PROGNOSTIC VALUE OF THE CLINICAL EXAMINATION OF THE DIABETIC FOOT ULCER

OBJECTIVE: To determine the value of the history, physical examination , and magnetic resonance imaging (MRI) in predicting successful primar y healing of a foot ulcer in a diabetic patient. DESIGN: Prospective c ohort study. SETTING: Durham (NC) Veterans Affairs Medical Center. PAT IENTS: Sixty-four consecutive diabetic patients with 78 dermal ulcers through the full thickness of the skin and at or distal to the malleol i of the ankle. MEASUREMENTS AND MAIN RESULTS: A structured clinical h istory and physical examination were performed by two examiners, a phy sician participating in the study and the referring physician. Fifty o f these patients with 63 ulcers underwent MRI. Patients were followed prospectively for 6 months after enrollment to ascertain healing of th e ulcer, amputation, and death. During the 6-month follow-up period, 8 (13%) of the patients died. Seventeen (22%) of the ulcers were amputa ted, 17 (22%) of the ulcers failed to heal, and 36 (47%) healed primar ily. Univariate predictors of healing at 6 months included age less th an 65 years, diagnosis of diabetes within the last 15 years, painless ulcer, palpable ankle pulse, ankle-brachial index greater than 0.5, an d the physician's assessment of the overall likelihood of osteomyeliti s. In a multivariable logistic regression model, predictors of healing included the presence of an audible pulse on Doppler examination (p = .01) and a painless ulcer (p = .04). The diagnosis of osteomyelitis o n MRI did not predict healing in these patients. CONCLUSIONS: Foot ulc ers in patients with diabetes frequently have poor outcomes; fewer tha n half the patients in this study healed their ulcers within 6 months. The vascular components of the clinical examination are the best pred ictors of healing in patients with a diabetic foot ulcer.