Diabetic foot ulcer: A comprehensive review of pathophysiology and management modalities

Table 1 Wagner’s classification of diabetic foot ulcers

Grade	Characteristic
Wagner grade 1	Partial- or full-thickness ulcer (superficial)
Wagner grade 2	Deep ulcer extending to ligament, tendon, joint capsule, bone, or deep fascia without abscess or OM
Wagner grade 3	Deep abscess, OM, or joint sepsis
Wagner grade 4	Partial-foot gangrene

OM: Osteomyelitis.

Table 2 Stem cell therapies available for diabetic foot treatment

Stem cell type	Stem cell sub-types	Administration route
Adult stem cell	(1) Bone marrow-derived mesenchymal stem cells; (2) Adipose-derived stem cells; Human umbilical cord-derived; (3) Mesenchymal stem cells; and (4) Peripheral blood-derived mesenchymal stem cells	Local: Intramuscular and subcutaneous; Systemic: Intravenous and intraarterial
Embryonic stem cell	Cell mass of blastocyst by in vitro fertilization	Proposed local or systemic administration

Table 3 Overview of diabetic foot management strategies

Treatment modality	Level of evidence	Strength of recommendation
Non-invasive modalities
Wound dressing	High	Strong recommendation
Antibiotics	Low to moderate	Strong recommendation
Total-contact casting and pressure offloading techniques	High	Strong recommendation
Maggot therapy	Low	Weak recommendation
Hyperbaric oxygen	Low	Weak recommendation
Topical growth factors	Moderate	Could be beneficial
Cell therapy	Low (more studies required)	Weak recommendation
Invasive modalities
Debridement	Moderate to high	Strong recommendation
Skin grafting	Moderate	Could be beneficial
Revascularization	Moderate	Strong recommendation