J Diabetes Investig. 2016 May;7(3):413-9. doi: 10.1111/jdi.12425.

Color-coded etiological keys: A simple survey tool towards amputation-free limb survival in diabetic foot lesions.

Sharkawy M, Samadoni AE.

Department of Vascular Surgery Cairo University Cairo Egypt. 



We devised a simple implementable color-coded etiological key survey based on six significant categories to screen and manage all diabetic foot patients. The study results were analyzed to verify the impact of this survey.


First we carried out a retrospective internal survey of all diabetic patients that presented to us during the period from January 2004 to January 2007. We used this analysis to develop the color-coded etiological survey, and applied it to analyze patients prospectively for 5 years from May 2007 to May 2012. Out of 4,102 diabetic foot patients, 739 patients were referred by other medical facilities for major amputation as a result of the severity of their foot lesions. This group was then subjected to further analysis to study the value and impact of the survey on amputation-free limb survival.


Blood quality abnormalities were most prevalent followed by peripheral occlusive diseases, whereas tissue loss was the least. After the completion of the assessment process, management was implemented according to the defined protocol based on the lesions‘ characteristics. The primary end-point of major amputation-free limb survival was achieved in 72.5% of patients, with an average hospital stay of 13.3 days. Statistical analysis of the etiological keys showed a significant impact of tissue loss, and previous foot surgery as a poor predictor of limb loss.


We conclude that the implementation of the color-coded etiological key survey can provide efficient and effective service to diabetic foot victims with comparable outcomes to dedicated diabetic foot clinics.


Color‐coded etiological key; Non‐traumatic limb amputations; Screening and management of diabetic foot patients

PMID: 27330729


Supplement: An innovative examination protocol for efficient management of diabetic Foot lesions to salvage limbs


Diabetes is a metabolic disorder with a growing epidemic, and by the year 2025, 300 million people is likely to be affected by this metabolic disorder which is characterized by hyperglycemia as a common denominator along with derangement of other biochemical parameters. Based on the prevalence rate of diabetes, Egypt is currently in the ninth place and is expected to move to the seventh place by 2030(1).

The most common complication of diabetes mellitus leading to frequent hospital admission is diabetic foot lesion, and at least 15 % of the diabetic patients will experience one or the other form of diabetic foot lesion (2). Further, nearly 85 % of the non-traumatic amputations were due to diabetic foot lesion (3, 4).

Despite adequate screening and diagnostic techniques along with the dedicated team for diabetic foot care, the prevalence of amputation arising out of diabetic foot lesion is still high. The reason could be that there are possibilities that the primary etiological factor could be overlooked leading to improper management, resulting in an endangered limb or amputation.

To ensure that the key determinants in the healing of the diabetic foot lesion are not missed out, in our hospital, we have devised color-coded etiological keys that were used to bring about an amputation-free survival of the diabetic foot lesion and the results of the same were published earlier this year (5). The idea of this review article is to devise a protocol that would be easy and efficient regarding theamputation-free survival of the diabetic foot lesion.

The major determinants of the outcome of the diabetic foot lesion include the modifiable and non-modifiable risk factor as enlisted below in this Table 1 adapted from Sharkawy et al (5).


Table 1: Key factors determining the outcome of diabetic foot lesion



The modifiable risk factors mentioned in the above Table were grouped into six main etiological subgroups as shown in Table 2.

Table 2: Six key etiological categories



In our hospital, we designed a simple screening protocol in such a way that it will ensure that the key factors which are crucial in determining the outcome of diabetic foot lesion were not missed out. The key elements of our protocol are as follows;

Personal data

  • Name, age, sex, region, standard of living, occupation, contact address and number

General assessment

  • Anemia – Presence or absence of pallor and Hb value

Diabetes mellitus

  • Presence or absence of family history
  • Insulin dependent or on oral hypoglycemic agents
  • Whether blood sugar in control or not

Manifestation of peripheral neuropathy

  • Assess for the involvement of sensory, motor, and autonomic nervous system, if present check for claudication pain, rest pain and tissue loss

Assessment for diabetic nephropathy

  •  Serum creatinine, urine albuminuria, serum albumin, serum protein levels
  •  If on CRF, whether or not on hemodialysis

History of foot infection

  • Enquire about duration, medication taken, and any surgical intervention if done earlier

Local assessment

  •             Foot examination
  •             Skin: dryness, eczema, and foot cracks
  •             Foot deformity: assess the cause: bone infection, peripheral neuropathy or both.Clawing foot
  •             Look for callosity: note the site
  •             Foot ulcers: see if they are on the natural pressure area or the deformed pressure area
  •             Localize the areas where pus and sinuses are noted
  •             Site of the ulcer
  •             Look for fungal infection
  •             Identify the local cause and or underlying cause

Using imaging tools – Xray, MRI, Duplex arterial US

Culture from the wound

  •  Previous surgical intervention if any has to be noted.


With the above simple assessment protocol, the six etiological key factors can easily be identified and are highlighted in front of the patient’s file as a color code system so that the treating consultants may not overlook any of the key determinants of the outcome of the diabetic foot lesion. We have already published the effectiveness of the above said the simplecolor coded system in achieving amputation-free limb survival in chronic diabetic foot lesion if measures were taken to ensure the correction of the modifiable key factors.

In this review, we would like to summarize the outcome of seven patients referred to our department for amputation of the limb for chronic diabetic foot lesion. We used our protocol to identify the key etiological factors in determining the outcome of the diabetic foot lesion. We were able to bring about the amputation-free survival of the diabetic foot lesion in each of these patients.



Shown below is the preoperative and follow up images of the six patients whose limbs were saved by correcting the etiological key factors. The first column shows the image at presentation and the second column shows the radiological image and the third column shows the follow up images (Fig. 1-4).


Figure 1: Pre operative color coded key, x- ray and post operative outcome for case 1.


Figure 2: pre operative color coded key, x- ray and post operative outocome for case 2



Figure 3: pre operative color coded key and post operative outcome for case 6


Figure 4: Pre operative color key and x- ray for case 7.




Another simple scoring system that can be used even in the primary health care setup was adapted from Najarian et al (6). It categorizes patients into four categories based on the presence or absence of foot deformity, previous history of foot surgery or amputation, and ability to perceive 5.07u monofilament.

This simple risk categorization enables clinicians to identify at-risk lower limb extremity event and prevent the amputation risk by modifying the risk factors which were discussed above. Such an effective screening will allow prompt referral of at risk lower limb extremity before it reaches a point of no return but for amputation.

It is known that the primary risk factor for lower limb amputation in diabetic patients is the peripheral neuropathy as it underpins the development of diabetic foot ulcers which might eventually get infected to form a necrotizing diabetic wound. At least 50 % of adult patients with long-standingdiabetes have peripheral neuropathy with varying severity (6, 7). The chances of developing foot ulcers in these patients with peripheral neuropathy are 8.5 % to 25 % (8, 9).

It is imperative that any screening program, for identifying the at-risk diabetic foot must encompass the following as suggested by a diabetic committee of the American OrthopedicFoot and Ankle Society (Table 3).

Table 3: Screening check list as suggested by American Orthopedic Foot and Ankle Society.



The diabetic committee of the American OrthopedicFoot and AnkleSociety has given risk categorization based on the presence of the determinants of the at-risk diabetic foot risk factors.


The risk for foot amputation increases as the peripheral neuropathy progress, which will culminate in deformity, altered pressure points that progress to callus/keratoses formation. Eventually, an ulcer will be developed that may get infected. Any screening protocol should take into account to assess the severity of the peripheral neuropathy and vascular insufficiency which are key determinants of the progression of the pathogenesis of diabetic ulcer foot.

Although based on similar determinants, the way they categorize is little different as exemplified.. The risk of lower extremity amputation increases with the previous history of lower extremity events like foot ulcers with infection and or minor amputation.

In addition to having a good screening protocol, the patients, and their caregivers must be educated about the care of the foot as it may help the at-risk patient to look and recognize serious events in the foot and to seek earlier medical attention and intervention. The patient must be educated not to walk barefoot, and not to use callus or corn removers. They must be encouraged to bathe the foot with milder soap, to use soft brushes in cleaning the nails and nail folds, to keep the foot dry with particular attention to web space and to ensure that foot or the web space is not macerated,  and to use lamb’s wool in the web spaces if macerated. The foot must not be allowed to stay dry and should be encouraged to use lotion, oil or lanolin cream. When socks are used, they must ensure that they can absorb perspiration and breathe. Patients must be advised to use well-fitting shoes, with adequate cushions. Appropriate footwear both indoors and outdoors must be used and should be modified based on the altered biomechanics and foot deformity ensuring offloading of the pressure points in the deformed foot with adequate leg and toe room.

The presence of any of the determinants is considered to be an at-risk diabetic foot.



Diabetic foot clinics with more number of patients but without multidisciplinary team to assess the patients, must have a screening tool to easily identify at-risk foot and to treat modifiable risk factors that predispose diabetic patients to limb amputation. Such screening can happen only when an easy to use, highly sensitive and specific screening protocol is used. The protocol we followed in our hospital is based on color coded etiological keys, which have enabled us to identify and treat all the modifiable risk factors that predispose diabetic patients to lower extremity events, thereby bringing down the incidence of lower extremity amputation in our hospital. Patients must not be admitted under the specialty of the admitting physician, but based on the lesions identified using ourcolor-coded protocol.We have explained in brief about seven patientswhowere referred to our vascular surgery department for amputation and were benefited by this simple color coded etiological keys that were corrected to avoid a major amputation in each of this patient.

The key elements in the management of the diabetic foot ulcer as in practical guidelines on the management and prevention of the diabetic foot includes the following (11)

  1. Inspection and management of the at-risk diabetic foot on regular basis depending the magnitude of the disease process
  2. Identification of the at-risk foot
  3. Education of the patient, family and healthcare providers
  4. Appropriate footwear both indoors and outdoors
  5. Treating the identified pathology


The color-coded etiology identification tool adapted in our hospital have addressed each of the above said components and can be used in any hospital setting with limited resources regardingworkforce and financial aids. We have already published our data regarding the usage of this simple color-coded tool which has brought down the incidence of amputation and major amputation-free limb survival achieved in 72.5 % of our patients which underscores the success of implementing this simple tool. With the results, which we have obtained so far by using this color-coded sheets, the poor predictors of the limb survival were tissue loss and history of previous diabetic foot events.

The accumulated evidence shows that as the severity of the neuropathy progresses, the risk of the diabetic foot events regardingmajor or minor amputation increases. It is recommended that once the neuropathy has started in diabetic patients, all the above said key etiological factors are to be monitored and treated on a regular basis to avoid a major lower extremity amputation.



Although this review is not so exhaustive, we have done our best to ensure that most of the key determinants were takeninto account for creating a simple, easy to use and objective tool to identify etiological factors that are modifiable to reduce the incidence of major lower extremity amputation. 


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