WoundReference improves clinical decisions
 Choose the role that best describes you
I have a DM patient with an ulcer to the bone at the lateral malleolus level. Can I use the Wagner classification system? (Or does the ankle not count). I would like to do HBO on this patient. Thanks for you help
May 10, 2022 by Shanna Newbold, MD, ABWMS, ABEM
6 replies
Samantha Kuplicki
MSN, APRN-CNS, AGCNS-BC, CWS, CWCN-AP, CRNFA
Hi Shanna, thanks for your inquiry. I'm sure others will chime in, but for now here's some info, albeit basic, to get us thinking through this topic, as I've heard this question many times.

Neuropathic ulcers are precipitated and perpetuated by the combined effects of motor, sensory, and autonomic neuropathies in patients with diabetes. These primarily effect the striking surface of the forefoot and hindfoot (nomenclature often used in classification systems) that are subject to repeated trauma and pressure. For this to make clinical sense, the patient would likely need to have sensory neuropathy to the level of the ankle and significant athropathy/deformities causing traditional footwear to erode the tissue of the malleolus. This is not impossible, but I've found that typically ulcers in this location are more due to arterial insufficiency versus the classical definition of neuropathic ulcers.

I hope this helps.
May 10, 2022
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Just a quick note from a physician perspective ... I agree completely with Samantha. I happen to know the senior author of a previous edition of the UHMS Indications Manual, specifically for diabetic foot ulcers. I'm quite certain that he would say you were perilously close to a fraud and abuse violation.

I have seen and heard this discussed in several venues. I can't make a neuropathic plantar foot diabetic foot ulcer stick for an ulcer at the ankle.

Agree, this patient is a prime candidate for an interventional radiology look at the arteries below the knee and at the ankle.
May 10, 2022
Shanna Newbold
MD, ABWMS, ABEM
Thank you for your feedback. I certainly don’t want to be close to any fraud. Perhaps more information is needed He is a 36 year old DM no arterial disease, multiphasic arterial studies. He developed the ulcer from neuropathy and a boot. He then had an abscess that was I&D. The wound has exposed bone but both the x-ray and CT of the ankle was negative for osteomyelitis. The ulcer is at the level of the lateral malleolus but does extends down towards the foot. Please see picture. I did a bone culture and he is currently on Bactrim. (unknown culture results from podiatry). He was sent here for HBO referral. CMS seems to say below the malleolus is the foot and can be called a DFU but if it is still close to fraud I would not proceed. Thanks for looking at the picture
22281.jpg
May 10, 2022
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Shanna, thank you for the picture. I'll comment briefly and I'm sure that Samantha will have more to say that can help guide you. The fraud and abuse depends entirely (for medicare) on your fiscal intermediary. Personally, this is not a plantar neuropathic diabetic foot ulcer. So, I would not stretch what is plainly visible on your picture. Just my opinion.

From my perspective, I cannot see the undermining of this ulcer. My guess is that it is larger than appears on the picture. I won't over-diagnose (A common problem with diagnosis using only a picture of the lesion ... ), but I would start at an aggressive debridement to get rid of all the slough present in the picture. This may be a good candidate for NPWT after debridement, especially in the case of "good" arterial studies.

I will tell you this ... the degree of arterial compromise follows the development and extent of neuropathy. Be careful not to be swayed by multiphase arterial studies. I still run to CT angio (at the least) if there is a concern about arterial supply (and I have that concern here) ...

Enough from me ... good luck.
May 10, 2022
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
One last post ... sorry ... I am a believer in angiosome identification in DFUs. If one can improve blood supply to the angiosome, chances of healing go up.

Have a look at this paper. If I see your photo correctly, this ulcer is in angiosome 6, a calcaneal branch of the lateral peroneal artery. Sometimes, surgeons have told me that they avoid making incisions in this area due to the arterial watershed. Translated to wound care, this area may be more difficult to heal if there is arterial insufficiency here.

https://www.researchgate.net/publication/260196977_Results_of_Infrapopliteal_Endovascular_Procedures_Performed_in_Diabetic_Patients_with_Critical_Limb_Ischemia_and_Tissue_Loss_from_the_Perspective_of_an_Angiosome-Oriented_Revascularization_Strategy/fulltext/030f070a0cf2252d540200be/Results-of-Infrapopliteal-Endovascular-Procedures-Performed-in-Diabetic-Patients-with-Critical-Limb-Ischemia-and-Tissue-Loss-from-the-Perspective-of-an-Angiosome-Oriented-Revascularization-Strategy.pdf
May 11, 2022
Shanna Newbold
MD, ABWMS, ABEM
Thank you! This was very helpful
May 11, 2022
* Information provided without clinical evaluation and is not intended as a replacement for in-person consultation with a medical professional. The information provided through Curbside Consult is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.