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Review: Principles of STAGE Management for Diabetic Foot Ulcers Based on the Wagner and Texas Classification System

By Temple University School of Podiatric Medicine Journal Review Club

Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

Article: Principles of STAGE Management for Diabetic Foot Ulcers Based on the Wagner and Texas Classification Systems

Authors: Zhu C, Zhou B, Lü J, et al

Journal: Int J Low Extrem Wounds. 2019;18(4):367-375

Reviewed by: Brandon Mojica, class of 2022, Temple University School of Podiatric Medicine


A diabetic foot ulcer (DFU) is a wound that has a high risk of becoming chronic, leading to amputation and, in some cases, even death. Currently, the Wagner and University of Texas classifications are used worldwide to assess the extent of diabetic foot lesions. The authors of this article believed that there was a lack of wound treatment principles based on both classification systems.

The authors therefore summarized the STAGE principles of wound treatment for clinical practice based on the Wagner and Texas classification systems. The STAGE principles refer to surgical intervention during wound treatment of a DFU, with a focus on the anatomical layers of the wound, the management of blood supply, layer-by-layer incision to the infected area, maintenance of adequate wound drainage, and step-by-step treatment of the wound. STAGE represents management of an ulcer through its anatomical layers and processes: skeleton, tendon, angiogenesis, granulation, and epithelialization.

Material and Methods

The Wagner classification assesses the depth and extent of a DFU. This system, however, does not include the degree of ischemia as a factor in the assessment. The Texas classification, in contrast, does include the degree of ischemia and the presence of infection. The authors of this article used both classifications to assess DFUs to determine whether the wound had indications for the use of STAGE. The Wagner classification evaluated the anatomical level and severity of the wound, whereas the Texas classification system evaluated the blood supply of the ulcer and the severity of infection. Absolute indications included Wagner grade 2 or higher and Texas 1B or higher.

Understanding Diabetic Foot Ulcer Classification SystemsUnderstanding Diabetic Foot Ulcer Classification Systems

After evaluation, the STAGE principles were applied according to anatomy, stratified incision drainage, and processing wound healing stage. In summary, the STAGE principles with the objectives for the respective anatomical layers listed here:

(S)keleton: Determine bone and joint destruction and infection. Take appropriate action (e.g., timely osteotomy).

(T)endon: Treat necrotic tendon (removal of necrotic tendon, ligation of stump tendon, adequate drainage of the tendon sheath).

(A)ngiogenesis: Perform percutaneous transluminal angioplasty to increase blood flow if needed. Use pharmacotherapy to improve blood flow.

(G)ranulation: Promote granulation tissue (Chinese medicine and dressings that promote granulation tissue).

(E)pithelialization: Promote epithelialization of the wound (e.g., punch skin grafts, topical agents).


The authors found that when treating a patient according to the STAGE principles, it is essential to pay close attention to bone, tendons, adequate drainage, and infection control. Blood supply is the most critical factor in wound healing and must improve through all phases of the STAGE process. According to the authors, surgeons need to be aware that although large numbers of bacteria can be found in the local tissue of a wound, symptoms related to infection may be concealed by severe vascular lesions, neuropathy, and poor metabolic control. Grafts, Chinese medicine, and negative pressure wound therapy are all modalities used during the granulation and epithelialization phases of STAGE.


The STAGE principles aim to guide treatment of a DFU by using an anatomical incisional approach from deep to superficial. STAGE has some problems and limitations, however. It is not a linear approach to wound care. Angiogenesis is the most critical phase in STAGE and should be incorporated at every step. Although the STAGE principles provide an adequate guideline for treating diabetic foot wounds, they should also include other wound management principles to help eliminate any issues that may arise during treatment. STAGE seems more like a mnemonic for an anatomical surgical approach to treating a diabetic foot wound than a set of guidelines for treating a DFU.

About The Author

brandon_mojica.jpg Brandon Mojica is a second-year podiatric medical student at Temple University School of Podiatric Medicine (TUSPM) in Philadelphia, Pennsylvania. He received his Bachelor's degree in Health Science at the University of Central Florida in 2014. Brandon discovered his love for podiatry through his mentor, Dr. Christopher Reeves, the former President of the American College of Foot and Ankle Surgeons. After working for three years with Dr. Reeves as his medical assistant, Brandon decided to attend TUSPM to pursue his dream of becoming a foot and ankle surgeon. Within these past two years, Brandon has become a leader within the school and his class. He is currently the Chairman for the Class of 2022 Boards Committee, which he created with the help of his peers as a way to prepare his class for their upcoming board exams. Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia. 

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.