Stages according to clinical manifestations
Stage I Asymptomatic stage, only weakness of lower limbs after vigorous exercise.
Stage II Pain in the lower limbs when walking at normal speed.
Stage III Lower limb pain at rest – resting pain.
Stage IV Lower limb pain at rest with local nutritional disorders, dystrophic ulcers and gangrene.
Pathological stage
Phase I: Early lesion stage: Patients often have coldness, numbness and leg “cramps” in the lower extremities, which can be easily mistaken for “cold legs” or calcium deficiency in the elderly, leading to delayed disease.
Phase 2: Local ischemic phase: “intermittent claudication”, i.e. pain in the lower limbs after walking for a certain distance, forcing to stop the movement, which can be relieved after resting for a while, and then the pain reappears after walking again for a certain distance. As the disease progresses, the patient walks shorter and shorter distances. In addition, there is abnormal sensation in the foot, weak arterial pulsation, and functional > organic.
Phase III: Dystrophic phase: resting pain, i.e. pain in the lower extremity that occurs when the patient is not walking and resting, which is intense burning pain, especially at night. The limb is dystrophic and the arterial pulsation disappears, organic > functional.
Stage 4: gangrene: persistent severe pain, dry ulcers and wet ulcers, ischemic necrosis of tissues, which can be combined with infection and eventually lead to amputation, and in severe cases can be life-threatening.
The commonly used grading method is wagner grading method as follows.
(1) Grade 0 – refers to feet with high risk factors for ulcers. For these patients who do not have foot ulcers at present, regular follow-up visits, education on foot protection and specific guidance from podiatrists should be enhanced, if necessary, to prevent the occurrence of foot ulcers. Feet with risk factors for the development of foot ulcers that are currently free of ulcers.
(2) Grade 1 – foot skin surface ulcers without clinical infection. The prominent presentation is a neuropathic ulcer. These ulcers tend to occur in prominent areas of the foot i.e. pressure bearing points, such as the heel, foot or base of the toe, where the ulcer is surrounded by callus. The surface ulcer is clinically uninfected.
(3) Grade 2 – deeper, penetrating ulcers, often combined with soft tissue infection, but without osteomyelitis or deep abscesses, some specific bacteria such as anaerobic and gas-producing bacteria may be present at the ulcer site. Deeper ulcers, often combined with soft tissue infection (CELLULITIS), without abscess or infection of the bone.
(4) Grade 3 – deep ulcers, often affecting bone tissue, with deep abscesses or osteomyelitis.
(5) Grade 4 – characterized by ischemic ulcers, localized or gangrene in specific areas of the foot. It is usually combined with neuropathy. Gangrene without severe pain is suggestive of neuropathy. The surface of the necrotic tissue may be infected.
(6) Grade 5 – Gangrene affects the entire foot. Aortic obstruction plays a major etiologic role, with neuropathy and infection also affecting. Total gangrene.
The DUSS system: a new method for grading diabetic foot ulcers
Beckert et al. of the University of Tübingen, Germany, recently proposed a new method for grading the severity of diabetic foot according to the nature of the ulcer. Based on this, they developed a new diabetic foot ulcer severity score (DUSS) system and evaluated 1,000 patients using this score system, which proved to be a relatively accurate predictor of prognosis for patients with diabetic foot ulcers. Although there are several accepted classification systems for diabetic foot ulcers, there is still a lack of scientific, accurate and practical scoring systems to assess the severity of diabetic foot and determine the prognosis.
The DUSS system scores four clinical indicators, which are.
(1) whether the foot artery pulsation can be palpated (0 for yes, 1 for no)
(2) Whether the ulcer is deep to the bone surface (0 points for no, 1 point for yes)
(3) Location of the ulcer (0 for toe, 1 for other areas) and whether it is multiple (0 for no, 1 for yes), resulting in a maximum theoretical score of 4.
The researchers evaluated 1,000 patients with diabetic foot ulcers using the DUSS system and followed them until the ulcers healed or were amputated or until one year had elapsed. The results showed that those with a score of 0 had significantly higher ulcer healing rates, while those with higher scores had lower ulcer healing rates and higher amputation rates; there were significant differences in ulcer healing rates between subgroups of patients with the same score. Further analysis showed that for every 1-point increase in score, the ulcer healing rate decreased by 35%; similarly, the higher the score, the larger the initial ulcer size, the longer the ulcer history, and the greater the likelihood of requiring hospitalization or surgery.
The study suggests that the scoring system is simple and practical and can be easily applied by every physician to predict the prognosis of patients with diabetic foot ulcers and thus promptly advise patients to receive specialist care.