Foot ulcers are a common complication of diabetes and represent a major source of morbidity. Fifteen percent of diabetics develop foot ulcers during their life time with significant health related decrease in quality of life and consumption of a great deal of healthcare resources [1,2].

Numerous foot ulcer classification systems, such as the Meggit-Wagner system and the University of Texas systems, have been developed in an effort to classify ulcers more effectively and enable effective comparison of the results of routine management in various centers and treatment approaches. These systems have been utilized to compare the results and vary based on the location of the ulcer, its depth and the presence or absence of neuropathy, infection and peripheral arterial disease [3,4].                

Based on the inclusion and exclusion criteria listed below, 100 diabetic patients with diabetic foot ulcers (below ankle) of any duration who attended The Oxford Medical College Hospital, surgical outpatient clinics and getting hospitalized were included in the study.

Detailed clinical history elicited routine demographic data including age, sex, occupation, socio-economic and education status, details about habits and treatment history noted.

Thorough general physical examination and local examination of the affected foot with ulcer done, DUSS calculated and correlated with the outcome with follow up for 6 months.

Inclusion Criteria

All inpatients above 18 years with foot ulcers (below ankle) and suffering from Diabetes mellitus (as per WHO criteria).

Table 1: Diabetic Ulcer Severity Score

Exclusion Criteria

• All non-diabetic ulcers over foot

• Patients currently on immunosuppressive therapy

• Ulcers situated above the ankle

• Any existing active neoplastic disease

• Patients with Necrotising fasciitis

• Venous stasis ulcers with Diabetes mellitus

• All patients with less than two follow up visits during observation period

• Non diabetic neuropathic ulcers (Table 1)

Observations

About 100 patients with diabetic foot were included in our study. The following are our observations. The most commonly affected age group was 41-60 years, with mean age of 50+ = 2 years. Males were most commonly affected accounting to 68%.

DUSS Parameters (Ulcer Characteristics)

• Ulcer Site: In our study most of the subjects had ulcers over the foot 72%

• Ulcer Number: Majority of patients had single ulcers (66%) on presentation which showed positive results in terms of wound healing compared to those with multiple ulcers (34%)

• Peripheral Pulses: 60.5% has palpable peripheral pulses. Those with absent peripheral pulses had higher amputation rates

• Probing to Bone: Probing to the bone by a sterile blunt probe indicates depth of ulcer. In our study 61 patients (30.5%) had probing to the bone. These patients had higher scores with poorer outcomes

Out of 100 patients, 29% of patients had major amputation i.e. above knee and below knee amputations, while 25% of them underwent minor amputations i.e. toe disarticulation or fore foot amputation. 24% and 22% of ulcers healed by primary intention and split skin graft respectively (Figure 1).

Figure 1: Distribution of Patients According to DUSS Score Categories (DUSS 0–4)

• Most of the ulcers were given DUSS score of 1(25% of patients), followed by DUSS score of 2 (22% of patients)

• Among 45 patients with DUSS score 0 and 1 

• 50% of ulcers healed by primary intention

• 37% of patients underwent split skin graft

• 4.2% underwent minor amputation

• 8.8% had major amputation

• 6 out of 22(27.27%) patients with DUSS score of 2 underwent major amputations (Figure 2)

• while 8 out of 17 with DUSS score of 3 and 11 out of 16 with DUSS score of 4 had major amputations

Figure 2: Graph Illustrating the Inverse Relationship Between Healing and Amputation Probabilities Across Increasing DUSS Scores

• The probability of amputation with DUSS score was analyzed using Kaplan Meir statistics. The probability of amputation with score of 0 was 5%, with score 1 was 12%, with score 2 was 27.28%, with score 3 was 47.06% and with score 4 was 68.75% (Table 2)

• Summary of the results of the study

Table 2: Distribution of Patient Outcomes (Healing and Amputation) and Percentage of Amputation According to Diabetic Ulcer Severity Score (DUSS)

Overall, 54 of 100 people had amputations in our study. Major amputation (below or above knee amputation) was done for 29% of patients in our study. Minor Amputation (toe or forefoot amputations) was done in 25% of patients in our study [5,6].

In the original study by Beckert et al. Patients with a score of 0 had no risk of major amputation, while patients with a score of 1 had a 2.4%, patients with a score of 2 had a 7.7%, patients with a score of 3 had an 11.2% and patients with a score of 4 had a 3.8% [1,7,8]. 

In comparison in our present study 1 out of 20 with score 0, 3 out of 25 with score 1, 6 out of 22 with score 2, 8 out of 17 people with score 3 and 11 out of 16 people with score 4 had major amputations [9,10].

The DUSS scoring system combines four clinically measurable wound-based characteristics to create a simple diagnostic tool for predicting the likelihood of healing or amputation.

It is very simple scoring system and easy to apply for diabetic patients with foot ulcers on routine basis.

In order to give a straightforward, streamlined method in a clinical context without the need for advanced investigative tool, the research groups can be stratified based on the severity of the ulcers. However, this does not change the process of wound management.

1. Beckert, S. et al. “A new wound-based severity score for diabetic foot ulcers.” Diabetes Care, vol. 29, 2006, pp. 988–992.

2. Jeffcoate, W. et al. “The Charcot foot.” Diabetic Medicine, vol. 17, 2000, pp. 253–258.

3. Das, A.K. and A. Agarwal. “A precipitating factor in tropical diabetic foot ulcer in India.” Journal of the Association of Physicians of India, vol. 39, no. 5, May 1991, pp. 426.

4. Kalaivani, V. and H.M. Vijay Kumar. “Short communication: diabetic foot in India reviewing the epidemiology and the Amit Jain’s.” Scholars Academic Journal of Biosciences, vol. 1, no. 6, 2013, pp. 305–308.

5. Deribe, B.K. et al. “Prevalence and factors influencing diabetic foot ulcer among diabetic patients attending Arbaminch Hospital, South Ethiopia.” Journal of Diabetes and Metabolism, vol. 5, no. 1, 2014, pp. 2–7.

6. Karthikesalingam, A. et al. “A systematic review of scoring systems for diabetic foot ulcers.” Diabetic Medicine, vol. 57, no. 5, 2010, pp. 544–549.

7. Buckley, C.M. et al. “Timing of access to secondary healthcare services for diabetes management and lower extremity amputation in people with diabetes: a protocol of a case–control study.” BMJ Open, vol. 3, no. 10, 2013, article e003871.

8. Kumar, S.T. et al. “Diabetic ulcer severity score: clinical validation and outcome.” International Surgery Journal, vol. 3, 2016, pp. 1606–1610.

9. Shashikala, C.K. et al. “Validation of diabetic ulcer severity score (DUSS).” Annals of International Medical and Dental Research, vol. 3, no. 1, 2017, pp. SG27–SG30.

10. Menezes, J.V.F. et al. “Clinical utility of diabetic ulcer severity score in surgical practice.” International Surgery Journal, vol. 6, 2019, pp. 2469–2474.