ulcer, not penetrating any structure 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.

Infection

Infection of a diabetic foot ulcer is defined as invasion and multiplication of micro-organisms in body tissues associated with tissue destruction or a host inflammatory response.

Grade 1: no symptoms or signs of infection

Grade 2: infection involving the skin and the subcutaneous tissue only Grade 3: Erythema > 2 cm plus one of the items described above (swelling, tenderness, warmth, discharge) or Infection involving structures deeper than skin and subcutaneous tissues such as abscess, osteomyelitis, septic arthritis, fasciitis.

Grade 4: Any foot infection with the signs of a systemic inflammatory response syndrome (SIRS).

Sensation

Grade 1: no loss of protective sensation on the affected foot detected, defined as the presence of sensory modalities described below

Grade 2: Loss of protective sensation on the affected foot is defined as the absence of perception of one of the following tests in the affected foot:

 Absent pressure sensation

 Absent vibration sensation