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Francis Derk1, Troy Wilde2,
Tim Pham2, Mike Griffiths3
1South Texas VA Medical Center (San Antonio, United States)
2UTHSC (San Antonio, United States)
3AOTI (Oceanside, United States)
To develop a structured and detailed evidence based
wound conversion algorithm, incorporating advanced
present day wound therapies & utilizing the University
of Texas Wound classification system as its matrix.
The algorithm is evidenced based and formulates a
singular or multi modal approach from simple to
highly complex phases.
The algorithm is intended to provide the clinician with
a retrograde methodology, intended to drive the
wound to healing by converting higher grade wounds
to lesser grade levels and finally to full healing.
The authors conducted evidence based research
analysis using various treatment approaches, including
all available wound modalities; evidence based
analysis, and numerous clinical applications with
established wound protocols, single and or multi
modal processes, wound treatments and outcomes.
The University of Texas Wound Classification system
serves as the framework, along with standardized
definitions of infection, laboratory test limits, and
ischemia parameters.
>1.30 Poorly compressible vessels,
arterial calcification
0.90–1.30 Normal
0.60–0.89 Mild arterial obstruction
0.40–0.59 Moderate obstruction
<0.40 Severe obstruction
Classic signs:
Inflammation (erythema,
warmth, tenderness,
ain or induration
purulent secretions
Presence of systemic findings
of infection (fever, chills,
night sweat, nausea, vomiting,
malaise)
Secondary signs:
Non-purulent secretions,
friable or discolored
granulation tissue,
undermining of wound edges,
foul odor)
Stages
Stage A: No infection or ischemia
Stage B: Infection present
Stage C: Ischemia present
Stage D: Infection and ischemia present
Grading
Grade 0: Epithelialized wound
Grade 1: Superficial wound
Grade 2: Penetrates to tendon or capsule
Grade 3: Penetrates to bone or joint
UTHSCA WOUND CLASSIFICATION SYSTEM
ERYTHROCYTE
SEDIMENTATION
RATE (ESR)
TEST
Westergren
NORMAL
VALUE
Child 0-10 mm/hour
Adult (male) 0-15 mm/hour
Adult (female 0-20 mm/hour
Adult 4.5-11.0
Neutrophils Bands
3-5% (total
WBC count)
Segs 54-62%
Lymphocytes 25-33%
Monocytes 3-7%
Eosinophils 1-3%
Basophils 0-0.75%
Leukocyte (WBC) Normal Values
Ischemia, PVD and PAD: Defined by ABI/NIV studies, ultrasound, clinical wound assessment including
necrosis, eschar, gangrene, lack of lower extremity and pedal pulses, findings consisting of pallor,
cyanosis, lack of digital hair growth, and advanced studies including MRA and Angiography.
Definitions
Ankle-brachial Index (ABI)
Interpretation
Infected wound: per infectious disease
guidelines the presence of infection is
defined by ≥ 2 classic findings of
inflammation or purulence
In clinical practice within a large wound care center, the
algorithm has validated and has been found to be
especially useful when treating higher grade wounds
which may require surgical intervention, a multi-
disciplinary team approach, wound staging, and
advanced adjunctive therapies.
We found that classifying a wound, determining
etiology, and taking a holistic approach that progressed
the wound from more severe to less severe grades
resulted in better outcomes.
Wounds
Stage C
Location
GRADE 1
Stage BStage A Stage D
Size
Assessment
of edema
Nutritional
Status
PMH
Biologicals
TWO2
Offloading
Wound
Debridement
Wound Bed
preparation
Topicals
Daily wound
care
Monitor decrease in size
Wound
Conversion to
lesser grade
Montior WBC, CRP,
Sed Rate
X-rayC&S
Surgery/debridement
Eliminate
Infection
Consider Infectious
Disease consult prn
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
No Vascular
Intervention
Vascular
intervention
TWO2
Build Wound Matrix
Wound
Conversion
Montior WBC, CRP,
Sed Rate
C&S X-rays
Eliminate
Infection
Antibiosis
Surgical Debridement
TWO2
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
Wound
Conversion
Depth
Wound base
Granular/Non-granular
Non-Granular / FibrousGranular
Conversion to Granular
Wound Bed
Denotes Multi-modality
Therapy: prn
TWO2
(2)
(10, 17, 19)
(10, 17, 19) (13, 19)
(12, 18)
(1,10, 19)
(12, 18)
(5, 9)
(3, 5) (8)
(10, 17, 19)
(5, 16)
(6, 19)
(6, 19)
(12,18)
(10, 11, 13, 17, 19)
(5, 9)
(3,5) (8)
(10, 17, 19)
(12,18)
(6, 19)
(6, 19)
Evidence Based Wound Conversion
Algorithm for
University of Texas Grade 1 Wounds
and Classification System
Infected Ischemic Infected / IschemicNo Infection or Ischemia
(11,15)
(11,15)
TWO2
Topical Wound Oxygen
Wound
Stage C
Location
GRADE 2
Stage BStage A Stage D
Size
Assessment
of edema
Nutritional
Status
PMH
Biologicals TWO2
Offloading
Wound Matrix
Assessment
Wound Bed
preparation
Topicals
Monitor decrease in
size and depth
Wound
Conversion to
Grade 1
Montior WBC, CRP,
Sed Rate
X-raysC&S
Surgery/debridement
Eliminate
Infection ID Consult
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
No Vascular
Intervention
Vascular
intervention
TWO2
Build Wound Matrix
Wound
debridement
Montior WBC, CRP,
Sed Rate
C&S X-rays
Eliminate
Infection
Antibiosis
Surgical Intervention
TWO2
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
Depth
Granular
Bed
Tendon / Capsule
Exposure
Negative
Pressure
Build Wound Matrix
Multi-modal
Therapy
Cam Boot
TCC
MRI
Serial Films
Monitor Labs
Monitor wound
Monitor C&S
Manage necrotic /
escharotic tissue prn
Monitor
granulation tissue
Consider Negative
Pressure adjunct
Ascertain elimination of
Infection
Vascular intervention
or Non-intervention
Continue TWO2
Wound base
Granular/Non-granular
Denotes Multi-modality
Therapy: prn
MRI
Negative
Pressure
Monitor wound
Build wound matrix
TWO2
(2)
(10, 11, 19)
(13, 19)
(10, 17, 19)
(12, 18)
(12, 18)
(12, 18)
(12, 18)
(4, 19)
(4, 19)
(4, 19)
(10, 11, 13, 17, 19)
(1)(10, 11, 17, 19)
(5, 9)
(3, 5)
(8)
(10, 17, 19)
(5, 16)
(10, 11, 13,
17, 19)
(10, 11, 13,
17, 19)
(10, 17, 19)
(6, 19)
(6, 19)
(6, 19)
(10, 17, 19)
(3, 5) (8)
(5, 9)
Infected / IschemicNo Infection or Ischemia Infected Ischemic
(11,15) (11,15)
TWO2
Topical Wound Oxygen
Evidence Based Wound Conversion
Algorithm for
University of Texas Grade 2 Wounds
and Classification System
Wound
Stage C
Location
GRADE 3 Stage BStage A Stage D
Size
Assessment
of edema
Nutritional
Status
PMH
Biologicals
TWO2
Offloading
Wound Matrix
Assessment
Wound Bed
preparation
Topicals
Monitor decrease in size and depth
Wound Conversion to
lesser grade/lesser depth
Monitor WBC, CRP,
Sed Rate
X-raysC&S
Surgery/debridement
Eliminate Infection
ID Consult prn
Vascular Assessment
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
Vascular intervention
TWO2
Build Wound Matrix
Wound
debridement
Montior WBC, CRP,
Sed Rate
C&S X-rays
Eliminate
Infection
Antibiosis
Surgical /Vascular
Intervention
TWO2
NIVs/ABIs
Transcutaneous O2
Angiogram/MRA
Depth
Granular Wound
Base
Negative
Pressure
Build Wound Matrix
Multi-modal
Therapy
Cam Boot /TCC
MRI
Serial Films
Monitor Labs
Monitor wound Manage necrotic
/escharotic tissue
Monitor
granulation tissue
Consider Negative
Pressure adjunct
Limb Salvage
Amputation prn
Fibrous
Tissue
Surgery/debridement prn
TWO2
Wound Conversion
to lesser grade
Amputation
TWO2
HBO2
May not be
a Candidate
HBO2
May Stage for
further Surgery
Continue with
TWO2
Wound base
Granular/Non-granular
Bone
(2)
(10, 11, 19)
(10, 11,
19)
(10, 17, 19)
(10, 17,
19)
(10, 17, 19)
(12, 18)
(12, 18)
(12, 18)
(12, 18)
(10, 11, 19)
(4, 19)
(4, 19)
(10, 17, 19)
(12, 18)
(13, 19)
(10, 11,
17, 19)
(1)
(5, 9)
(3, 5) (3, 5)(8)
(8)
(5, 9)
(5, 16)
(6, 10)
(6, 19)
(7, 14)
(7, 14)
(6, 19)
(6, 19) (6, 19)
Denotes Multi-modality
Therapy: prn
No Infection or Ischemia Infected Ischemic Infected / Ischemic
(11,15)
(11,15)
TWO2 Topical Wound Oxygen
Evidence Based Wound Conversion
Algorithm for
University of Texas Grade 3 Wounds
and Classification System
The authors propose a holistic Wound Conversion Algorithm as a
retrograde, step-wise therapeutic intervention guide for wound
healing, that has been validated in daily clinical practice in a busy
wound care center.
The wound conversion algorithm utilizes a blended approach of
evidenced based modality use, advanced wound therapies, and
practical field application which have yielded positive results.
Future publication encompassing clinical based outcome evidence
utilizing the algorithm will be forthcoming.
The authors fully expect modification of this algorithm with future
advances with modalities in wound care, but propose a useful tool
in wound care at the present.
1. Armstrong, David, and Et Al. "Quality of Life in Healing Diabetic Wounds Does the End Justify the Means?" THE JOURNAL OF FOOT & ANKLE SURGERY (2008): 278-
82. Web.
2. Arnold, Meghan, and Adrian Barbul. "Nutrition and Wound Healing." Plastic and Reconstructive Surgery 117.7s (2006): 42-56.
3. Bernard, Louis, Ilker Uçkay, Albert Vuagnat, Mathieu Assal, Richard Stern, Peter Rohner, and Pierre Hoffmeyer. "Two Consecutive Deep Sinus Tract Cultures Predict
the Pathogen of Osteomyelitis☆." International Journal of Infectious Diseases (2009): n. pag. Print.
4. Birke-Sorensen, H., M. Malmsjo, P. Rome, and Et Al. "Evidence-based Recommendations for Negative Pressure Wound Therapy: Treatment Variables (pressure
Levels, Wound Filler and Contact Layer) – Steps towards an International Consensus." Journal of Plastic, Reconstructive & Aesthetic Surgery 64 (2011): S1-S16.
Print.
5. Crouzet, J., and L.p Lavigne. "Diabetic Foot Infection: A Critical Review of Recent Randomized Clinical Trials on." International Journal of Infectious Diseases 15
(2011): 601-10. Print
6. Datillo, Phillip. "Critical Limb Ischemia: Endovascular Strategies for Limb Salvage." Progress in Cardiovascular Diseases 54 (2011): 47-60. Print.
7. Duzgun, A., H. Satir, O. Ozozan, B. Saylam, B. Kulah, and F. Coskun. "Effect of Hyperbaric Oxygen Therapy on Healing of Diabetic Foot Ulcers." The Journal of Foot
and Ankle Surgery 47.6 (2008): 515-19. Print.
8. Elgazzar, Abdelhamid H., Hussein M. Abdel-Dayem, James D. Clark, and Harry R. Maxon. "Multimodality Imaging of Osteomyelitis." European Journal of Nuclear
Medicine 22.9 (1995): 1043-063. Print.
9. Fleischer, Adam E., James S. Wrobel, Andrea Leonards, Scott Berg, Daniel P. Evans, Robert L. Baron, and David G. Armstrong. "Post-treatment Leukocytosis Predicts
an Unfavorable Clinical Response in Patients with Moderate to Severe Diabetic Foot Infections." The Journal of Foot and Ankle Surgery 50.5 (2011): 541-46. Print.
10. Frykberg, Robert G. "The Science Of Advanced Wound Care: What Should You Be Using In Your Office?" Superbones West Conference. Las Vegas. 24 Oct. 2010.
Lecture.
11. Goldman, Robert, and Et Al. "More than One Way to Measure a Wound: An Overview of Tools and Techniques." ADV SKIN WOUND CARE 15 (2002): 236-45.
12. Gordillo, Gayle M., Sashwati Roy, Savita Khanna, Richard Schlanger, Sorabh Khandelwal, Gary Phillips, and Chandan K. Sen. "Topical Oxygen Therapy Induces
Vascular Endothelial Growth Factor Expression And Improves Closure Of Clinically Presented Chronic Wounds." Clinical and Experimental Pharmacology and
Physiology 35.8 (2008): 957-64.
13. Jones, I., L. Currie, and R. Martin. "A Guide to Biological Skin Substitutes." British Journal of Plastic Surgery 55.3 (2002): 185-93. Print.
14. Kalani, Majid. "Hyperbaric Oxygen (HBO) Therapy in Treatment of Diabetic Foot Ulcers." Journal of Diabetes and Its Complications 16 (2002): 153-58. Print.
15. Lavery, Lawrence, and Et Al. "Classification of Diabetic Foot Wounds." THE JOURNAL OF FOOT AND ANKLE SURGERY 35.6 (1996): 528-31.
16. Lipsky, Benjamin, Anthony Berendt, and Et Al. "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic
Foot Infections." Clinical Infectious Diseases 54.12 (2012): 132-73.
17. Nusbaum, Aron G. "Effective Method to Remove Wound Bacteria: Comparison of Various." Journal of Surgical Research 176 (2012): 701-07. Print.
18. Orsted HL, Poulson R, and the Advisory Group. Evidence-based practice standards for the use of topical pressurised
oxygen therapy. Int Wound J 2012; doi: 10.1111/j.1742-481X.2012.00956.
19. Rogers, Lee C. “Key Concepts From The 2010 Consensus Statement On Diabetic Foot Ulcerations.” Superbones West Conference, Las Vegas, 24 Oct 2010: Lecture
20. Armstrong, David G, Lavery, Lawrence A, Harkless, Lawrence B. “Validation of a Diabetic Wound Classification System.” Diabetes Care 21 (1998): 855-859.
21. Tahir, Khan, Farooqui, Falahat, Niazi, Khusrow. “Critical Review of the Ankle Brachial Index.” Current Cardiology Reviews 2008: 101-106
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EWMA 2013 - Ep543 - Evidence Based Wound Conversion Algorithm for University of Texas Wounds and Classification System

  • 1. Francis Derk1, Troy Wilde2, Tim Pham2, Mike Griffiths3 1South Texas VA Medical Center (San Antonio, United States) 2UTHSC (San Antonio, United States) 3AOTI (Oceanside, United States)
  • 2. To develop a structured and detailed evidence based wound conversion algorithm, incorporating advanced present day wound therapies & utilizing the University of Texas Wound classification system as its matrix. The algorithm is evidenced based and formulates a singular or multi modal approach from simple to highly complex phases. The algorithm is intended to provide the clinician with a retrograde methodology, intended to drive the wound to healing by converting higher grade wounds to lesser grade levels and finally to full healing.
  • 3. The authors conducted evidence based research analysis using various treatment approaches, including all available wound modalities; evidence based analysis, and numerous clinical applications with established wound protocols, single and or multi modal processes, wound treatments and outcomes. The University of Texas Wound Classification system serves as the framework, along with standardized definitions of infection, laboratory test limits, and ischemia parameters.
  • 4. >1.30 Poorly compressible vessels, arterial calcification 0.90–1.30 Normal 0.60–0.89 Mild arterial obstruction 0.40–0.59 Moderate obstruction <0.40 Severe obstruction Classic signs: Inflammation (erythema, warmth, tenderness, ain or induration purulent secretions Presence of systemic findings of infection (fever, chills, night sweat, nausea, vomiting, malaise) Secondary signs: Non-purulent secretions, friable or discolored granulation tissue, undermining of wound edges, foul odor) Stages Stage A: No infection or ischemia Stage B: Infection present Stage C: Ischemia present Stage D: Infection and ischemia present Grading Grade 0: Epithelialized wound Grade 1: Superficial wound Grade 2: Penetrates to tendon or capsule Grade 3: Penetrates to bone or joint UTHSCA WOUND CLASSIFICATION SYSTEM ERYTHROCYTE SEDIMENTATION RATE (ESR) TEST Westergren NORMAL VALUE Child 0-10 mm/hour Adult (male) 0-15 mm/hour Adult (female 0-20 mm/hour Adult 4.5-11.0 Neutrophils Bands 3-5% (total WBC count) Segs 54-62% Lymphocytes 25-33% Monocytes 3-7% Eosinophils 1-3% Basophils 0-0.75% Leukocyte (WBC) Normal Values Ischemia, PVD and PAD: Defined by ABI/NIV studies, ultrasound, clinical wound assessment including necrosis, eschar, gangrene, lack of lower extremity and pedal pulses, findings consisting of pallor, cyanosis, lack of digital hair growth, and advanced studies including MRA and Angiography. Definitions Ankle-brachial Index (ABI) Interpretation Infected wound: per infectious disease guidelines the presence of infection is defined by ≥ 2 classic findings of inflammation or purulence
  • 5. In clinical practice within a large wound care center, the algorithm has validated and has been found to be especially useful when treating higher grade wounds which may require surgical intervention, a multi- disciplinary team approach, wound staging, and advanced adjunctive therapies. We found that classifying a wound, determining etiology, and taking a holistic approach that progressed the wound from more severe to less severe grades resulted in better outcomes.
  • 6. Wounds Stage C Location GRADE 1 Stage BStage A Stage D Size Assessment of edema Nutritional Status PMH Biologicals TWO2 Offloading Wound Debridement Wound Bed preparation Topicals Daily wound care Monitor decrease in size Wound Conversion to lesser grade Montior WBC, CRP, Sed Rate X-rayC&S Surgery/debridement Eliminate Infection Consider Infectious Disease consult prn Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA No Vascular Intervention Vascular intervention TWO2 Build Wound Matrix Wound Conversion Montior WBC, CRP, Sed Rate C&S X-rays Eliminate Infection Antibiosis Surgical Debridement TWO2 Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA Wound Conversion Depth Wound base Granular/Non-granular Non-Granular / FibrousGranular Conversion to Granular Wound Bed Denotes Multi-modality Therapy: prn TWO2 (2) (10, 17, 19) (10, 17, 19) (13, 19) (12, 18) (1,10, 19) (12, 18) (5, 9) (3, 5) (8) (10, 17, 19) (5, 16) (6, 19) (6, 19) (12,18) (10, 11, 13, 17, 19) (5, 9) (3,5) (8) (10, 17, 19) (12,18) (6, 19) (6, 19) Evidence Based Wound Conversion Algorithm for University of Texas Grade 1 Wounds and Classification System Infected Ischemic Infected / IschemicNo Infection or Ischemia (11,15) (11,15) TWO2 Topical Wound Oxygen
  • 7. Wound Stage C Location GRADE 2 Stage BStage A Stage D Size Assessment of edema Nutritional Status PMH Biologicals TWO2 Offloading Wound Matrix Assessment Wound Bed preparation Topicals Monitor decrease in size and depth Wound Conversion to Grade 1 Montior WBC, CRP, Sed Rate X-raysC&S Surgery/debridement Eliminate Infection ID Consult Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA No Vascular Intervention Vascular intervention TWO2 Build Wound Matrix Wound debridement Montior WBC, CRP, Sed Rate C&S X-rays Eliminate Infection Antibiosis Surgical Intervention TWO2 Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA Depth Granular Bed Tendon / Capsule Exposure Negative Pressure Build Wound Matrix Multi-modal Therapy Cam Boot TCC MRI Serial Films Monitor Labs Monitor wound Monitor C&S Manage necrotic / escharotic tissue prn Monitor granulation tissue Consider Negative Pressure adjunct Ascertain elimination of Infection Vascular intervention or Non-intervention Continue TWO2 Wound base Granular/Non-granular Denotes Multi-modality Therapy: prn MRI Negative Pressure Monitor wound Build wound matrix TWO2 (2) (10, 11, 19) (13, 19) (10, 17, 19) (12, 18) (12, 18) (12, 18) (12, 18) (4, 19) (4, 19) (4, 19) (10, 11, 13, 17, 19) (1)(10, 11, 17, 19) (5, 9) (3, 5) (8) (10, 17, 19) (5, 16) (10, 11, 13, 17, 19) (10, 11, 13, 17, 19) (10, 17, 19) (6, 19) (6, 19) (6, 19) (10, 17, 19) (3, 5) (8) (5, 9) Infected / IschemicNo Infection or Ischemia Infected Ischemic (11,15) (11,15) TWO2 Topical Wound Oxygen Evidence Based Wound Conversion Algorithm for University of Texas Grade 2 Wounds and Classification System
  • 8. Wound Stage C Location GRADE 3 Stage BStage A Stage D Size Assessment of edema Nutritional Status PMH Biologicals TWO2 Offloading Wound Matrix Assessment Wound Bed preparation Topicals Monitor decrease in size and depth Wound Conversion to lesser grade/lesser depth Monitor WBC, CRP, Sed Rate X-raysC&S Surgery/debridement Eliminate Infection ID Consult prn Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA Vascular intervention TWO2 Build Wound Matrix Wound debridement Montior WBC, CRP, Sed Rate C&S X-rays Eliminate Infection Antibiosis Surgical /Vascular Intervention TWO2 NIVs/ABIs Transcutaneous O2 Angiogram/MRA Depth Granular Wound Base Negative Pressure Build Wound Matrix Multi-modal Therapy Cam Boot /TCC MRI Serial Films Monitor Labs Monitor wound Manage necrotic /escharotic tissue Monitor granulation tissue Consider Negative Pressure adjunct Limb Salvage Amputation prn Fibrous Tissue Surgery/debridement prn TWO2 Wound Conversion to lesser grade Amputation TWO2 HBO2 May not be a Candidate HBO2 May Stage for further Surgery Continue with TWO2 Wound base Granular/Non-granular Bone (2) (10, 11, 19) (10, 11, 19) (10, 17, 19) (10, 17, 19) (10, 17, 19) (12, 18) (12, 18) (12, 18) (12, 18) (10, 11, 19) (4, 19) (4, 19) (10, 17, 19) (12, 18) (13, 19) (10, 11, 17, 19) (1) (5, 9) (3, 5) (3, 5)(8) (8) (5, 9) (5, 16) (6, 10) (6, 19) (7, 14) (7, 14) (6, 19) (6, 19) (6, 19) Denotes Multi-modality Therapy: prn No Infection or Ischemia Infected Ischemic Infected / Ischemic (11,15) (11,15) TWO2 Topical Wound Oxygen Evidence Based Wound Conversion Algorithm for University of Texas Grade 3 Wounds and Classification System
  • 9. The authors propose a holistic Wound Conversion Algorithm as a retrograde, step-wise therapeutic intervention guide for wound healing, that has been validated in daily clinical practice in a busy wound care center. The wound conversion algorithm utilizes a blended approach of evidenced based modality use, advanced wound therapies, and practical field application which have yielded positive results. Future publication encompassing clinical based outcome evidence utilizing the algorithm will be forthcoming. The authors fully expect modification of this algorithm with future advances with modalities in wound care, but propose a useful tool in wound care at the present.
  • 10. 1. Armstrong, David, and Et Al. "Quality of Life in Healing Diabetic Wounds Does the End Justify the Means?" THE JOURNAL OF FOOT & ANKLE SURGERY (2008): 278- 82. Web. 2. Arnold, Meghan, and Adrian Barbul. "Nutrition and Wound Healing." Plastic and Reconstructive Surgery 117.7s (2006): 42-56. 3. Bernard, Louis, Ilker Uçkay, Albert Vuagnat, Mathieu Assal, Richard Stern, Peter Rohner, and Pierre Hoffmeyer. "Two Consecutive Deep Sinus Tract Cultures Predict the Pathogen of Osteomyelitis☆." International Journal of Infectious Diseases (2009): n. pag. Print. 4. Birke-Sorensen, H., M. Malmsjo, P. Rome, and Et Al. "Evidence-based Recommendations for Negative Pressure Wound Therapy: Treatment Variables (pressure Levels, Wound Filler and Contact Layer) – Steps towards an International Consensus." Journal of Plastic, Reconstructive & Aesthetic Surgery 64 (2011): S1-S16. Print. 5. Crouzet, J., and L.p Lavigne. "Diabetic Foot Infection: A Critical Review of Recent Randomized Clinical Trials on." International Journal of Infectious Diseases 15 (2011): 601-10. Print 6. Datillo, Phillip. "Critical Limb Ischemia: Endovascular Strategies for Limb Salvage." Progress in Cardiovascular Diseases 54 (2011): 47-60. Print. 7. Duzgun, A., H. Satir, O. Ozozan, B. Saylam, B. Kulah, and F. Coskun. "Effect of Hyperbaric Oxygen Therapy on Healing of Diabetic Foot Ulcers." The Journal of Foot and Ankle Surgery 47.6 (2008): 515-19. Print. 8. Elgazzar, Abdelhamid H., Hussein M. Abdel-Dayem, James D. Clark, and Harry R. Maxon. "Multimodality Imaging of Osteomyelitis." European Journal of Nuclear Medicine 22.9 (1995): 1043-063. Print. 9. Fleischer, Adam E., James S. Wrobel, Andrea Leonards, Scott Berg, Daniel P. Evans, Robert L. Baron, and David G. Armstrong. "Post-treatment Leukocytosis Predicts an Unfavorable Clinical Response in Patients with Moderate to Severe Diabetic Foot Infections." The Journal of Foot and Ankle Surgery 50.5 (2011): 541-46. Print. 10. Frykberg, Robert G. "The Science Of Advanced Wound Care: What Should You Be Using In Your Office?" Superbones West Conference. Las Vegas. 24 Oct. 2010. Lecture. 11. Goldman, Robert, and Et Al. "More than One Way to Measure a Wound: An Overview of Tools and Techniques." ADV SKIN WOUND CARE 15 (2002): 236-45. 12. Gordillo, Gayle M., Sashwati Roy, Savita Khanna, Richard Schlanger, Sorabh Khandelwal, Gary Phillips, and Chandan K. Sen. "Topical Oxygen Therapy Induces Vascular Endothelial Growth Factor Expression And Improves Closure Of Clinically Presented Chronic Wounds." Clinical and Experimental Pharmacology and Physiology 35.8 (2008): 957-64. 13. Jones, I., L. Currie, and R. Martin. "A Guide to Biological Skin Substitutes." British Journal of Plastic Surgery 55.3 (2002): 185-93. Print. 14. Kalani, Majid. "Hyperbaric Oxygen (HBO) Therapy in Treatment of Diabetic Foot Ulcers." Journal of Diabetes and Its Complications 16 (2002): 153-58. Print. 15. Lavery, Lawrence, and Et Al. "Classification of Diabetic Foot Wounds." THE JOURNAL OF FOOT AND ANKLE SURGERY 35.6 (1996): 528-31. 16. Lipsky, Benjamin, Anthony Berendt, and Et Al. "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections." Clinical Infectious Diseases 54.12 (2012): 132-73. 17. Nusbaum, Aron G. "Effective Method to Remove Wound Bacteria: Comparison of Various." Journal of Surgical Research 176 (2012): 701-07. Print. 18. Orsted HL, Poulson R, and the Advisory Group. Evidence-based practice standards for the use of topical pressurised oxygen therapy. Int Wound J 2012; doi: 10.1111/j.1742-481X.2012.00956. 19. Rogers, Lee C. “Key Concepts From The 2010 Consensus Statement On Diabetic Foot Ulcerations.” Superbones West Conference, Las Vegas, 24 Oct 2010: Lecture 20. Armstrong, David G, Lavery, Lawrence A, Harkless, Lawrence B. “Validation of a Diabetic Wound Classification System.” Diabetes Care 21 (1998): 855-859. 21. Tahir, Khan, Farooqui, Falahat, Niazi, Khusrow. “Critical Review of the Ankle Brachial Index.” Current Cardiology Reviews 2008: 101-106 References: