This study aimed to identify predictors of poor outcome (non-healing) of diabetic foot ulcers at Assiut University Hospital. 100 patients with diabetic foot ulcers were prospectively followed for 1 year. Male sex, diabetes duration over 10 years, severe peripheral neuropathy, ulcer duration over 3 months, Wagner grade 3 ulcers, Texas grade 2D/3D ulcers, and ABI under 0.8 were found to independently predict non-healing of ulcers based on multivariate regression analysis. Baseline characteristics, foot examination findings, ulcer characteristics, and laboratory values of patients with healed versus unhealed ulcers after 1 year were also compared.

2. Predictors of the outcome of
diabetic foot ulcer at Assiut
university hospital
By
Walaa Anwar Muhammad Khalifa
M.B.B.CH
M.ScFaculty of medicine
M.ScFaculty
Assiut University
Under supervision of
Prof. Dr. Lobna Farag Eltoony
Professor of internal medicine&head of endocrinology unit
Faculty of medicine
Assiut University
Dr. Mona Muhammad Soliman
Lecturer of internal medicine
Faculty of medicine
Assiut University

3. Introduction
 Diabetic foot ulcers are a common and much
feared complication of diabetes, with recent
studies suggesting that the lifetime risk of
developing foot ulcer in diabetic patients may be
as high as 25% (Singh et al.,2005).
 Up to 50% of older patients with type 2 diabetes
have one or more risk factors for foot ulceration.
 A list of the principal risk factors that might
result in foot ulcer development are
demonstrated ( Abbott et al ., 2002.)

4. Risk factors of foot ulcer
1- Previous amputation.
2- Past history of foot ulceration.
3- Peripheral neuropathy.
4- Peripheral vascular disease.
5- Foot deformity.
6- Visual impairment.
7- Diabetic nephropathy.
8- Poor glycemic control.
9- Cigarette smoking

6.  The most common triad of causes that
interact and result in foot ulceration has
been identified as neuropathy, deformity
and trauma ( Boulton et al., 2004)

7. • The risk of amputation is 15 to 40 times
greater in a person with diabetes than in
one who doesn't have the disease
( Nabuurs et al..2005).

8.  The population of diabetic patients who
present with foot ulceration are
heterogenous,there are characteristics that
may vary among patients, such as the
presence of peripheral arterial disease
infection,andco-morbidities.
Peripheral arterial disease is considered
an important predictor of outcome
(Prompers et al., 2007).

9.  Therefore. Outcome data on these patients
with diabetic foot ulcer are needed such a
requirement is underlined by the fact that
although diabetic foot ulcers are usually
reported and analyzed as one clinical
entity marked differences in patient, foot
and ulcer characteristics can exist between
patients. These observations raise the
question of wether predictors of outcome in
patients may differ (Prompers et al., 2007).

10. The aim of the study
 To assess the potential baseline clinical and
laboratory characteristics that best predict poor
outcome (non healing of the foot ulcer).
 The main outcome of the study is complete
healing of the foot within the maximum follow
up period of 1 year.
 Healing was defined as healing (intact skin) of
the whole foot at two consecutive visits.

11. Patients & study design
 It is a prospective study in which 100
patients with diabetic foot ulcer will be
followed and managed for 1 year.
 About 50 patients are still under
research.
 Patients included were those presenting
for the first time with a new foot ulcer
within period of 12 months.

12. Excluded patients
1- Patients who had been treated for an
ulcer on the ipsilateral foot during the
previous 12 months.
2- Patients with sever end organ
failure.
3- Patients with gangrenous foot. eg,
gas gangrene.

13. Method
 Data collected prospectively of patients
referred to a foot care clinic
recorded
Data include.
 Demographics,detailed history and complete
physical examination
 Data on co- morbidities including ( retinopathy
nephropathy, hypertension and ischemic heart
disease) .

14.  Data on foot examination
include.
(foot inspection, Pedal
pulse, ABI measurement
and joint examination).
 Data on ulcer
characteristics.
ulcers were classified
according to
1-PEDIS system.
( perfusion, extent, depth,
infection and sensation ) .

15. -2Meggitt- wagner classification of
foot ulcers
Grade0:Pre- or post- ulcerative lesion
completely epithelialized
Grade1:Superficial, full thickness ulcer limited
to the dermis, not extending to the subcutis
Grade 2:Ulcer of the skin extending through the
subcutis with exposed tendon or bone and
without osteomyelitis or abscess
Grade 3:Deep ulcers with osteomyelitis or
abscess formation
Grade 4:Localized gangrene of the toes or the
forefoot
Grade 5:Foot with extensive gangrene

16. 3- The university of Texas classification 1998
Grade
Stage
0 1 2 3
Pre- or post- Superficial Wound Wound
A ulcerative wound not penetrating penetrating
lesion involving to tendon or to bone or
completely tendon, capsule joint
epithelailizd capsule or
bone
With With With With
B infection infection infection infection
With With With With
C ischemia ischemia ischemia ischemia
With With With With
D infection infection infection infection
and and and and ischemia
ischemia ischemia ischemia

17.  Laboratory data include
Complete blood picture, liver
function, urea and creatinine ,24
hrs proteins in urine, creatinine
clearance, lipogram and (Hb A1c)
.

18. Management of diabetic foot ulcer
All Patients were treated According to protocols based
on the international consensus on the diabetic foot
which include offloading ,diagnosis and treatment of
infection, assessment of vascular status and regular
wound debridement .

19. Results of 50 patients:
In 50 patients: 34 (68%) females ,
the mean age 50.76 ± 13.35.

20. Diagram (2) :shows results of patient
s
om
pt
m
sy
c
hi
at
op
ur
ne
p y
ra
characteristics
e
th
lin
su
in
n
tio
ta
pu
am
of
y
or
st
hi
st
pa
s
er
ok
sm
n-
no
0
50
40
30
20
10
no. of cases

21. Diagram(3):shows results of
foot inspection

22. Table(1)Baseline characteristics of patients with healed and unhealed ulcers
Healed Unhealed Total
Variable P-value
(n= 31) (n= 19) (n= 50)
Age: 47.39 ± 11.42 56.26 ± 16.76 50.76 ± 13.35 0.021
Sex:
Males n% 6(37.5%) 10(62.5%) 16 0.014
Females n% 25(73.6%) 9(26.4%) 34
Smoking (n%) 2(20.0%) 8(80.0%) 10 0.007
BMI 31.64 ± 3.88 29.21 ± 5.60 30.72 ± 4.71 NS
Diabetes duration:
< 10 years 22(84.6%) 4(15.4%) 26 0.001
≥ 10years 9(37.5%) 15(62.5%) 24
Insulin use (n%) 25(61.0%) 16(39.0%) 41 NS
Retinopathy (n%) 10(50%) 10(50%) 20 NS
Hypertension 10(47.6%) 11(53.4%) 21 NS
Ischemic heart disease 6(42.9%) 8(57.1%) 14 NS
Nephropathy 6(35.3%) 11(64.7%) 17 0.005

23. Table(2)Baseline characteristics of ulcer examination and
relation to healing
Variable Healed( n=31) Unhealed n=19 Total P-value
Sever neuropathy(n % 4(30.7%) 9(69.3%) 13 0.018
ABI 0.93±0.05 0.75±0.09 0.86±0.8 0.000
Colour change (n%) 1(10%) 9(90.0%) 10 0.001
Superficial infection 8(53.3%) 7(46.7%) 15 NS
Deep infection 2(20%) 8(80%) 10 0.007
Ulcer site:
For foot 10(32.2%) 3(15.8%) 13 NS
Mid foot 4(12.9%) 4(21%) 8 NS
Hind foot 6(19.3%) 7(36.8%) 13 NS
Toes 8(25.8%) 4(21%) 12 NS
Dorsum 3(9.6%) 1(5.2%) 4 NS
Ulcer extent
1-5cm 23(76.7%) 7(23.3%) 30 0.009
>5cm 8(40.0%) 12(60.0%) 20
Ulcer duration
<1 week 15(88.3%) 2(11.7%) 17
0.001
1 week-3months 13(68.4%) 6(31.6%) 19
>3 months 3(21.4%) 11(78.6%) 14

24. Base line characteristics of ulcer examination and relation to healing
(cont.)
Variable Healed Unhealed Total p. value
Ulcer depth (n%)
Grade.1 16(88.9%) 2(11.1%) 18
0.005
Grade.2 13(54.2%) 11(45.8%) 24
Grade.3 2(25.0%) 6(75.0%) 8
Texas class. (n%)
1A+2A 21(84%) 4(16%) 25 0.001
2D+3D 1(10.0%) 9(90.0%) 10 0.001
Wagner class. (n%):
Grade 1 16(88.9%) 2(11.1%) 18
0.001
Grade 2 13(59.1%) 9(40.9%) 22
Grade 3 2(20%) 8(80%) 10

25. Table (3) aboratory data and relation to healing
Variable UnHealed n=19 Healed n=31 P-value
Urea mmol/L 8.09 ± 2.63 6.68 ± 1.94 NS
S.Creatinine umol/L 206.63 ± 165.50 93.36 ± 36.60 0.001
Cr.Clearance ml/min 56.25 ± 32.07 92.53 ± 27.18 0.000
24 hr protein in urine mg/l 442.42 ± 226.22 229.71 ± 149.42 0.000
WBCS k/ul 11.39 ± 3.90 7.33 ± 2.04 0.000
Hgb gm/dl 10.11 ± 1.73 11.62 ± 1.08 0.004
Platelets k/ul 247.00 ± 28.93 235.10 ± 27.07 NS
Hb A1c H% 12.88 ± 2.03 8.06 ± 0.99 0.008
Serum albumin g/l 26.28 ± 5.87 30.69 ± 4.37 0.004
Bilirubin umol/l 11.31 ± 3.05 10.97 ± 2.61 NS
ALT Iu/l 20.31 ± 4.81 15.72 ± 6.20 NS
AST Iu/l 18.03 ± 6.46 16.65 ± 5.95 NS
S. Cholest mg/dl 228.47 ± 67.16 189.39 ± 45.35 0.010
TG mg/dl 162.56 ± 40.69 139.42 ± 87.64 0.000
HDLmg/dl 37.49 ± 8.07 43.15 ± 8.60 0.000
LDLmg/dl 113.42 ± 29.78 95.92 ± 16.14 0.048

26. Table (4)Multivariate regression analysis of predictor
.variables towards unhealing
Outcome: unhealing
Predictor variable
Sig. OR 95.0%C.I.
Duration of diabetes: > 10 yrs 0.008* 2.16 1.02-2.61
Male sex 0.024* 1.11 1.03-2.86
Sever p.neuropathy 0.012* 1.13 0.89-1.46
Texas grade 2D, 3D 0.004* 1.24 1.15-3.24
Wagner grade-3 0.005* 1.18 1.09-2.98
>3 months Ulcer duration 0.013* 1.12 1.33-2.85
ABI< 0.8 0.006* 1.16 1.05-2.68

28. (Case (1

29. (Case (2

30. (Case (3

31. Case 4

32. Case 5

33. Case 6

34. Unhealed cases

35. Conclusion
 In conclusion, the major findings from this
study are, male sex, duration of diabetes
≥10years, sever pripheral neuropathy, ulcer
duration>3month,Wagner grade3,Texas
grade2D,3D and limb ischemia as ABI<0.8
independently predict poor outcome
(unhealing) of diabetic foot ulcer .

36. References
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