Robert J.

Snyder, DPM, MSc, CWS

Professor and Director of Clinical Research
Barry University SPM
Screening is important to identify PAD, and intervene
when possible…

1. Ischemia = peripheral
arterial disease (PAD)
Malperfusion results in…
1. Ischemia… all ischemic wounds are
hypoxic

2. Hypoxia…not all hypoxic wounds are

ischemic
Macrovascular Arterial Occlusive Disease

Chronic underlying
ischemia
Marston WA, et al. Natural history of limbs with
arterial insufficiency and chronic ulceration treated
without revascularization. J Vasc Surg 2006; 44:108-
114.

 ABI < 0.5 associated with 23% limb loss at 6 months,

28% at 12 months
 ABI > 0.5 associated with 10% limb loss at 6 months,
15% at 12 months (p = .01)
Angiographic Evaluation of PVD as a Prognostic
Determinant for Major Amputation in Diabetics
with Foot Ulcers
 Stenoses causing vessel lumen reduction 50% or greater
detected in 99% of 104 consecutively admitted diabetic patients
with foot ulcers, 1993-1995
 Stenoses were detected in patients with palpable foot pulses,
ankle-brachial indexes greater than 1
 Stenoses were detected in patients with PtcO2 values greater
than 50 mmHg

Faglia et al. Diabetes Care. 1998; 21(4):625-530

 Microvascular Arterial Occlusive Disease

Microcirculatory dysfunction
exacerbates wound ischemia
No response to painful stimuli
Microvascular Arterial Occlusive Disease

Pressure producing intermittent,

recurring, ischemia-reperfusion injury
 Normal Normoxic Wound

Hypoxic Wound
Center
Zone of Tissue
Injury
Normally Perfused
And Oxygenated
Periwound Tissue
 Partially Corrected Periwound
Hypoxia

Hypoxic Wound
Center
Zone of Tissue
Injury
Malperfused but
Hyperoxygenated
Periwound Tissue
We want to screen for, identify,
and intervene when possible…
1. Peripheral arterial
disease (PAD)…
Macrovascular Disease

2. Hypoxia…Microvascular Disease,
Edema, etc.
Key Concepts:
 The assessment of vasculature requires a holistic
approach. Symptoms, signs, or investigations
taken in isolation can be misleading
 The presence of a venous disease, for example,
does not imply that an ulcer is of purely venous
etiology. The patient may have a co-existing
arterial disease
 In a similar analogy, the presence of a dorsalis
pulse does not rule out co-existing arterial disease
Investigation of Arterial Disease
 Specific risk factors for atherosclerosis such as
diabetes mellitus, smoking, and
hypercolesterolemia should be assessed
 Chest pain suggestive of ischemic heart disease,
weakness, falls, or dysrhythmias possibly related to
cerebrovascular accidents should also be assessed
for general vascular status
 Vascular episodes outside the limbs are associated
with vascular disease within the limbs
Intermittent claudication
 Caused by insufficient blood supply in
the presence of increased demand
created by the leg muscles as the
patient exercises
 Indicative of mild to moderate PVD
Rest Pain
 Represents end-stage PAD
 Typically occurs in the toes or foot at night (however, can occur
anywhere in the lower limb)
 Elevation of the legs to the same level as the heart (or above) while
sleeping causes a fall in the arterial pressure, which was previously
aided by the forces of gravity in the standing or sitting position (Leg
elevation exacerbates symptoms!)
 Rest pain is thus characteristically relieved by swinging the legs
over the side of the bed or by standing (or treatment chair in your
office!)
 Some patients will sleep in a chair to circumvent the symptoms
Physical Examination
 Inspection
 Tissue loss
 Palpation
When foot ulcers are present
 Auscultation in patients with diabetes
“Time is Tissue”
Vascular
 Evaluate pedal pulses, popliteal, femoral( if necessary): DP absent in
8.1% of healthy individuals; PT in 2%.
 CFT < 3 sec
 Hair growth; trophic skin changes; fissures; thickened toenails
 Skin temperature warm to warm, distal to proximal B/L lower
extremity (Cold to warm, or cold to cold could indicate PAD)
 Always examine for temperature with the back of your hand
 Temperature can also be measured with a thermal thermometer; In
patients with diabetes, a 4 degree difference in temperature from one
foot to the other may indicate increased risk of foot ulcer
Vascular
 Hand held Doppler (triphasic, biphasic, monophasic, absent)
 Ankle-Brachial Index/ABI (0.9-1.29)
 If ABI >1.29 ( often seen in patients with diabetes as “pipe-stem”
arteries indicating medial calcinosis); perform Toe Brachial Index/TBI
(not affected by medial calcinosis)
 Edema; lymphedema; lipodema
 If hyperemia is present, lift the leg to see if there is pallor on elevation
(Burger’s sign) and intense rubor on dependency( seen in an ischemic
limb)
Diagnosing Peripheral Arterial Occlusive
Disease (PAOD): Complete Physical
Examination
 Visual inspection:
 Skin
 Hair
 Nails

 Pulse examination
 Palpable
 ABI (or TBI in some diabetics)
 Provocative Tests (pathophysiology
deliberately induced i.e. reactive
hyperemia, treadmill )
 Oxygenation and Perfusion Testing
 Transcutaneous Oxygen
 Skin Perfusion Pressures
 Diagnosing Peripheral Arterial Disease (PAOD):
Complete Physical Examination

 Observe for signs of ischemia…

Rubor, cyanosis
Pallor on elevation
Delayed capillary refill
Necrosis of skin
Limitations of Pulse Exam
in Diagnosing PAD
Key Caveats in Pulse Evaluation
% Absent
 Significant inter observer variability

 Dorsalis pedis (DP) pulse absent in 8.1% of

healthy individuals
2.0
 Posterior tibial pulse (TP) absent in 2.0% of
healthy individuals

 Absence of both pulses strongly suggestive of

PAOD
8.1
 Pulses may be preserved in the face of significant
disease
Evaluate for Venous Disease
 Varicose veins,
hemosiderosis,
lipodermatosclerosis,
atrophie blanche,
pitting edema, brawny
edema
 Homan’s sign
Homan’s Sign
 A sign of deep vein thrombosis (DVT)
 A positive sign is present when there is pain in the calf or popliteal
region with examiner's abrupt dorsiflexion of the patient's foot at
the ankle while the knee is flexed to 90 degrees
 This sign is frequently elicited in clinical practice because of it’s
ease of use
 Specificity and sensitivity about 50%
 A positive Homans' sign does not positively diagnose DVT
(poor positive predictive value)
 A negative Homans' sign does not rule out the DVT diagnosis
(poor negative predictive value)
 Essentially, one might as well flip a coin to diagnose the presence
of a DVT
 Order a stat venous ultrasound if DVT is suspected
 The 5 P’s to Critical Limb Ischemia
6

 Pain
 Pulselessness
 Pallor
 Parasthesias Poikilothermia,
 Paralysis the inability to maintain a
constant core temperature independent of ambient temperature
loss of thermoregulation
Vascular
Vascular
Vascular
Vascular – Pedal Pulses
Vascular
Macrovascular Assessment
1. Hand-held Doppler/Ankle-Brachial Index (ABI)
2. Pulse Volume Recording (PVR)
3. Arterial duplex
4. Vascular consult for angiogram(CTA;MRA;CO2;
contrast angiogram)
Vascular
Microvascular Assessment
 Toe-brachial index (TBI)
 Photoplethysmography (PPG)
 TcpO2
 Skin Perfusion Pressure (SPP)
Peripheral Arterial Disease(PAD)
 Affects 10 million Americans
 Caused by arteriosclerosis
 Can begin in the lower extremities but usually is more
generalized with lesions at multiple sites (vasculopath)
 Increases risk of stroke and MI
 An abnormal ABI could alert the physician to “at risk”
patients for stroke and MI
PAD: 5 year prognosis
 20% will experience a non fatal stroke or MI
 30% will succumb to a fatal event
 Patients with Critical Limb Ischemia (CLI)
30% will require an amputation
20% willNot
be dead in 6 months
all patients with PAD are symptomatic
 There are 160,000 amputations performed in the US at a cost of 10 billion
dollars (i.e. intermittent claudication, rest pain)
 The Society of Interventional Radiologist reported that the Framingham
risk score (FRS) combined with the ABI could identify 45% of patients at
risk that were originally thought not to be
CONCLUSION:
Measurement of the ABI may improve the accuracy of cardiovascular risk prediction
beyond the FRS.
Ankle-Brachial Index Collaboration: Ankle-brachial index combined with Framingham risk score to predict cardiovascular events and
mortality: a meta-analysis. JAMA . 300(2): 197-208. 2008
When to “Escalate” the Vascular
Assessment
1. Abnormal pulse exam or abnormal ABI, TBI, SPP
2. Eschar or significant necrosis
3. Multiple ulcers on the foot or leg
4. Ulcer on the foot of a diabetic
Macrovascular Tests
Ankle-Brachial Index (ABI)
 Diagnosing Peripheral Arterial Disease (PAOD):
Lower Extremity Arterial Circulation

 Auscultate lower
extremity pulses with a
8-10 MHz Doppler
 Doppler Waveform Analysis
Triphasic Flow

Rapid antegrade
flow during
systole

Transient reverse
flow in early
diastole

Slow antegrade
flow in late Stenosis Induced Changes
diastole •Decreased rate of rise of the antegrade flow
•A reduced amplitude of the forward velocity
•Loss of reverse flow ('biphasic' waveform)
•Severe stenosis result in a monophasic
waveform
Calculating the ABI
To calculate the Ankle Brachial index, divide the
highest ankle pressure by the highest arm
pressure.

Ankle systolic pressure

ABI = Arm systolic pressure
ABI: American Heart Association
Recommendations
 > 1.3 non-compressible Perform TBI
 1.0-1.29 Normal vessels
 0.91-0.99 Borderline (equivocal: subject to more than
one interpretation): May be abnormal after exercise
 0.41-0.90 Mild –moderate disease; can produce
intermittent claudication
 0.00-0.40 Severe PAD; usually associated with rest
pain (end-stage vascular disease)
Doppler Interpretation
 Sound
 Numerical: calculation of the ABI and comparing to
validated guidelines
 Waveform

 When performing a hand-held Doppler study use a

high frequency continuous wave(CW) Doppler(8 MHz
probe) while maintaining a 60 degree angle (or less) to
the skin in the direction of the blood flow
Sound: Phasicity( the direction of
blood flow)
Subjective/ based upon examiners experience
 Triphasic
 Biphasic
 Monophasic
 Absent

 Peripheral blood vessels normally display a highly resistant flow pattern.

 Blood flow “bumps into” the branches of the terminal arteries and then “bounces
back”.
 The healthy elastic blood vessel, now filled with arterial blood during systole,
contracts again, propelling the blood forward
 All of these phases are represented audibly
 Triphasic
 The normal Doppler wave form
 Sound: Contains three separate components; distinct and rapid
 Waveform: Brisk, sharp uptake (systole); normal diastolic down stroke
 Vessel elasticity apparent

Early
diastole
Late
Systole diastole

Baseline
Biphasic
 Considered healthy but mildly abnormal
 May be caused by compensatory vasodilatation from inflammation or
exercise
 Could represent the initial effect on a waveform in the presence of
arterial obstruction
 Sound: “one-two” rather than “one, two, three”
 Waveform: The second component, representing flow reversal
(diastolic downstroke), is lost

Antegrade systole
blunted;
Retrograde diastole
lost
Monophasic
 Abnormal
 Sound: Only one component
 Waveform: Rounded peak

Rounded peaks
 Use of Ankle Brachial Index
(ABI) in Diagnosing PAD
 When compared to angiography, ABI
 95% sensitive
 100% specific (almost)
 May be falsely negative in patients with
calcified, poorly compressible vessels
 May be falsely negative in symptomatic
patients with moderate aortoiliac stenosis
 Eliminate some of the false negatives
 Exercise Testing
 Toe brachial index (TBI)
Wound Healing Prognostic Value of
Ankle and Toe Pressure
Apelqvist et al. (Diabetes Care. 1989)
 314 diabetic pts with foot ulcers.
 Higher Ankle/Toe pressures in healers vs non-
healers (p <.001)
 None healed with ankle pressure < 40 mmHg
 Ankle pressure upper limit of healed group
could not be defined.
ABI and Wound Healing Predictions

 ABI vs. Wound Healing is not correlated in diabetics and chronic renal
failure patients

(Padberg et al. J Surg research.1996)

Pulse Volume Recording (PVR)
Segmental Blood Pressures
Segmental Blood Pressures
 Cuffs are applied to the thigh, calf, and ankle
 Can used high and low calf method or a single larger thigh
cuff
 If, high and low calf method used, 4 cuffs are placed
around each limb
 Normally, the thigh pressure is about 20 mmHg above the
brachial pressure
 The two thigh cuff method differentiates between
aortoiliac disease and superficial femoral artery
disease{SFA} ( a lower thigh to brachial pressure may
indicate significant aortoiliac disease or proximal femoral
artery disease when the profunda and SFA’s are affected )
Interpretation of Segmental Blood
Pressures
 A 20 mmHg drop in pressure from proximal to distal
cuffs suggests hemodynamically significant disease
above the more distal cuff. Results may be different in
each lower limb
 Examples:
A 20 mmHg drop in pressure from the thigh to the
calf suggests distal superficial femoral or popliteal artery
disease.
A 20 mmHg gradient between the calf and ankle
suggests hemodynamically significant disease in the tibial
and peroneal segments, which include the anterior and
posterior and peroneal arteries.
Examples of Normal and
Abnormal Segmental Pressures
Abnormal
Wave
forms

Normal
Study

Right distal
SFA disease
Arterial Duplex
Arterial Duplex
 Helps localize and grade the vascular disease
 Not a screening test( can take 1-2 hours)
 Often used in conjunction with traditional PVR and
segmental limb pressures
 The peak systolic velocity determined by Doppler
ultrasound is an index of the percent diameter
reduction in the artery tested
Waveform Criteria
 The type of waveform observed depends on the
severity of arterial diameter reduction
 0%-19% reduction Triphasic waveform
 20%-49% reduction Biphasic
 50%-99% reduction Monophasic
 Total occlusion No waveform
Color Doppler of the Lower
Extremities
 Only qualitative
 May “light up” potential trouble spots
 Pulsed Doppler should be performed during any
arterial examination when quantitative information is
required
Color Doppler

 CDI demonstration of normal

hemodynamic patterns seen
at the anastomosis of a
femoral cross-over graft and
the CFA.
Arteriography
Microvascular Tests
Microcirculation
 Hypertensives and diabetics are examples of
patients that may have palpable pulses, but
still have significant microvascular disease
Photoplethysmography (PPG)
 Photoplethysmography (PPG) is used to determine if there is
sufficient capillary blood flow in tissue by measuring the
difference between the amount of light put out by an infrared
light emitting diode (LED) and the amount of light returned to
the sensor.

 This difference is a measure of the quantity of blood in the tissue

since the blood actually absorbs the light emitted by the LED.

 The greater the amount of light absorbed by the blood cells, the
greater is the amount of blood in the area and, therefore, the
higher the amplitude of the PPG waveform displayed. It also
indicates that perfusion to the site is more normal.
How PPG is used?
 PPG is used to assess the amount of blood in tissue at a
burn site, around a skin lesion, or to evaluate the
probable healing power of tissue at a proposed surgical
site
 The blood flow is represented in a waveform format.
The Dicrotic Notch corresponds to the transient
increase in aortic pressure
upon closure of the aortic valves
Toe Pressures are controversial
 Carter and Tate:
Toe pressures may reflect the overall obstruction in the arterial tree proximal to the
digits and are unaffected by arterial incompressibility
Toe pressures of 40mmHg or less correlated with severe deterioration such as tissue
loss, rest pain, and gangrene
The presence of diabetes increased the odds ratio for rest pain, skin lesions, or both
after controlling for systolic pressures and wave amplitude.
In summary:
Rest pain, skin lesions, or both were present in approximately 50% of limbs with toe
pressures less than or equal to 30 mmHg, in 16% of those with pressures of 31-40 mmHg,
and in 5% of limbs with arterial disease and toe pressure greater than 40 mmHg

 Ramsey et al:
Toe pressure measurements had an average sensitivity of 85% with a specificity of
88% in asymptomatic limbs and 89% and 86% for ischemic limbs
They concluded that toe pressures of 30 mmHg indicated good healing potential;
ankle pressure < 80 mmHg were associated with poor healing

Carter and Tate. Journal of Vascular Surgery, 24;258-265, 1996

Ramsey et al. J Cardio9vascular Surgery. 24;43: 200-211. 1983
Toe-Brachial Index (TBI)
 Normally lower than ankle pressures
 Is unaffected by medial calcinosis
 When calculating the TBI ratio, use the highest arm pressure

TBI= Toe systolic pressure

Arm Systolic Pressure
>0.7 Normal
<= 0.7 Abnormal

Ankle-Brachial Index Collaboration: Ankle-brachial index combined with Framingham risk score to predict cardiovascular
events and mortality: a meta-analysis. JAMA . 300(2): 197-208. 2008
Issues With PAD/CLI
Diagnosis and Standard Tests
Issue 1. Incompressible vessels render arterial occlusion
difficult, non-repeatable or even impossible
Issue 2. Distal occlusions
Issue 3. Unpredictability of toe as measurement site for
estimating distal perfusion
Issue 4. Separation of vascular from non-vascular causes of low
PtcO2
Toe as a Measurement Site
Toe pressures are painful in the
ischemic toe and plainly
impossible in certain cases.

The most common commercial

electrodes used in the
transcutaneous oximeter for PtcO2
can not be applied to the toe since
they are too wide to adhere to
narrow, curved areas
Transcutaneous PO2 (PtcO2)
Transcutaneous Oxygen
Monitoring
 The measurement of tissue oxygen provides
information concerning the amount of O2 that is
available to the tissue and is influenced by arterial
pO2 concentration and blood flow rates
 This technique can be very useful in patients with
diabetes because the Doppler derived ankle
pressures are falsely elevated secondary to
calcification of the vessels
 Comparison of Preoperative PtcO2 Associated
With Successful Healing
# Limbs TcPO2 With Successful Probe Temp Room Temp
Healing

Burgess, et al. 1982; J Bone Joint Surg 37 >40 mmHg 44-45 oC NR

64A: 378-382.

Franzeck, et al. 1982; Surgery 91 91(2): 35 >20 mmHg 45 oC 25 oC

156-162.

Dowd, et al. 1983; J Bone Joint Surg 24 >40 mmHg 44 oC 22 oC

65(B): 79-83.

Ito, et al. 1984; Int Surg 69: 59-61. 31 >30 mmHg 45 oC NR

Benscoter, et al. 1984; J AOA 83(8): 560- 14 >37 mmHg 45 oC 21 oC

574.

Rhodes, et al. 1984; Amer Surg 51:701- 12 >25 mmHg NR 37 oC

707.

Christensen, et al. 1986; J Bone Joint 42 >37 mmHg 45 oC 23 oC

Surg

From Transcutaneous pO2 in Peripheral Vascular Disease, Radiometer TC105

Wound Healing Impairment with
Decreasing PtcO2
40 mmHg

0 mmHg
Predictive Accuracy of PtcO2
(Franceck, et al, 1989)
 PtcO2
 Diabetic wounds 31/34 (91%)
 Non Diabetic wounds 22/22 (100%)
 Arterial Doppler
 Diabetic wounds 14/37 (37%)
 Non Diabetics 7/22 (77%)

 PtcO2 is more accurate than arterial Doppler in predicting

likelihood of healing
PtcO2 and Wound Healing Predictions

(Padberg et al. J Surg research.1996)

PTA in Diabetic Lower Extremity Limb Salvage
Hanna G et al. J Am Coll Cardiol, 1997; 30(3)

…PtcO2 vs. ABI as an indicator of success in 29 consecutive patients

Technical Success (26) 29.3 +/- 9.6 57.6 +/- 10.0 <0.0001
Clinical Success (23) 27.8 +/- 10.0 54.5 +/- 14.7 <0.0001
Pre-procedure Post-procedure
ABI Measurements
Technical Success (26) 0.68 +/- 0.17 0.67 +/- 0.19 ns
Clinical Success (23) 0.70 +/- 0.17 0.70 +/- 0.19 ns
 In-Chamber PtcPO2: The Best
Single Predictor of Healing
 PtcO2 in-chamber <100 mmHg:
18% benefited
 PtcO2 in-chamber 200-700
mmHg: 78 % benefited
 75% reliable in predicting
favorable outcome
Attinger CE, et al. Angiosomes of the
foot and ankle and clinical
implications for limb salvage:
Reconstruction, incisions, and
revascularization. Plast Reconstr Surg
2006; 117(suppl): 261S
 Microcirculatory abnormalities not always reversed by
correction macrovascular abnormalities…

 J Vasc Surg 2002;35:501-5 Arora et al (LoGerfo)

Impaired vasodilation in diabetic neuropathic
lower extremities improves but is not completely
reversed with successful bypass grafting.(laser
doppler trial)
 Post revascularization diabetic patients may still be
at risk for foot ulceration and may fail to heal the
ulcer despite adequate correction of macrovascular
flow
The Angiosome Concept
 A new paradigm in evaluating and treating vascular
disease in patients with diabetes
 Taylor and Palmer(1987)
 Dr. Chris Attinger: Pioneered the angiosome model in
the diabetic foot
Angiosomes in the Diabetic Foot

Three dimensional blocks of tissue

supplied by a source artery
Angiosomes in the Diabetic Foot: Three dimensional
blocks of tissue supplied by a source artery
 There are 6 angiosomes in the foot that originate
from the three major arteries in the lower leg ( PT,
AT/DP, Peroneal)
 Choke vessels mark the boundary of any angiosome
and can supply blood to an adjacent angiosome
through the delay phenomenon
 Arterial-arterial connections: Allow uninterrupted
blood flow to the entire foot despite the occlusion of
one or more arteries (vascular redundancy; vascular
rescue)
The distribution of 6 angiosomes in the foot create vascular redundancy.
This generates multiple pathways to augment blood supply to an ulcer
Choke vessels in a rat model
 X
X X X Distal lateral
and medial
calf
 Can probably get this site
fairly frequently.
X

X X These sites are in a watershed with

some crossover between angiosomes
but easily measured.
Both of these should be
obtainable.

X
X
Accuracy of measurement
at these sites will
Plantar Foot
be dependent upon
the thickness of
the Stratum
Corneum…may
be obtainable in
40-50% of X
cases, worth a try
but limited by technology
X
in the same
way that
SPP may also be affected
by very think SC limiting
laser penetration.
Skin Perfusion Pressure (SPP)
SPP is measured in the
Microcirculation
Diagram of the
microcirculation where laser
Doppler detection occurs
during SPP measurement.
Note nutritional capillaries,
arteriovenous shunts, and the
sub-papillary venous plexus.
SPP Graph
SPP Interpretation Guideline
(in mmHg)
 30 or less = Critical Limb Ischemia and the wound is
unlikely to heal

 30 to 40 = GRAY ZONE in Wound healing

 40+ = Wound healing probable

 40-50 = Mild Ischemia

 50 or more = Normal Skin Perfusion

 PtcO2 vs. SPP graphs, Superimposed
Steeper Sigmoid curve makes SPP more useful
“Wound Healing Prediction” tool

Padberg et al. J Surg Research.1996; Castronuovo et al. J Vasc Surg 1997

Resolution of Malperfusion
1. Optimize the macro circulation (large vessel blood
flow)…revascularization
2. Optimize the micro circulation…
 Reduce edema
 Prevent micro thrombosis
 Reduce vasoconstriction
3. Optimize oxygen delivery…
 Supplemental oxygen
 Correct anemia
 Hyperbaric oxygen
Venous Investigations -
Noninvasive
 Hand held Doppler
 Color flow duplex ultrasonography
 Photocell plethysmography
Duplex Venography
Invasive versus non-invasive
testing
 Noninvasive color flow duplex ultrasonography has
replaced venography in many centers for the diagnosis
of DVT and valvular disease
 When a duplex scan is ordered for venous
insufficiency, the radiologist report will only reflect
the presence or absence of DVT
 Call the radiologist before the test is performed;
evaluation of valvular incompetence requires a more
comprehensive evaluation( i.e. use of the valsalva
maneuver, testing while standing as well as supine,
etc)
Additional References
 Bowker JH: The Diabetic Foot, 7th ed. (Mosby: St Louis, 2008)
 JM McCulloch and LC Kloth (Eds.): Wound Healing: Evidenced Based
Management, 4th Edition. (EA Davis Company: PA 2010)
 AN Sidawy: Diabetic Foot Lower Extremity Arterial Disease and Limb
Salvage. (Lippincott, Williams & Wilkins: PA, 2006)
 Case TD: Primer of Noninvasive Vascular Technology (Little, Brown
and Company: Boston, 1995)
 Krasner DL: Chronic Wound Care, 3rd ed. (HMP Communications:
Wayne, 2001)
 Lorimer DL: Neale’s Disorders of the Foot and Ankle, 6th ed. (Churchill
Livingstone: London, 2002)
 Rolstad BS: Contemporary Wound Care: A Desk Reference. Johnson &
Johnson: Arlington, 1997)