Atypical Wounds Q&A

  • Jayesh B. Shah, MD, CWSP, UHM
  • Volume 07 - Issue 2



1. A patient has a diabetic wound that probes to the bone. ESR -103, CRP - 6. An X-ray suggests changes of periosteal elevation and sclerosis suggestive of osteomyelitis. Which of the following would you do next?

  A. radionuclide bone scan

    B. MRI of right foot

    C. start six weeks of IV antibiotics

    D. obtain a bone biopsy for culture prior to antibiotics

    E. culture the drainage prior to antibiotics

2. A 32-year-old male who works as a field worker in the U.S. and resides in Mexico developed small sinus lesions on the left foot three years ago and now has developed multiple recurrent sinuses on that foot. The patient took multiple courses of antibiotics from Mexico. He presents to the wound clinic with a completely deformed left foot, swollen with multiple sinus lesions with purulent drainage as seen in the photo. Gram stain shows Gram positive nonspore-forming anaerobic bacilli with sulphur granules. What is the diagnosis?





    A. actinomycosis

    B. skin abscess because of drug use

    C. Charcot foot arthropathy

    D. sporotrichosis

3. A 32-year-old woman is evaluated for a five-day history of nodules over her lower extremities, which happened after she visited a local spa that used whirlpool foot baths. She reports shaving her legs with a razor before her visit. Tissue culture grows a mycobacterial species within five days. Which of the following is the most likely cause of the infection?

  A. Mycobacterium marinum

    B. Mycobacterium ulcerans

    C. Mycobacterium fortuitum

    D. Mycobacterium avium complex

4. A 70-year-old female with a history of Type 2 DM, ESRD, on hemodialysis, presents with an extremely painful wound on her leg, which started as small darkened area that progressively increased in size with worsening pain. What is the diagnosis?

    A. spider bite

    B. pyoderma gangrenosum

    C. calciphylaxis

    D. calcinosis cutis

5. A 65-year-old HIV-positive patient with recurrent hidradenitis suppurativa lesions on both buttocks now presents with fungating growth as seen on the picture. What is the diagnosis?







  A. basal cell cancer

    B. squamous cell cancer

    C. Kaposi sarcoma

    D. fungal infection



  1. D — The patient with osteomyelitis should get a bone biopsy and culture before being subjected to six weeks of IV antibiotics. There was a huge discrepancy in the patient with open wounds with osteo between swab culture and bone culture.2 Also probe to bone sign is more specific for diagnosis of osteomyelitis than any other radiological study.1 In patients with clinical sign of probe to bone and X-ray positive for osteo, the next best test is to do a bone biopsy.
  2. A — This patient has actinomycosis. Actinomycosis israelii is Gram-positive, nonspore-forming anaerobic bacilli.3 The treatment is surgical excision and antibiotics for six months. Ampicillin is the drug of choice.
  3. C — Mycobacterium fortuitum furunculosis is a well- described skin infection in patients who obtain pedicures at nail salons that use contaminated whirlpool footbaths. M. fortuitum, M. chelonae or M. abscessus are rapid- growing mycobacteria, and culture grows in less than seven days. All other mycobacteria listed in question are slow-growing organisms.
  4. C — The patient with long-standing ESRD who is on hemodialysis develops dysfunctional calcium and phosphorus balance leading to calciphylaxis. A patient with calciphylaxis has a high risk of mortality, with 60 to 80 percent of patients dying within six months of diagnosis. The patient usually develops sudden superficial skin necrosis followed by painful, pruritic, violaceous skin discoloration in livedo reticularis pattern with black eschar. Biopsy shows metastatic calcification within the lumen of arterial vessels.5
  5. B— This patient with hidradenitis suppurativa now has fungating growth, patient’s ulcers has transformed into malignancy, and most common malignant transformation in chronic ulcer is squamous cell cancer.6 


  1. Meta-Analysis of DX tests for DM Osteo- (9 Studies: 1,054 patients). Infect Dis. 2008; 47:519-27.

  2. Senneville E, Melliez H, Beltrand E, et al. Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: concordance with ulcer swab cultures. Clin Infect Dis. 2006; 42:57-62.

  3. Bettesworth J, Gill K, Shah J. Primary actinomycosis of the foot: A case report and literature review. JACCWS. 2009 July; 1(3):95-100.

  4. Wentworth AB, et al, Increased incidence of cutaneous nontuberculous mycobacterial infection, 1980–2009: A population–based study. Mayo Clin Proc. 2013 Jan; 88(1):38-45.

  5. Rose EA. Evolution of treatment strategies for calciphylaxis. Am J Nephrol. 2011; 34(5):460-7.

  6. Alam M, Ratner D. Cutaneous squamous cell carcinoma. NEJM. 2001 Mar 29; 344(13):975-83.


About the Author


JAYESH B. SHAH, MD, CWSP, UHM, is president of South Texas Wound Associates, PA, and of TIMEO2 Healing Concepts, LLC, both in San Antonio, Texas. His degrees include an MBBS (bachelor of medicine and surgery) from Maharaja Sayajirao University in Baroda, India, and an MD in internal medicine from St. Luke’s Roosevelt Hospital, Columbia University, New York. He is board certified in internal medicine and in undersea and hyperbaric medicine and certified in wound management and in hyperbaric medicine.

Shah has more than 18 years’ experience in wound care and hyperbaric medicine practice and more than 12 years’ experience as program director for continuing medical education courses. He currently serves as the medical director for the Northeast Baptist Wound Healing Center. An adjunct professor in the Department of Family and Community Medicine at the University of Texas Health Science Center, Shah is coeditor of the Wound Care Certification Study Guide, First Edition (published by Best Publishing Company). He created the WoundDoctor app for smartphones and authored 19 chapters on various wound topics in four books in addition to more than 30 scientific articles on wound care and hyperbaric medicine.





  • Catholic Health Advanced Wound Healing Centers
  • Volume 07 - Issue 2




Continuing our series of interviews featuring outstanding hyperbaric and wound care centers around the world, we spotlight in this issue the Catholic Health Advanced Wound Healing Centers in Buffalo, New York.

If an accredited facility, how has seeking UHMS accreditation affected your clinic?

In 2010, Catholic Health opened its first Advanced Wound Healing Center under the medical direction of Dr. Lee Ruotsi. Although we had a consulting agreement with a management company, our model differed from other programs in our geographical area. In our program, each center is staffed by system-employed medical directors, RNs, CHTs, office staff and a director. Our second center opened in early 2011, when Dr. William Lagaly was recruited from Little Rock, Arkansas. Over the next four years, the staff and medical directors worked to build a reputation for quality wound care and high patient satisfaction, boasting strong clinical outcomes.

During 2014, Catholic Health submitted our application, and over the following year, we worked diligently to prepare for the survey. In late 2015, we achieved UHMS accreditation.

The process was educational not only for us but also for our health system as a whole. It forced us to examine our business and clinical processes from a unique viewpoint: the hyperbaric patient perspective. During our preparation for the survey, we found that although our previous practices often met the minimum criteria required by UHMS, there was typically room for improvement. The survey also allowed the Advanced Wound Healing Centers to gain more visibility in our very busy, robust health system. Our quality, safety and senior leadership teams gained a better perspective into the challenges our department faces, and the accreditation fostered a sense of unity within our organization. The accreditation process gave senior leadership an in-depth understanding of how complex hyperbaric oxygen therapy is and what a strong program we had developed.

What are the most common indications treated at your clinic?

The most common indications treated at our clinic are diabetic foot ulcers, late effect of radiation, and failed or compromised skin grafts.

What is the most memorable treatment success story that has come out of your clinic?

“Of many memorable treatment successes, one comes immediately to mind: a 67-year-old female who was in our care in 2014,” Dr. Lee Ruotsi said. “She originally presented with typical chronic venous leg ulcers and was treated with multilayer compression wrapping to closure. During her initial consultation, a history of gynecologic malignancy in 1995 was noted; however, there was no further discussion of this at that time.

On one of her last visits for her leg ulcers, further history- taking and conversation led to a diagnosis of hemorrhagic radiation cystitis secondary to extensive external beam radiation therapy. She related her problems began about 8-9 years after the radiation treatments, and initially the symptoms consisted of mild discomfort, urgency, and occasional bleeding. As the years went on, however, the discomfort turned to pain, the urgency became incontinence, and the occasional bleeding became daily frank bleeding with clots. On a scale of 1-10, the adverse impact on her life was a 15. She had not left her house in years to attend social events or to go out for dinner, and she would not even sit on her own furniture unless she put down pads first.

We initiated hyperbaric oxygen therapy at 2.5 ATA for 90 minutes 5 days per week for a total of 40 treatments. As the weeks progressed, she became less and less symptomatic. The incontinence slowly resolved as did the pain, and the bleeding declined to occasional spotting. On her last visit she said the adverse impact was now a 2 out of 10. She was back to going out for dinner and sitting unprotected on her furniture. She thanked us, a bit tearfully, for what she felt had been a miraculous recovery. For us, it was a most gratifying reminder of the impact of hyperbaric oxygen therapy.

Do you work with a management company? If so, which one?

Catholic Health manages all operations internally, but we do have a consulting contract with Precision Healthcare.

If you had to pick one thing to attribute your clinic’s success to, what would it be?

As a healthcare system, Catholic Health is dedicated to the needs of the community we serve. A lack of accessible wound care services was identified in the Western New York area. In response to this, we opened the Advanced Wound Healing Centers. Being a part of such a large, yet community-centered, healthcare system allows our program to remain patient focused while being able to offer access to a broad network of collaborative services. We believe these are the key factors to providing the best possible patient care, thus achieving the highest level of successful outcomes.

What is one marketing recommendation that you can make to help clinics increase their patient load?

Our largest barrier to new patient referrals is a lack of wound care and hyperbaric oxygen knowledge within the medical providers in our area. Therefore, the best source of marketing for our clinic has been to utilize a wide range of educational activities. Our physicians speak to the medical community multiple times each year, including presenting to residents, nurses, and home-care clinicians. In addition, Catholic Health hosts an annual wound symposium — a full day, continuing-medical-education event that we market to all levels of caregivers on the latest advances in wound care. We also present relevant wound-care topics to the general public in support-group settings. Every educational event is an opportunity to market the services offered in our clinics.


Clinic Name: Catholic Health Advanced Wound Healing Centers
Location: Buffalo, N.Y. (two locations)
Phone: Sisters Hospital, St. Joseph Campus: 716-891-2570; Mercy Ambulatory Care Center: 716-828-2330
How long in business: Opened in 2010
How many chambers: 3 at Sisters Hospital, St. Joseph Campus; 2 at Mercy Ambulatory Care Center
Chamber types: Sechrist Monoplace 3600
How many physicians/nurses/CHTs: 2 full-time physicians, 1 nurse practitioner, 5 RNs, 2 LPNs, 3 CHTs
Medical directors: Dr. Lee Ruotsi at Sisters Hospital, St. Joseph Campus; Dr. William Lagaly at Mercy Ambulatory Care Center
Date of UHMS accreditation: November 2015

Not All Swelling Is Equal: Differential Diagnosis of Edemas

  • Heather Hettrick PT, PhD, CWS, CLT, CLWT
  • Volume 07 - Issue 2

This article is the first in a series of three that will address the clinical importance of recognizing edema for differential diagnosis. The focus of this article will be on recognizing edema and performing appropriate clinical tests to help with clinical diagnosis. The second article will focus on the pathophysiology of lymphedema, and the third article will cover common complications seen with lymphedema.

Edema is a common condition many of us have experienced. It is seemingly benign and self-limiting. By definition, edema is the presence of abnormal amounts of fluid in the extracellular tissues. Typically, an equilibrium is maintained through a delicate balance between hydrostatic and osmotic pressure inside and outside the blood vessels.

Generally speaking, hydrostatic pressure is determined by blood pressure and the effects of gravity, whereas osmotic pressure is determined by the concentration of protein inside and outside the vessels. Under normal circumstances, the hydrostatic pressure that pushes fluid out of the veins is slightly higher than the osmotic pressure that keeps fluid in. This results in a slight loss of fluid into the interstitial space. Subsequently, this fluid is taken up by the lymphatic capillaries and returned to the venous circulation as lymphatic fluid. Daily fluctuations exist, but for the most part, the human body does an exceptional job maintaining fluid balance.

This may seem straightforward, but it isn’t. There are more than 30 medical causes of edema, which can range from mild dependent edema to swelling from a minor trauma such as an ankle sprain, to specific disease-related edemas to complex swelling associated with concomitant comorbidities. To help accurately identify the type of edema and determine the underlying pathophysiology and associated complications that patients may have, healthcare providers need to be aware of the clinical presentation of edema and the subtle variations that can exist. Early recognition of the type of edema is essential because not all edemas are managed the same nor benefit from standard interventions. This article will focus on how to clinically assess edema to assist with differential diagnosis and to direct the plan of care by providing the appropriate interventions based on the type of edema presenting.

Initially, it is important to examine the characteristics of the edema and involved tissue structures. The texture of the tissues as well as pitting and rebound qualities of the swelling can assist in differential diagnosis. Edema can present as pitting or nonpitting and can be determined by palpating the involved area or extremity. Pitting edema can be determined by applying firm, yet gentle pressure to the swollen area by depressing the skin with the finger. If the pressing results in an indentation that persists for some time after the release of the pressure, the edema is considered pitting edema. Rebound is the time it takes for the indentation to disappear and can be helpful in determining the severity of the edema. In nonpitting edema, the pressure applied to the skin does not result in an indentation, or the indentation may be difficult to induce and long to rebound. Pitting is indicative of fluid in the tissues, whereas rebound is indicative of fibrotic changes in the tissues.

Pitting edema is graded on a scale of one to four and is determined by the depth of the indentation as well as time to rebound or return to normal. Variations do exist. Table 1 is a culmination of the various pitting scales.

Nonpitting edema is typically indicative of lymphedema due to the fibrotic changes associated with this condition. Fibrosis leads to a hardening of the skin, which renders the tissues unyielding to indentation. In addition to determining the pitting or nonpitting quality of the edema, texture must also be assessed. Tissue texture, in the context of edema, can present on a spectrum or continuum as described in Table 2.

Appreciating  the pitting and texture characteristics of the edema will provide valuable insight into the potential underlying cause(s) of the edema. In addition, the tissue temperature should be assessed in the edematous area and compared to contralateral and/or noninvolved area(s) to ascertain whether the temperature is normal, elevated, or cooler to touch. Any deviation from normal should be further investigated and may warrant referral to a physician. Elevated temperatures could be indicative of active inflammation or infection. Cooler temperatures could be related to underlying circulatory impairments or a local ischemia.

Table 1. Edema Pitting Scale

Grade Definition
1+ 2 mm, barely detectable, pitting rapidly disappears, immediate rebound
2+ 4 mm, rebound varies from a few seconds to 10-15 seconds
3+ 6 mm, rebound varies from 10-12 seconds to 30 seconds to 1 minute; extremity appears fuller and swollen
4+ 8 mm, rebound varies from >20 seconds to 2-5 minutes; extremity is grossly edematous and distorted


Table 2. Tissue Texture

Normal Supple, pliable, elastic
Watery Edema Palpation manually displaces fluid; palpable pockets of fluid under thin, translucent skin
Soft Pitting Edema Soft; boggy; feels like dough when palpated or manipulated
Fibrotic Skin thickened, difficult to pinch or tent; difficult to induce pitting or pitting remains >30 seconds; dense connective tissue; less fibrotic —feels like a tube of toothpaste; more fibrotic —feels firms and leathery; skin may have a cobblestone or lumpy, bumpy appearance
Hard/ Noncompressible Nonpitting; nonpliable; appearance akin alligator skin or tree bark; typical of advanced or long-standing lymphedema

Temperature can be assessed by using one of three methods in clinical practice. The first method is manual assessment by placing the back of the hand on the area in question and comparing it to the contralateral and/or noninvolved area(s) to detect temperature discrepancies. Two other methods involve simple, handheld clinical tools. A thermistor measures surface temperature with a probe that requires surface contact. Thermistors are appropriate on skin that is intact and not denuded or weeping. A radiometer measures surface temperature by infrared radiation. It does not require surface contact and therefore can be used on tissue that is disrupted, impaired, or weeping.

Table 3. Common Clinical Presentations of Swelling
  CVI Lymphedema Lipedema CHF
Etiology Failure of valves in deep, perforating or superficial veins Lymph transport failure Abnormal fat depositions and metabolism (not obesity) Heart Failure
Protein Content Low High Low Low
Stemmer Sign Negative Positive Negative Negative
Symmetry Symmetrical Asymmetrical Symmetrical Symmetrical
Appearance Edema in gaiter area Edematous legs with square-shaped toes, deep folds, loss of contours Large hips, thighs, feet spared, disproportionately small trunk and arms Buffalo hump on dorsal feet
Texture Brawny Lumpy, bumpy or hard, crusty; earlypitting, long- standing nonpitting Loose, lobular Soft, doughy, deeply pitting
Progression Distal, below knee Distal to proximal Distributed evenly hips and thighs Distal to proximal
Response to Elevation Reduces Persists Unaffected (not a fluid problem) Reduces rapidly
Onset Slow Slow Slow; primarily affects females Rapid
Pain Achy, worse at end of day Rarely painful Painful to palpation Distention discomfort
Wounds Weeping, blistering, shallow, uncomfortable, venous ulcers common Ulcers uncommon, lymphorreah with skin denudement common Bruise easily; no ulcers or weeping Distention and weeping, watery edema, blisters
Skin Changes Hemosiderin staining, strophe blanche, lipodermatosclerosis, brawny or taut skin, varicose veins, dermatitis Progressive fibrosis, lichenification, hyperkeratosis, papillomatosis Bruises easily, weak connective tissue, loose and lobular fatty tissue Cyanosis, jugular distention, shortness of breath
Infection Rarely cellulitis, can be polymicrobial Recurrent cellulitis and fungal infections No cellulitis No cellulitis
Tests and Measures ABI, venous duplex ultrasound ABI, venous duplex ultrasound N/A unless concurrent CVI or lymphedema ABI ro arterial disease and venous duplex ultrasound to r/o DVT
Treatment Multilayered compression bandaging to reduce, day compression garment to maintain, 30-40 mmHg, wound care Complete decongestive therapy, diuretics are contraindicated (unless other medical condition warrants use) Supportive compression garment 20-30 mmHg, diuretics not indicated, may progress to CVI and/or lymphedema; require those interventions Medical management, diuretics, thigh high compression 20-30 mmHg
NOTE: Created by Robyn Bjork, International Lymphedema and Wound Training Institiute. Reprinted with permission. Modified by author.

Another clinically relevant test is the Stemmer Sign. A thorough physical examination is7-2image considered the gold standard for the diagnosis of lymphedema. A complete history, systems review, inspection, and palpation can assist in determining whether the edema is lymphedema. At present, the only clinical test that has been proven reliable and valid to clinically diagnose lymphedema is the Stemmer Sign. The fibrotic changes associated with lymphedema can lead to a thickening of the skin over the proximal phalanges of the toes or fingers. If the clinician is unable to tent or pinch the skin on the involved extremity, this indicates the presence of lymphedema (positive Stemmer Sign as shown in the photo to the right). A negative finding (where the tissue is still pliable and soft), however, does not rule out the presence of lymphedema. It just may be the lymphedema is still in the early stages before tissue proliferation and fibrosis has occurred.

In clinical practice, the most common forms of edema seen are due to congestive heart failure (CHF), deep vein thrombosis (DVT), chronic venous insufficiency (CVI), and lymphedema. Patients with lipedema often are thought to have edematous limbs, even though this condition is not fluid-related but rather a pathological deposition of adipose tissue. An excellent resource to learn more about lipedema can be found at It is important to note that lymphedema is often complicated by other conditions leading to combination forms of complex swelling. For example, lymphedema with concomitant CVI is plebolymphedema. Lymphedema in patients with lipedema is lipolymphedema. Patients can also present with lymphedema, CVI, and lipedema, which is known as phlebolipolymphedema. A detailed article on lymphedema will follow in the next issue of WCHM magazine. Please refer to Table 3 for a comprehensive overview comparing various edemas.

A thorough patient history should be conducted on any patient presenting with edema of unknown origin. Reviewing the medications the patient is taking is of utmost importance, as many medications can induce or exacerbate swelling.

It is also important to perform noninvasive vascular testing on patients with lower-extremity edema. It is vital to appreciate the health of patients’ venous and arterial systems, as compression is often the cornerstone therapy for edema management. To safely and effectively use compression, healthcare providers must understand if a patient’s body can tolerate compression.

The Ankle Brachial Index (ABI) is a noninvasive vascular exam to screen for arterial insufficiency. It compares blood- flow pressure in the lower leg to blood-flow pressure in the upper arm. By dividing ankle pressure by brachial pressure, a ratio is determined, which is the ABI value. Variations exist in the literature, but the interpretation shown in Table 4 is widely accepted in clinical practice.


Table 4. ABI Values and Interpretations
1.0-1.4 Normal None
0.9-1.0 Acceptable None
0.8-0.9 Some Arterial Disease Treat risk factors
0.5-0.8 Moderate Arterial Disease

Refer to vascular specialist (do not compress)

<0.5 Severe Arterial Disease

Refer to vascular specialist (do not compress)

Realize, however, that ABI screening may not be accurate in diabetic patients whose vessels are often calcified. Their values tend to be falsely elevated (often > 1.2) and may often be mistaken for normal. Transcutaneous oxygen, tcpO2 or TCOM, and toe pressures are more reliable vascular screens for patients with diabetes.

Comprehensive skin assessment, including a thorough review for edema, should be part of every patient encounter. Recognizing and appreciating the qualities and characteristics of edema will assist healthcare providers with differential diagnosis to promote appropriate interventions and improve patient outcomes.

About the Author


HEATHER HETTRICK, PT, PHD, CWS, CLT, CLWT, is an associate professor in the Physical Therapy Program at Nova Southeastern University in Ft. Lauderdale, Florida. As a physical therapist, her expertise resides in integumentary dysfunction with clinical specialties in wound, burn and lymphedema management. Hettrick has three certifications including: Certified Wound Specialist by the American Board of Wound Management, Certified Lymphedema Therapist by the Academy of Lymphatic Studies, and is dual certified internationally as a Certified Lymphedema and Wound Therapist through the International Lymphedema Wound Training Institute.

Hettrick has diverse work experience in academia and the private sector. Her more recent employment history includes Assistant Professor and Director of Clinical Education at the University of New Mexico; Vice President of Academic Affairs and Education for Gordian Medical, Inc. dba American Medical Technologies; Clinical Assistant Professor in the Department of Physical Therapy at New York University; Adjunct Professor at Drexel University; Program Coordinator for Burn Rehabilitation Research at the William Randolph Hearst Burn Center at NY Presbyterian Hospital and a Master Clinician at the Hospital for Joint Diseases at the Diabetic Foot and Ankle Center.

Hettrick is a past president of the American Board of Wound Management and served on the Executive Committee and Board of the Association for the Advancement of Wound Care. She was recently appointed to the Board of the World Alliance of Wound and Lymphedema Care, and she is helping to establish a lymphatic filariasis morbidity plan for Haiti. She is actively involved in numerous professional organizations, conducts research and publishes, presents and teaches nationally and internationally on integumentary-related issues.


Continuing Education in Wound Care: It’s A Big Deal

  • Terry Treadwell, MD, FACS, Medical Director
  • Volume 07 - Issue 2



Almost everyone who provides health care has some basic “smarts” or they would not have made it through school to become a practitioner. I would be the first to agree that professional schools and postgraduate training programs are difficult, requiring significant dedication to finish. Once one walks out of that room or auditorium with the final certification and license to practice, there is a great feeling of finally being “done.” Unfortunately, that time in our lives only marks the beginning.

Despite all we have learned, it has been shown by many people through the years that at least half of what we learn in school and postgraduate programs will be useless or proved wrong by the time we finish our careers.1 I can WCC-STUDYGUIDEtruthfully say that fully half of the technologies and products we use daily in our wound treatment center did not exist 10 years ago. For these reasons, continuing to look for the best approach to treating wounds is critical.

A recently published book, Wound Care Certification Study Guide, 2nd Edition, edited by Drs. JB Shah, PJ Sheffield and CE Fife is a resource I would recommend to help with your search for information.2 As one can tell by the title, it has been developed to assist anyone planning to take any of the wound certification examinations, but the amount and scope of the information in the book can serve as a textbook for anyone who wants an updated source of wound care information.

The book contains 33 chapters covering all the basic and advanced topics likely to be faced by someone treating patients with any type of wound. Since the first edition was published in 2011, all of the chapters have been updated, and a chapter introducing the use of hyperbaric oxygen has been added. Each chapter has numerous references to the topics if further reading is desired. There are illustrative questions included at the end of each chapter to help the reader evaluate his/her comprehension of the subject before moving to the next.

Each chapter contains numerous photos that detail the issues being discussed. The underlying pathophysiology of each condition is included, leading the reader to a better understanding of the problem and why certain treatments are selected. Chapter 7: Patient Preparation and Education presents a unique perspective for helping the patient and family understand what to expect from having a chronic wound and the proposed treatments, including pain management, dressing changes and possible treatments outside of the wound center.

Because of the importance of bacteria in chronic wounds, the editors have included three chapters dealing with the topic. The first is an overview of microbiology to refresh one’s memory about the basics of the subject. This is followed by a chapter on infection control and subsequently, an overview of wound infections. If a biopsy culture is to be obtained and anesthesia is required, it is important to remember many topical anesthetics have antimicrobial actions of their own, which should preclude their use when taking specimens for culture. Berg and associates reported that any topical anesthetic, especially Emla cream, has a rapid and powerful antibacterial effect within 30 minutes of applying it to the wound surface.3 Use of this anesthetic can lead to unreliable tissue culture results. For this reason, the only anesthetic recommended for tissue biopsies done for culture is 1 percent preservative-free lidocaine.3

The chapter on lymphedema reminds the reader of the importance of this condition. Lymphedema is often overlooked when one deals with chronic wounds, but it should be remembered that the periwound lymphatics are always damaged, resulting in much of the periwound swelling being due to high-protein lymphedema fluid and not just low- protein edema fluid. This should remind all of the importance of compression bandaging and other forms of compression therapy in the treatment of any patient with swelling of the periwound tissues. It should also be realized that compression therapy can be successfully and safely used in the treatment of patients with an ankle/brachial index (ABI) of less than 0.8. Many feel this should not be done, but the safety and efficacy of careful compression in this group of patients has been well documented.4,5,6 If these patients are denied compression therapy, they will not improve or get well.

The chapter on burns presents a brief overview of the types of burns that may be encountered. Most severe burns are the purview of burn surgeons treating these patients in burn units. The topical treatment of second-degree burns is mentioned, but care should be taken when using any silver dressing in the treatment of these wounds. The toxicity of silver-containing products is well-recognized and is known to delay the healing of these burns. It must be noted that silver-containing topicals and dressings can be especially hazardous in infants and children.7-12

The chapter on dermatological review and unusual wounds should be of importance to all.

Treating patients in a wound-center setting does not rule out the possibility of being asked to see any patient with a skin defect or problem. Many times differentiating one skin defect from another can be difficult and must be done accurately and timely to avoid treatment that can be inappropriate, wasting both resources and time. The number of patients seen with “unusual wounds” may depend on where one lives and one’s diagnostic abilities. For example, in the South, brown recluse spider bites are not uncommon, whereas in the Northeast they are rarely seen. Many people say they never see pyoderma gangrenosum in their wound centers. I did not either until I was able to make the diagnosis. Do malignancies occur in or masquerade as ulcers? It depends on how hard one looks for them. I encourage wound biopsy if you are unsure of the diagnosis or if the wound has failed to respond to what you consider good therapy after four weeks of treatment.13-14

All in all, this is a good book for learning about and updating one’s knowledge of wounds, whether in preparation for a certifying exam or for continuing learning. Many consider continuing education a waste  of time or something for others. If we do not continue to learn throughout our professional careers, we will soon find ourselves behind everyone else. We certainly want to provide the best care possible for our patients. By increasing and updating our knowledge, we can provide better care for our patients.


  1. Vetto JT. Reflections: The Other Half. J Cancer Edu. 2014; 29:808-809.
  2. Shah JB, Sheffield PJ, Fife CE, eds. Wound Care Certification Guide, 2nd Edition. North Palm Beach, FL: Best Publishing Company; 2016.
  3. Berg JO, Mossner BK, Antibacterial properties of EMLA and lidocaine in wound tissue biopsies for culturing. Wound Rep Reg. 2006; 14:581-585.
  4. Woo KY,Alavi A, Evans R, et al. New Advances in Compression Therapy for Venous Ulcers. Surg Technol Int. 2013; 23:61-68.
  5. Mosti G, Iabichella ML, Partsch H. Compression Therapy in Mixed Ulcers Increases Venous Output and Arterial Perfusion. J Vasc Surg. 2012; 55:122-128.
  6. Neill K, Turnbull K. Use of Specialist Knowledge and Experience to Manage Patients with Mixed Aetiology Leg Ulcers. J Wound Care. 2012; 21:168, 170, 172-174.
  7. McCauley RL, Li YY, Poole B, Evans MJ, Differential Inhibition of Human Basal Keratinocyte Growth to Silver Sulfadiazine and Mafenide Acetate. J Surg Res. 1992; 52(3):276- 285.
  8. Cho Lee AR. Effect of Silver Sulfadiazine on the Skin Cell Proliferation and Wound Healing Process in Hairless Mouse 2nd Degree Burn Model. J Kor Pharm Sci. 2002; 32:113-117.
  9. Cho Lee AR, Moon HK. Effect of Topically Applied Silver Sulfadiazine on Fibroblast Cell Proliferation and Biomechanical Properties of the Wound. Arch Pharm Res. 2003; 26(10):855-860.
  10. Treadwell TA, Fuentes ML, Walker D. Treatment of Second Degree Burns with Dehydrated, Decellularized Amniotic Membrane (Biovance) vs. a Silver Dressing (Acticoat). Wound Rep Reg. 2008; 16:A39.
  11. Poon VKM, Burd A. In Vitro Cytotoxicity of Silver: Implication for Clinical Wound Care. Burns. 2004; 30:140-147.
  12. Wang XQ, Kempf M, Mott J, et al. Silver absorption on Burns after the Application of Acticoat: Data from Pediatric Patients and Porcine Burn Model Reported Raised Serum Silver Levels in Pediatric Burn Patients. Journal of Burn Care and Research. 2009; 30(2):341-348.
  13. Ackroyd JS, Young AE. Leg Ulcers That Do Not Heal. Br Med J.1983; 286:207-208.
  14. Hansson C, Anderson E. Malignant Skin Lesions on the Legs and Feet at a Dermatological Leg Ulcer Clinic During Five Years. Acta Derm Venereol 1997; 78:147-148.


About the Author


DR. TERRY TREADWELL received his medical education at the University of Texas Southwestern Medical School in Dallas, Texas. He served his general and vascular surgical residencies at Scott and White Medical Center in Temple, Texas, and practiced vascular and general surgery in Montgomery, Alabama. In October 1998, Treadwell founded the Institute for Advanced Wound Care at Jackson Hospital in Montgomery. He served as medical director of the center and treated wound patients on a full-time basis, providing the best possible care to this seemingly forgotten group of patients. In February 2006, the Institute for Advanced Wound Care moved to Baptist Medical Center in Montgomery. Treadwell serves as the medical director of the institute. He has been involved with numerous educational and research initiatives and directs wound- care educational programs at his wound center to help educate physicians and other medical personnel in the current therapy of acute and chronic wounds.

Treadwell has shared his experience in the treatment of chronic wounds through lectures, presentations and publications. Wound-care practitioners from around the world have attended preceptorships at the Institute for Advanced Wound Care. He has assisted in the establishment of wound treatment centers in Ghana, Africa, and Port-au-Prince, Haiti. He is the clinical editor of Wounds magazine and is a member of the World Association of Medical Editors. He is a member of the Wound Healing Society and the Association for the Advancement of Wound Care. He has served two terms as the Physician Member of the Association for the Advancement of Wound Care board of directors, and has served as the president and past-president of the AAWC.

He is serving on the World Health Organization Committee, the World Alliance for Wound and Lymphedema Care, to develop wound education and treatment guidelines for treatment of acute and chronic wounds in underdeveloped countries of the world. He is the current vice president of the World Alliance for Wound and Lymphedema Care board of directors and the president-elect. He was recently named Associate Professor of Wound Care at the University of Medicine and Pharmacy, Port-au-Prince, Haiti.


Prevention of New and Recurrent Foot Wounds

  • Michael B. Strauss, MD; Anna M. Tan, DPM; Lientra Q. Lu
  • Volume 07 - Issue 2

Part 1: Introduction and Misconceptions

In our previous articles in Wound Care and Hyperbaric Medicine we discussed the evaluation and management of "problem" wounds and the roles of hyperbaric oxygen for them (Figure 1).1-12 Regardless of immediate results, what really counts  is the durability of the healed wound and the restoration of function. This makes the prevention of new and recurrent wounds an essential component of the care provided to the patient. The adage “An ounce of prevention is worth a pound of cure” is nowhere more true and appropriate than in the healing of the diabetic foot wound.

FIGURE 1. Evaluation, Management and Prevention of Problem Wounds

FIGURE1Legend: Important elements of the evaluation management and prevention of wounds are depicted above. Almost all of the evaluation and prevention items have been published as separate articles (References 1-12). The remainder of this paper will introduce the subject of prevention measures.

Often during hospitalization and subsequent skilled nursing care, the patients’ activities are so controlled that healing is achieved. When the patients return to their home environments and the restoration of their prewound activities, however, the wound recurs. This paper is the first in a series of five for Wound Care and Hyperbaric Medicine that expounds on the prevention of new and recurrent wounds in the lower extremities. This initial paper discusses myths and misconceptions about healing of the foot wound — especially in the diabetic — and introduces the four preventive measures for new and recurrent wounds, each of which will become a subsequent article.

Although this paper and the subsequent papers in this series are primarily directed at diabetic foot wounds (DFWs), it is equally applicable to problem foot as well as other lower-extremity wounds in patients who are not diabetic. This concept was appreciated by Dr. William Wagner, for whom we are indebted because of using his nearly universally accepted diabetic foot ulcer grading system. In his initial paper on the subject, he limited his grading system to diabetic foot ulcers.13 Two years later he revised his algorithms to include foot ulcers in nondiabetics as well.14

Foot wounds in diabetics and patients with peripheral artery disease are common — 10 to 100 times more so than those without these problems. About 1 in 15 diabetics will develop a foot wound sometime during their lifetime.15 Approximately 85 percent of lower-limb amputations are preceded by nonhealing foot wounds.16 The majority of foot wounds are easy to manage and resolve completely in their incipient stages. We computed the costs to prevent a foot wound to be 1/50th of the costs to treat one.

Our Observations

Once a foot wound is healed, the majority — that is, more than 90 percent of the cases in our experiences — of new foot wounds occur because of one or more confounding factors, which include the following: 1) underlying deformity (bone, bursa and/or cicatrix), 2) deep infection (especially of the deformity-related structures just mentioned) and/or 3) ischemia-hypoxia.17

Table 1. Why wounds-Especially of the feet-Arise or Recur
Factor Effect/Problem Management Comment
Comfounding Factors, i.e. the "Troublesome Triad"
Deformity Pressure sores Off---load, surgical correction One or more of these factors found,in 90% of the patients hospitalized with diabetic foot ulcers we studied
Deep Infection Inflammation, cell death Antibiotics, debridement  
Ischemia---hypoxia Impairment of metabolic processes, cell death Revascularization, hyperbaric O2  
Other Explanations
Malnutrition Inhibits generation of sub-states; lowers resistance Supplements, G---tube, hyper alimentation Quantified with albumin & prealbumin measurements
Diabetes Hastens atherosclerosis fosters infection, Insulin, medications, weight loss Quantified with blood glucoses & HbA1c
Matrix metallo---proteinases Enzymatic degradation of wound healing precursors Debridements, hygiene, tetracyclines, Promulgram® Postulated to stall wound healing; but questionable
Collagen vascular diseases Vasculitis, primary endothelial dysfunction Wound care, live with chronic---stable wounds Distal toe & foot amputation; oeen fail; lead to BKAs
Lymphedema O2 diffusion distance through tissue fluids Elevation, elastic wraps, diuretics O2 diffuses from capillary to cells through tissue fluids
Steroids/Immunosuppressors Hinders healing & infection defenses Vitamin C, antibiotics, Interferes/halts inflammatory responses
Anemia Decreased O2 delivery/availability to tissues Iron supplements, erythropoietin, transfusion May benefit perfusion; less cell mass in sluggish flow
Chronic kidney disease Unhealthy environment for metabolism Medications, dialysis, renal transplant Edema & anemia; immunosuppressers (transplants)
Liver disease Hampers generation of proteins; eliminates wastes Diet, medications, transplants As above for chronic kidney disease
Immune deficiencies Uncontrolled infections; life/ limb threatening Antibiotics, transfusions, vasopressors Associated with adrenal shutdown, splenectomy

These are labeled confounding factors because they are often not appreciated to the extent necessary to prevent new or recurrent wounds, overlooked or outright discarded. This latter consideration is especially important in the noncompliant patient; and/or the patient lost in the exigencies of eponymic health maintenance organizations (HMOs) and insurance payers authorization; and increasingly onerous documentation requirements. Each confounder has defined techniques for diagnosis and specific interventions for management and has been mentioned in the first author's previous publications.1,18

It has been reported that 60 percent of patients with a diabetic foot wound will develop a recurrent wound.19,20  Problems  such as malnutrition, adequate glycemic control, matrix metalloproteinases, collagen vascular diseases, lymphedema, requirement for steroids/immune-suppressors, anemia, chronic kidney disease, liver failure and immune deficiency disease that interfere with healing are usually adequately managed during hospitalizations, but for the reasons discussed in the preceding paragraph often lack adequate posthospitalization follow-up care (Table 1). Succeeding articles in this series of wound-prevention articles will further elaborate on the four prevention strategies.

Misconceptions Regarding Prevention of New and Recurrent Diabetic Wounds

In our region, and it is probably no different in other regions of the USA, once the HMO patient is discharged from an emergency hospitalization because of a foot wound and the wound is nearly healed and/or markedly improved, follow-up care is often delayed or the patient is returned to one of the HMOs contracted providers who lacks the expertise in optimizing wound care. The consequences often are worsening of the wound after discharge from the hospital.
If authorizations for follow-up care with wound care specialists are eventually provided, often the delay in follow-up care reveals absence of appropriate wound care in the interim, worsening of the wound, inappropriate use of protective footwear or the need for rehospitalization with additional surgeries. Other consequences include failure to recognize new or continuing confounding factors that need to be addressed to prevent new or recurrent wounds.

1. Once a foot wound heals, the wound will inevitably recur after activity is resumed.

Fact #1: The reasons for this misconception are the high recurrence rates observed when activity is resumed after wounds heal with hospital management, rest and offloading and as is especially observed with malperforans ulcers after total contact casting.21 Without attention to the underlying deformities and the other wound confounders, new and recurrent foot wounds are likely to occur.

Fact #2: With attention to managing deformities, muscle imbalances, wound hypoxia and infection — and initiation of prevention strategies (as will be discussed in subsequent articles), new or recurrent wounds can be prevented.

Fact #3: Furthermore, once a wound is healed, the metabolic demands to maintain the wound site in a healthy condition are but a small fraction of what was required for healing and infection control. As much as a 20-fold increase in perfusion and metabolic activity compared to the resting, healed state may be required.22 The increased perfusion arises from redistributing the human body’s limited blood volume (about 5 liters) from noncritical — in terms of perfusion — to the wound site in response to sympathetic nervous system activity and cytokines.

Even in the presence of peripheral arterial disease, the approximately 1/20th reduction in perfusion and metabolic activity is usually sufficient to meet the minimal metabolic demands of the noncritical tissues. Consequently, with the prevention strategies, healed wounds, especially of the feet and ankles, remain healed regardless of marginal perfusion to these areas.

Fact #4: Patient compliance is a crucial factor in avoiding new and recurrent foot wounds. Although much is written about the importance of compliance, little information is available on how to quantify it. Our next article for Wound Care and Hyperbaric Medicine, which will focus on patient education, will offer much information on measuring patient compliance and how to use this information for managing patients.

2.Preserving the foot has little functional significance in the marginal ambulatory.

Fact #1: A lower-limb amputation in the minimal ambulator who had been independent with activities of daily living may increase the energy demands for walking with a prosthesis to the point that the patient requires assisted living.

Fact #2: Energy demands for walking with a prosthesis, as measured by oxygen consumption, essentially double with a below-knee amputation and more than triple with an above- knee amputation.23,24

Fact #3: Additionally, weakness and arthritic changes in the upper extremities may make donning and removing the prosthesis difficult, if not impossible. With such comorbidities, the use of crutches or front-wheel walkers may be markedly restricted.

Fact #4: Rehabilitation and confidence in using a prosthesis may take a year or more to maximize strength, balance and endurance. In patients with cardiac and pulmonary comorbidities, oxygen-consumption demands for walking with a prosthesis may exceed the patients’ maximal aerobic capabilities.

Fact #5: Although an amputation may appear to be immediately cost-effective by expediently moving a patient from the acute hospital setting to a lower level of care, the total costs for managing the wound may be overall cost beneficial. For example, expenses for surgery, prostheses and rehabilitation exceed $50,000 during the initial 18 months after an amputation.25,26

Fact #6: Challenges for fitting the prosthesis are anticipated in the patient with cardiac and renal impairments where marked variations in stump volume occur. This can be further compounded by stump tissue atrophy, knee joint contractures, short stump lengths and lack of soft tissue padding over the end of the tibia.

3.Once a leg is amputated, amputation of the other limb will soon follow.

Fact #1: If the lower limb amputation is due to severe, diffuse, bilateral peripheral artery disease that cannot be revascularized, this statement may be true. With wound- prevention measures (which will be subsequently presented in future editions of Wound Care and Hyperbaric Medicine), however, contralateral lower-limb amputations can usually be avoided. This observation is supported by our previous discussion of the great differences in perfusion and metabolic activity to heal a wound in contrast to the steady state, nonwound, noninfection state.

Fact #2: If the lower-limb amputation is due to wounds associated with uncontrollable deformities such as Charcot neuroarthropathy or distal leg-ankle fracture nonunions, subsequent amputation of the other extremity is highly unlikely in the absence of new problems in the remaining extremity.

Fact #3: In the situations in which a lower-limb amputation becomes necessary, be it unilateral or for the opposite limb in the patient who is already an amputee, one or more criteria for amputation are invariable present. Undoubtedly, one of the most important is uncontrollable pain. Other reasons for the lower-limb amputation include gangrene of the foot, deformity severe enough that functional use of the extremity is not possible, nonhealing wounds secondary to vasculitis in patients with collagen vascular diseases and a subset of diabetic patients with foot wounds infected with methicillin-resistant Staphylococcus aureus. In this latter situation we have observed that as long as the patient remains on antibiotics, the wound appears healed, but once the antibiotics are discontinued — even after months of therapy — the wound recurs, usually moving proximally up the foot and leg. It appears this subset of diabetic patients is deficient in host factors needed to eradicate residual occultly infected tissues at the original wound site.

4.Care of the limb-threatening wound in the diabetic is different than in the patient without diabetes.

Fact #1: The severity of the wound is the overriding consideration for making decisions about management of the wound. Our Wound Score, which integrates information from the four most commonly used wound-grading systems, objectively grades wounds in a user-friendly format that determines the severity of the wound and provides the basis for management (Table 2). If the wound is in the “healthy” or “problem” wound categories, management using the strategies of 1) optimal wound base management, 2) appropriate protection and stabilization, 3) medical management including antibiotics, 4) suitable wound dressing agents and 5) adequate perfusion-oxygenation from our previous reviews resulted in more than a 90 percent positive predictive value for wound healing.18,27,28 It is irrelevant whether the patient is diabetic or not with use of our wound grading and management strategies.

TABLE 2. The User-Friendly 0 (Worst) to 10 (Best) Wound Score to Objectively Categorize Wounds


Fact #2: If the wound is serious enough that a lower-limb amputation becomes an option for management, then additional patient information — such as their health status and their goals — is required. Like the Wound Score, these scores are each based on five assessments graded from 2 (best) to 0 (worst) and have been previously described in Wound Care and Hyperbaric Medicine (Tables 3 and 4).1,18 These scores help to justify the decision whether to salvage the foot or recommend a lower-limb amputation and apply equally well to the diabetic as well as the nondiabetic.

TABLE 3. Wellness Score Quantity Patients' Health Status



TABLE 4. Goal Score Quantifies Patients' Desire to Avoid Lower Limb Amputation


Fact #3: The majority of patients with venous stasis disease ulcers are not diabetic. Again, management that utilizes the five strategies as described previously is employed. With venous stasis ulcers, the protection and stabilization strategy with compression dressings is a key element. Management of the wound base is also essential. When the ulcers are chronic and seemingly refractory to treatment, they require operating-room debridement to remove an impervious layer of cicatrix between the ulcer base and the underlying healthy vascularized tissue that may extend through the subcutaneous tissue to the underlying fascia (Figure 2). Once a healthy granulating wound base develops, split- thickness skin grafting is almost uniformly successful.

FIGURE 2. Cicatrix Excision from a Refractory

FIGURE2Legend: Nearly a quarter-inch (6 mm) thick layer of scar tissue has developed between the ulcer base and the underlying fascia. This is an impervious barrier between the ulcer base and the healthy underlying muscle fascia. The ulcer had failed to improve because of lack of perfusion to bring the necessary elements for wound healing to the surface of the ulcer.

Elevation, compression wraps, enzymatic debriding agents and bioengineered wound dressings had not been successful due to the impenetrability of the layer of cicatrix.


5. Neuropathy is the primary reason foot wounds fail to heal.

Fact #1: Neuropathy with absence of sensation is an indirect cause of wounds. It, in itself, does not cause wounds. Foot wounds are caused by stresses such as shear, pressure concentrations and/or trauma that exceed the skin’s ability to mitigate the aggravating factors. Contributing causes as previously mentioned include underlying deformities and ischemia-hypoxia.

The main concern of neuropathy-associated wounds is that it delays diagnosis. In the absence of pain, the wound may go unnoticed or be totally disregarded until others complain of odor, ascending infection develops or the patient becomes septic.

Other neuropathy contributing factors to wounds include 1) muscle imbalances (such as those leading to clawed toes) from motor neuropathy (these concentrate pressure stresses at the deformity sites); 2) excessive shear stresses from impaired proprioception (wounds occur with ambulation and shoe wear); 3) increased vulnerability of the skin to breakdown due to autonomic nervous system dysfunction (this leads to skin dryness, atrophy, loss of elasticity and wasting away of underlying soft tissue padding).

Fact #2: Neuropathy is not the reason a wound fails to heal. Paradoxically, neuropathy may facilitate wound healing by increasing blood flow through loss of autonomic nerve function controlling vasoconstriction. This leads to hyperperfusion as is so often in association with Charcot neuroarthropathy. Another reason there may be increased blood flow is that the blood vessels are calcified (atherosclerotic) and do not constrict in response to sympathetic nervous system stimulation.

Fact #3: Diabetic foot wounds in the presence of sensory neuropathy are typically the easiest to manage because dressing changes and wound debridements can be optimized since they do not lead to discomfort for the patient.

Fact #4: Even more convincing evidence to dispel the misconception that neuropathy is a direct cause of foot wounds is the observation that once the wounds are healed in patients with sensory neuropathy, recurrences are the exception in the well-motivated patient. This is attributed to compliance of the patient for the prevention measures (e.g., education, foot skin and toenail care, protective footwear and proactive surgeries), which each will be discussed in subsequent articles in Wound Care and Hyperbaric Medicine.

6. It is difficult to predict which patients are prone to wound development in their feet.

Fact #1: Consensus workshops uniformly agree that five risk factors — especially in diabetics — need to be recognized and appropriately addressed to prevent new and recurrent wounds in patients prone to develop ulcerations in their feet.29-32 The risk factors are: 1) deformity, 2) peripheral vascular disease, 3) history of previous wound, 4) previous amputation and 5) neuropathy

Fact #2: Other risk factors such as obesity, diabetes mellitus, malnutrition, smoking, myopathies, loss of proprioception (as in Charcot neuroarthropathy), collagen vascular diseases, inappropriate activities, improper footwear and compliance can also be contributing factors to new and recurrent foot wounds. Many of these can be recognized with an appropriate evaluation of the patient; several are remedial and manageable with appropriate care and counseling such as diabetes, malnutrition and smoking. Smoking and compliance will be discussed in subsequent articles in this series. Myopathies and loss of proprioception are factors rarely mentioned as causes of foot wounds. Because of abnormal gait mechanics leading to disproportionate shear stresses with ambulation, foot wounds are prone to develop in patients with these problems.

7. The patients’ physicians and other caregivers have little to offer in terms of preventing new or recurrent foot wounds.

Fact #1: It is crucial that appropriate medical follow-up be done to prevent new and recurrent foot wounds. Four items are essential for the follow-up evaluations (Figure 3): They include 1) patient education, 2) foot skin and toenail care, 3) proper protective footwear and 4) proactive surgeries. Each needs to be an element of follow-up evaluation and will be the subject for future articles in this series.

Fact #2: The more risk factors for foot wounds (i.e., deformity, previous wound, previous infection, peripheral artery disease and neuropathy) that are present in a patient, the more important follow-up evaluations are.

Fact #3: Follow-up intervals need to be tailored to the patient’s needs. For some patients, follow-ups may need to be done only once or twice a year, whereas in others they may need to be done at biweekly intervals to prevent new or recurrent foot wounds. As expected, there is an inverse relationship between the recommended frequency of patient follow-ups and patient compliance.

FIGURE 3. The Four Strategies to Prevent New and Recurrent Foot Wounds

FIGURE3Legend: Prevention strategies are fundamental for preventing new and recurrent foot wounds. Each complaints the others. Each evaluation and management of a patient with one or more of the risk factors predictive for foot wounds (namely deformity, neuropathy, peripheral artery disease, previous foot wound, or partial foot/toe amputation) should always address all of the four strategies. The prevention of a wound is highly cost effective versus dollars and dollars to cure it. (i.e. "An ounce of prevention is worth a dollar of cure.") Each strategy will be seperately discussed in our succeeding Wound Care & Hyperbaric Medicine articles.


Preventive medicine is assuming increasingly important roles in patient management. We previously published articles on risks factors, indirect and direct causes of diabetic foot wounds and the four-pronged approach to preventing diabetic foot ulcers. 33,34 This paper expands on these topics and lays the foundation for separate articles on each of the preventions strategies.

Periodic examinations with care providers is necessary in integrating the prevention strategies. Whereas annual physical examinations rely largely on laboratory data to make management recommendations, the prevention of new and recurrent foot wounds is dependent on examination

of the patient’s feet. As a further contrast, much of the preventive care offered to the patient from laboratory data is achieved through medications. For prevention of foot problems, the care is largely hands-on, such as skin and toenail care, selection of protective footwear and proactive surgeries. There are mutual concerns, of course, such as smoking history and obesity that are fundamental components of an examination and have ramifications for the entire body as well as the feet. Consequently, there is no better portal for prevention of new and recurrent foot

wounds than examination of the feet. Awareness of the five major risk factors (deformity, previous wound, previous amputation, peripheral artery disease and neuropathy) for developing foot wounds is the examination starting point for any patient to prevent new and recurrent foot wounds.

In the introduction, the magnitude of foot wound problems was mentioned. Examination of cost considerations give added justification for being proactive in preventing new and recurrent foot wounds. If a foot wound evolves to a necrotizing soft-tissue infection with underlying deep infection and/or osteomyelitis, hospitalization is required to save life and limb. The hospitalization for a serious diabetic foot wound typically exceeds $30,000. One or two surgeries at an estimated $10,000 each and 10 days of hospital care at $2,000 a day is an example of how quickly hospital care charges amass. Conversely, a lower-limb amputation is not necessarily a cost-beneficial approach to the foot wound problem. More than 15 years ago the estimated cost of a below-knee amputation with 18 months of follow-up including prosthesis costs and rehabilitation was more than $50,000.25,26 Today the total expenditures may be double this amount. For example, the charges for a below-knee prosthesis is about $15,000, and the computerized knee component alone for an above-knee prosthesis is $50,000.

The costs of hospital care and the prostheses do not represent the complete long-term costs and emotional toil a lower-limb amputation accrues. These “costs” can arise from inability to return to gainful employment and/or continue in an independent living status. Each has its own detriment to a patient’s emotional status and self-worth. Assisted living or skilled nursing costs $3,000 to $5,000 or more a month. The maintenance of independence in a marginal ambulator with their limbs intact, but managing to continue in an independent living status is far superior to the above options.

The donning and removing of a prosthesis and walking with the additional weight of the prosthesis plus loss of lower- limb proprioception may confine the patient to being able to use only the prosthesis to do transfers. Such scenarios can be emotionally devastating for the patient and extremely challenging for the patient’s family. Hence, the prevention of new and recurrent foot wounds extends beyond cost considerations alone.

A final consideration: Is it fair to discriminate levels of care between diabetics and nondiabetics (as mentioned in the fourth misconception discussed previously) with actual or impending foot wounds? Presently, there are major discrepancies between what care options are available through Medicare/CMS provisions and other third-party insurance providers for diabetics and nondiabetics. Two obvious examples include the provision of protective footwear for diabetics in accordance with the Diabetic Footwear Bill and the use of hyperbaric oxygen for specific diabetic foot wound problems (e.g., diabetic foot ulcers not improved with surgery and antibiotics for 30 days or more that involve deep abscess and/or osteomyelitis).

As noted before, Wagner expanded his diabetic foot grading system two years after his original publication to include nondiabetic foot wounds.14 Wagner differentiated only between the diabetic and nondiabetic using ankle-brachial indexes greater than 0.45 in the diabetic versus 0.35 in the nondiabetic for making decisions about limb salvage. Other than that, his algorithms for management were identical. Thus, we advocate equal diligence in preventing new or recurrent foot wounds regardless of whether or not the patient is diabetic.


The prevention of new and recurrent foot wounds is more than a cost-benefit consideration. Of all the preventive measures (not withstanding immunizations) used in medicine and surgery, the prevention of new and recurrent foot wounds is one of the most predicable and cost beneficial. Many misconceptions exist about foot wounds and their prevention. This article presents seven examples and provides facts and answers to dispel the misconceptions. Additional articles to follow in this series will elaborate on the specific strategies to prevent new and recurrent foot wounds and will include the subjects of patient education, skin and toenail care, protective footwear and proactive surgery. Although much attention has been given to this subject in the diabetic, we feel that all foot wounds — especially in the nondiabetic with peripheral artery disease — deserve the same attention as for the diabetic.


  1. Strauss MB, Miller SS, Aksenov IV. Challenges of Wound Healing. Wound Care and Hyperbaric Medicine, 2011; 2(1):28-37.
  2. Strauss MB, Miller SS. Preparation of the Wound Base: The Science and Art of Debridement. Wound Care and Hyperbaric Medicine, 2011; 2(2):14-30.
  3. Strauss MB, Penera KE, Miller SS. Protection and Stabilization of the Wound. Wound Care and Hyperbaric Medicine, 2011; 2(3):33-53.
  4. Aksenov IV, Strauss MB, Miller SS. Medical Management of the Patients with Problem Wounds. Wound Care and Hyperbaric Medicine, 2011; 2(4):13-32.
  5. Strauss MB, Miller SS, Aksenov IV. Making the Scoring of Wounds Objective. Wound Care and Hyperbaric Medicine, 2012; 3(1):21-37.
  6. Strauss MB, Miller SS, Aksenov IV, Manji K. Wound Oxygenation and an Introduction to Hyperbaric Oxygen Therapy: Interventions for the Hypoxic/Ischemic Wound. Wound Care and Hyperbaric Medicine, 2012; 3(2):36-51.
  7. Strauss MB, Hart GB, Miller SS, et al. Mechanisms of Hyperbaric Oxygen, Part 1. Wound Care and Hyperbaric Medicine, 2012; 3(3):27-42.
  8. Strauss MB, Hart GB, Miller SS, et al. Mechanisms of Hyperbaric Oxygen, Part 2. Wound Care and Hyperbaric Medicine, 2012; 3(4):45-66.
  9. Strauss MB, Lew DC, Miller SS. The Wagner Wound Grading System: What is it? What are its Ramifications for Hyperbaric Medicine? Wound Care and Hyperbaric Medicine, 2012; 3(4):38-44.
  10. Strauss MB, Manji K, Dierker RL, et al. Wound Dressing Agents. Wound Care and Hyperbaric Medicine, 2013; 4(1):41-69.
  11. Strauss MB, Manji KA, Miller SS, Manji AA. Bursa and Callus: Friend or Foe. Wound Care and Hyperbaric Medicine, 2013; 4(2):19-28.
  12. Strauss MB, Miller SS, Nhan L. The End-Stage Wound: Its Determination and Management. Wound Care and Hyperbaric Medicine, 2013; 4(4):19-26.
  13. Wagner FW. Classification and treatment program for diabetic, neuropathic and dysvascular foot problems. Instructional Course Lectures 28. American Academy of Orthopaedic Surgeons. 1979; 28:143-165.
  14. Wagner FW. The dysvascular foot: a system of diagnosis and treatment. Foot & Ankle International. 1981; 2(2):64-122.
  15. Reiber GE, Ledous WE. Epidemiology of diabetic foot ulcers and amputations: evidence for prevention, The evidence base for diabetes care. London: John Wiley & Sons; 2002:641-65.
  16. Mayfield JA, Reiber GE, Sanders LJ, et al. Preventative foot care in people with diabetes. Diabetes Care. 1998; 21(12):2161-77.
  17. Strauss MB, Moon H, Craig AB, et al. The Incidence of Confounding Factors in Diabetes Mellitus Patients Hospitalized for Diabetic Foot Ulcers. Wounds, 2016. In Press.
  18. Strauss MB, Aksenov IV, Miller SS. MasterMinding Wounds, North Palm Beach, FL: Best Publishing Company; 2010.
  19. Helm PA, Walker SC, Pullium GF. Recurrence of neuropathic ulcerations following healing in a total contact cast. Arch Phys Med Rehabil. 1991; 72(12):967-70.
  20. Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcerations. Diabetes Care. 1995; 18(10):1376-1378.
  21. Frigg A, Pagenstert G, Schäfer D, et al. Recurrence and prevention of diabetic foot ulcers after total contact casting. Foot Ankle Int. 2007; 28(1):64-9.
  22. Strauss MB. Diabetic foot and leg wounds: principle, management and prevention. Primary Care Reports. 2001; 7:187-98.
  23. Walters RL, Perry J, Antonelli D, Hislop H. Energy cost of walking of amputees: the influence of level of amputation. J Bone Joint Surg Am. 1976; 58(1):42-6.
  24. Pinzur MS, Gold J, Schwartz D, Gross N. Energy demands for walking in dysvascular amputees as related to the level of amputation. Orthopedics. 1992; 15(9):1033-6.
  25. MacKenzie EJ, Jones AS, Bosse MJ, et al. Health-care costs associated with amputation or reconstruction of a limb- threatening injury. J Bone Joint Surg Am. 2007; 89(8):1685-92.
  26. Mackey WC, McCullough JL, Conlon TP, et al. The costs of surgery for limb-threatening ischemia. Surgery. 1986; 99(1):26-35.
  27. Strauss MB, Strauss WG. Wound scoring system streamlines decision-making. BioMechanics. 1999; VI(8):37-43.
  28. Borer KM, Borer Jr KC, Strauss MB. Prospective evaluation of a clinical wound score to identify lower extremity wounds for comprehensive wound management. Undersea Hyperbaric Med. 2000; 27(Suppl): 34.
  29. Boyko EJ, Ahroni JH, Stensel V, et al. A prospective study of risk factors for diabetic foot ulcer, The Seattle Diabetic Foot Study. Diabetes Care. 1999; 22(7):1036-42.
  30. McNeely MJ, Boyko EJ, Ahroni JH, et al. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration, How great are the risks? Diabetes Care. 1995; 18(2):216-9.
  31. Boyko EJ, Ahroni JH, Cohen V, et al. Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study. Diabetes Care. 2006; 29(6):1202-7.
  32. Abbott CA, Carrington AL, Ashe H, et al. North-West Diabetes Foot Care Study, The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med. 2002; 19(5):377-84.
  33. Nhan L, Strauss MB, Miller SS. Risk Factors for Diabetic Foot Ulcers: The First Step in Prevention. Consultant. 2013; 53(11):800-3.
  34. Nhan L, Strauss MB, Miller SS. Preventing Diabetic Foot Ulcers: A 4-Pronged Approach. Consultant. 2013; 53(12):865-72.

About the Authors


MICHAEL STRAUSS, M.D., an orthopaedic surgeon, is the retired medical director of the Hyperbaric Medicine Program at Long Beach Memorial Medical Center in Long Beach, California. He continues to be clinically active in the program and focuses his orthopaedic surgical practice on evaluation, management and prevention of challenging wounds. Dr. Strauss is a clinical professor of orthopaedic surgery at the University of California, Irvine, and the orthopaedic consultant for the Prevention- Amputation Veterans Everywhere (PAVE) Problem Wound Clinic at the VA Medical Center, Long Beach, California. He is well known to the readers of WCHM from his multiple articles related to wounds and diving medicine published in previous editions of the journal. In addition, he has authored two highly acclaimed texts, Diving Science and MasterMinding Wounds.



LIENTRA LU is a research assistant at the VA Medical Center in Long Beach, California, under the guidance of Dr. Ian Gordon, a vascular surgeon, and Dr. Michael Strauss, the first author of this paper. She received a bachelor of science degree in chemical biology at the University of California, Berkeley, in 2015 and subsequently has taken medically related courses at the University of California, Los Angeles. Miss Lu is helping with diabetic foot and venous leg ulcer studies in addition to research on abdominal aortic aneurysms at the VA Medical Center while also serving as an assistant in patient care at the PAVE Clinic there. Her other interest is disaster preparedness, where she works with the American Red Cross.



ANNA M. TAN, DPM, is a second- year podiatric medicine and surgery resident at Long Beach Memorial Medical Center. She graduated cum laude from the University of Southern California in 2006 and received the Dean’s Award for her undergraduate research on netrin-1, a protein involved in axonal guidance. Subsequently, she attended the California School of Podiatric Medicine at Samuel Merritt University in Oakland, California, receiving her doctor of podiatric medicine degree in 2014. Dr. Tan has special interests in surgical management of problem wounds, limb salvage and unifying the classification of mental disorders and personalities. In her spare time, she enjoys Bikram yoga, cooking and traveling.


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