Introduction
Diabetes mellitus represents a major global health challenge, with its prevalence continuing to escalate worldwide. As of 2025, the International Diabetes Federation (IDF) estimates that 11.1% of adults aged 20–79 years, or approximately 589 million people, are living with diabetes globally. In India, which bears the highest burden of diabetes cases, the prevalence among adults stands at around 10.5%, affecting an estimated 89.8 million individuals [1].
Foot complications are among the most debilitating sequelae of diabetes, with approximately 19% to 34% of individuals with diabetes developing a foot ulcer during their lifetime [2]. In India, the annual incidence of DFUs among people with diabetes ranges from 1.9% to 4.0%, often exacerbated by peripheral neuropathy and delayed healthcare access [3]. These complications span from minor issues like calluses to severe conditions such as abscesses, osteomyelitis, and gangrene, imposing substantial social, psychological, and economic burdens on patients, their families, and healthcare systems. The economic impact is particularly acute in resource-limited settings, where inadequate screening and management facilities amplify the problem [4,5].
Wagner’s classification remains one of the simplest, most widely recognized, and clinically practical tools for evaluating the severity of diabetic foot lesions and guiding treatment decisions. The Wagner scale is user-friendly, focusing on wound depth, with intermediate stages incorporating osteitis and advanced stages addressing gangrene. Its simplicity allows for rapid assessment in busy clinical environments, though it has limitations in not explicitly accounting for ischemia or infection severity, which are addressed in more modern systems [6,7].
Diabetic foot issues are often overlooked by patients and physicians, resulting in higher rates of major amputations. Early diagnosis and timely intervention are crucial for improving outcomes and reducing societal costs. Wagner’s classification aids in tailoring treatments to lesion grades, with lower-grade lesions (0-2) often responding well to conservative approaches like antibiotics, debridement, and offloading, achieving healing rates above 80% in multidisciplinary settings, while higher grades (3-5) frequently necessitate surgical interventions to prevent progression [8-10]. Implementing this system can enhance prognosis, minimize amputations, and optimize resource allocation in high-burden regions like India.
Materials and Methods
Study Design: This Observational study was conducted between July 2024 and December 2025 at the Sri Guru Ram Das Institute of Medical Sciences and Research.
Ethical Approval: The present research study received approval from the Institutional Ethics Committee (SGRD/IEC/2024-296) and the Institutional Research Committee of SGRDIMSR, Sri Amritsar.
Participant Selection: The inclusion criteria were patient with patients with diabetic foot aged more than 18 years and Diabetic foot patients with varicose ulcers, Charcot’s joint, trauma, ulcers due to diabetic neuropathy, and peripheral vascular disease (PVD). Non-diabetic foot patients (such as those with traumatic or other neuropathic ulcers) and Pregnant women with diabetes were excluded.
This study included patients with diabetic foot presenting to Sri Guru Ram Das Institute of Medical Sciences and Research, Vallah, Amritsar from July 2024 to December 2025. These patients were classified according to Wagner’s classification of diabetic foot and the relevant management protocol was implemented for each patient.
The outcomes of each management protocol among all patients were observed and tabulated.
Follow-up of the patients was done for 6 weeks.
| Grade | Description |
| Grade 0 | High-risk foot, no ulceration |
| Grade 1 | Superficial ulcer, cellulitis |
| Grade 2 | Deep ulcer |
| Grade 3 | Osteomyelitis with ulceration, abscess |
| Grade 4 | Partial foot gangrene |
| Grade 5 | Gangrene of the entire foot |
| Grade | Treatment |
| Grade 0 | Preventive care |
| Grade 1 | Antibiotics and good glycemic control |
| Grade 2 | Debridement, Antibiotics and good glycemic control |
| Grade 3 | Incision and drainage of abscess; debridement and some form of amputation for osteomyelitis with ulceration |
| Grade 4 | Debridement and amputation |
| Grade 5 | Below-knee amputation |
Statistical Analysis
The data collected in the present study were entered, organized and analyzed using Microsoft Excel spreadsheets. Statistical analysis was limited to descriptive methods only and no inferential statistical tests or formulas were applied. The observations were summarized using simple frequency counts and percentages to describe the distribution of variables among the study participants. Tables were generated in Excel to present the number of cases in each category, providing a clear and systematic representation of the data.
Results
1. Demographic and Clinical Characteristics of the Study Population (n=82)
In the present study, the most common age of presentation in patients with diabetic foot lesion was >50 years yrs (Table 1). In this study, out of 82 patients, 71 patients (86.6%) were male and 11 patients (13.4%) were female. A study was carried out including 82 patients who were admitted with diabetic foot; their mode of presentation was as follows – 30 cases (36.59%) present with gangrene, 37 cases (45.12%) with ulcer, 7 cases (8.54%) with cellulitis, 1 case (1.22%) with abscess, and 7 cases (8.54%) presented with mixed features, i.e., combination of the above factors. The most common site was foot in 60 patients (73.2%). In the present study, out of 82 cases studied, 58 cases were having history of trauma, which accounts for 70.7% of the total cases (Table 1).
| Characteristic | Category | Frequency (n) | Percentage (%) |
| Age | <50 years | 20 | 24.4 |
| >50 years | 62 | 75.6 | |
| Gender | Male | 71 | 86.6 |
| female | 11 | 13.4 | |
| Mode of presentation | Gangrene | 30 | 36.6 |
| Ulcer | 37 | 45.1 | |
| Cellulitis | 7 | 08.5 | |
| Abscess | 1 | 01.2 | |
| Mixed | 7 | 08.5 | |
| Site of lesion | Foot | 60 | 73.2 |
| Toe | 22 | 26.8 | |
| History of trauma | Present | 58 | 70.7 |
| Absent | 24 | 29.3 |
2. Distribution of Glycemic Status and Microbiological Profile in Study Participants
In this study, 28 patients (34.2%) having blood sugar <200 mg/dl and 54 patients (65.8%) having blood sugar >200 mg/dl. In this study of 82 patients, wound swab was sent preoperatively which shows pattern of causative organism. 12 patients had Pseudomonas, 12 patients had Staphylococcus, 15 patients had E. coli, 13 patients had Klebsiella and 30 patients had negative wound swab (Table 2).
| Characteristic | Category | Frequency (n) | Percentage (%) |
| Random blood sugar | <200 mg/dl | 28 | 34.2 |
| >200 mg/dl | 54 | 65.8 | |
| Organism | E. coli | 15 | 18.3 |
| Klebsiella spp. | 13 | 15.9 | |
| Pseudomonas spp. | 12 | 14.6 | |
| Staphylococcus spp. | 12 | 14.6 | |
| No growth | 30 | 36.6 |
3. Distribution of Patients According to Wagner’s Classification, Treatment Modalities, and Clinical Outcomes
Maximum patients present with Grade 4 and Grade 2 Wagner’s lesion, followed by Grade 5 and Grade 3, as ulcer is one of the most common presentations of diabetic foot. Debridement was the most common treatment modality among various treatment modalities. In this study of 82 patients, who were presented with diabetic foot, 74 patients were healed, 8 patients were not healed (9.8%) (Table 3).
| Characteristic | Category | Frequency (n) | Percentage (%) |
| Wagner’s Grade | Grade 1 | 11 | 13.4 |
| Grade 2 | 19 | 23.2 | |
| Grade 3 | 15 | 18.3 | |
| Grade 4 | 20 | 24.4 | |
| Grade 5 | 17 | 20.7 | |
| Treatment | Antibiotics and glycemic control | 11 | 13.4 |
| Debridement | 25 | 30.5 | |
| Debridement and SSG | 1 | 1.2 | |
| I & D | 1 | 1.2 | |
| Toe amputation | 9 | 11.0 | |
| TMT amputation | 17 | 20.7 | |
| BK amputation | 18 | 22.0 | |
| Outcome | Healed | 74 | 90.2 |
| Non-Healed | 8 | 9.8 | |
| Total | 82 | 100 |
Discussion
The present study was undertaken to evaluate the clinical profile, microbiological spectrum, treatment modalities, and outcomes of diabetic foot lesions classified and managed according to Wagner's classification [11] thereby enabling objective assessment of disease severity.
In the present study, the majority of patients were >50 years, accounting for nearly two-thirds of all cases. This clearly demonstrates that diabetic foot complications predominantly affect middle-aged and elderly individuals. Similar age distribution patterns have been reported by Boulton et al.,[12] and Jeffcoate & Harding, [13] who emphasized that increasing age is associated with cumulative microvascular damage, peripheral neuropathy, impaired immunity, and delayed wound healing.
A striking male predominance (86.6%) was observed in this study. This finding is consistent with numerous Indian and international studies, including those by Shahi et al.,[14] where males constituted more than 70-80% of diabetic foot cases. This predominance has been attributed to increased outdoor activity, occupational hazards, higher rates of trauma, poor foot care practices and delayed health-seeking behavior among males.
Ulceration was the most common mode of presentation in this study (45.12%), followed closely by gangrene (36.59%). Cellulitis, abscess, and mixed lesions formed a smaller proportion. This distribution aligns with observations by Reiber et al.,[15] and Edmonds & Foster,[16] who reported that most diabetic foot lesions initially present as neuropathic ulcers that progressively worsen due to infection and ischemia, eventually leading to gangrene if untreated. The high proportion of gangrene in the present study reflects delayed presentation and poor glycemic control, which are common challenges in developing countries.
The foot was the most commonly affected site (73.2%), followed by toes (26.8%). This finding correlates well with studies by Armstrong & Lavery,[17] and Lavery et al.,[18] who highlighted that pressure-bearing areas of the foot are particularly prone to ulceration due to neuropathy-related loss of protective sensation and abnormal plantar pressure distribution.
A history of trauma was present in 70.7% of cases, emphasizing trauma as a major precipitating factor in diabetic foot lesions. Minor injuries such as thorn pricks, shoe bites, barefoot walking, and nail trimming injuries often go unnoticed due to neuropathy, leading to secondary infection and ulcer formation. Similar findings have been reported by Apelqvist et al.,[19] who noted that trivial trauma is frequently the initiating event in diabetic foot pathology.
Poor glycemic control was a consistent finding in this study. With a majority having blood glucose levels exceeding 200 mg/dL. Chronic hyperglycemia adversely affects leukocyte function, collagen synthesis, and angiogenesis, thereby impairing wound healing and increasing susceptibility to infection. These observations are in agreement with the American Diabetes Association and studies by Boulton & Whitehouse [20].
Culture results showed no growth in 36.6% of cases, likely due to prior antibiotic use before presentation. Among culture-positive cases, gram-negative organisms predominated, with Escherichia coli, Klebsiella, and Pseudomonas being the most common isolates, while Staphylococcus species represented the major gram-positive pathogen. This polymicrobial pattern is consistent with studies by Lipsky et al.,[21] and Ramakant et al.,[22] particularly in chronic and high-grade Wagner lesions.
The majority of patients presented with Wagner Grade 2, 4, and 5 lesions, indicating advanced disease. Higher Wagner grades were strongly associated with surgical interventions, including debridement and amputations. Debridement was the most frequently performed procedure (30.5%), while major amputations were required in a substantial proportion of patients. These findings parallel those of Apelqvist et al.,[19] who demonstrated a direct relationship between Wagner grade and amputation risk. Re-surgery was required in 17.1% of patients, commonly due to persistent infection or non-healing wounds. Despite advanced disease, a favourable outcome was achieved in 90.2% of patients, indicating that timely surgical intervention, appropriate antibiotic therapy, and strict glycemic control can significantly improve outcomes even in severe cases.
Conclusion
Diabetic foot lesions were more common in elderly male patients with long-standing and poorly controlled diabetes. Trauma and infection played important roles in lesion development. A significant number of patients presented in advanced Wagner grades, leading to a higher requirement for surgical interventions, including major amputations.
Despite late presentation, classification-based management using Wagner's system combined with appropriate surgical procedures, glycemic control, and culture-guided antibiotics resulted in a high overall healing rate (90.2%). Early detection, strict glycemic control, patient education regarding foot care, and timely intervention could further reduce the need for amputations and improve outcomes in diabetic foot patients.
Declarations
Ethical Approval and Consent to Participate
All procedures performed in this case series were conducted in accordance with institutional ethical standards and the principles of the Declaration of Helsinki. Ethical approval was obtained from the appropriate institutional review board where required. Written informed consent was obtained from all patients or their legal guardians prior to the procedures.
Consent for Publication
Written informed consent for publication of clinical details and images was obtained from the patients or their legal guardians. All identifying information has been anonymized to protect patient confidentiality
Availability of Supporting Data
The data supporting the findings of this study are available from the corresponding author upon reasonable request, subject to institutional and ethical regulations
Competing Interests
The authors declare that they have no competing interests related to this work.
Funding
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Authors’ Contributions
All authors contributed substantially to the conception, data acquisition, analysis, drafting, and critical revision of the manuscript. All authors have read and approved the final version of the manuscript.