new clasification dm foot

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Open access publishingThe Journal of Diabetic Foot Complications

A NEW CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS:

A SIMPLE AND EFFECTIVE TEACHING TOOL

Authors:

The Journal of Diabetic Foot Complications, 2012; Volume 4, Issue 1, No. 1, Pages 1-5 All rights reserved.

Dr Amit Kumar C Jain*

Abstract:

Key words: diabetic foot, classication, Wagners, teaching tool

Corresponding author:

Dr Amit Kumar C JainConsultant General, Diabetic Lower Limb and Podiatric SurgeonDepartment of SurgerySt Johns Medical CollegeBangalore -560034Ph :- 09731717134

Email:[email protected]

Afliations:

1. Department of Surgery, St. Johns Medical College, Bangalore

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The prevalence of diabetes mellitus is growing at epidemic proportions world wide. Of the many complicationsaffecting the person with diabetes, none are more devastating than those involving the foot. The incidenceof diabetic foot complications is increasing in developing countries as the disease is often neglected bothby patients and treating doctors. Various classications have been used in the West since the last 30 yearsto describe diabetic foot lesions. Wagners and University of Texas are two well established classications.However, most of these classications are difcult to understand and they do not include various commondiabetic foot complications. The author proposes a new classication of diabetic foot complications that is easyto remember and includes all the common complications of the diabetic foot. This classication system can beused as a teaching tool to disseminate the knowledge of diabetic foot complications among various health care

professionals, especially in developing countries.

*MBBS, D.DIAB, F.DIAB, DNB[Gen Surgery], FPS[Podiatric Surgery]

Diabetes mellitus has become an epidemicworldwide. In the United States, the incidenceof diabetes is increasing 1% per year. (1) In theU.S, diabetes is the seventh leading cause ofdeath, mainly secondary to cardiovascular com-

plications. It was estimated in 2000 that therewere 32million people with diabetes in India, anumber that is predicted to increase to nearly 80million by 2030.(2) Foot problems are an associ-ated complication and an increasing problemsamong individuals with diabetes. Diabetic footulcers will complicate the disease in more than15% of these people during their lifetime. (3)Footulcers precede more than 80% of non traumaticlower limb amputations. (4) The most common

sites for ulcer are toes, followed by the plantarmetatarsal heads and the heel. Foot risk factorsinclude peripheral neuropathy, peripheral arterialdisease and foot deformities. Arterial diseasewas present in 48% of foot ulcers in Germany,

but only 11% in Tanzania and 10% in India.(5)

Treatment of infected foot wounds comprisesup to one quarter of all diabetic hospital admis-sions in the US and Britain, making this the mostcommon reason for diabetes related hospitaliza-tion in these countries. The estimated cost forfoot ulcer care in the US ranges from $4,595 perulcer episode to nearly $28,000 for the 2 yearsafter diagnosis. (6)

Introduction


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WAGNER- MEGGITTS CLASSIFICATION :

UNIVERSITY OF TEXAS WOUND CLASSIFICATION :

Classication of diabetic foot woundsis needed for many purposes. Among the mostimportant is our need to adequately describethe lesions that we treat in order to study patient

outcome as well as to further our understandingof the diabetic foot. Clinicians and researchershave used various classication schemes for footrelated complications of diabetes for 30 years.The usefulness of these systems is attested by

the fact that over a dozen have been devisedsince the original Meggitt-Wagner gradingsystem. Some of the classications includeKings College Hospital classications, University

of Texas classication, PEDIS classication, etc.However, the two most well established clas-sication systems are the Meggitt-Wagner andUniversity of Texas systems.

This classication [Table 1], which was developedin the 1970s, has been the most widely acceptedand universally used grading system for lesions ofthe diabetic foot. (7) The original system has sixgrades of lesions. The rst four grades (grade 0,1, 2, and 3)are based on the physical depth of thelesion in and through the soft tissues of the foot.The last two grades (grade 4 and5)are completelydistinct because they are based on the extent ofgangrene and lost perfusion in the foot. Grade 4

refers to partial foot gangrene and Grade 5 refersto a completely gangrenous foot. The problem withWagners classication is that this classication doesnot adequately address all diabetic foot ulcerationsand infections. (8) Only one of the six grades (Grade3) infers infection. (9) Further, the system is limited inits ability to identify and describe vascular diseaseas an independent risk factor. In addition, supercialwounds that are infected or dysvascular are not ableto be classied by this system.

The University of Texas classication (7)representsan advance in the treatment of the diabetic foot. Thissystem [Table 2]uses four grades, each of whichis modied by the presence of infection (Stage B),ischaemia(Stage C), or both(Stage D). This system

has been validated and is generally predictiveof outcome, since increasing grade and stage ofwounds are less likely to heal without revasculariza-tion or amputation. It is now widely used in manyclinical trials and diabetic foot centres.

Open access publishingThe Journal of Diabetic Foot Complications 2012; Volume 4, Issue 1, No. 1, Pages 1-5

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Grade 0 Foot symptoms like pain,only

Grade 1 Supercial ulcers

Grade 2 Deep ulcers

Grade 3 Ulcer with bone involvement

Grade 4 Forefoot gangrene

Grade 5 Full foot gangrene

GRADE-0 GRADE-1 GRADE-2 GRADE-3

STAGE-A Preulcerative or postul-cerative lesion completely

epithelialized

Supercial wound, notinvolving tendon, capsule

or bone

Wound penetrating totendon or capsule

Wound penetrating tobone or joint

STAGE-B Infection Infection Infection Infection

STAGE-C Ischemia Ischemia Ischemia Ischemia

STAGE-D Infect ion and Ischemia Infection and Ischemia Infect ion and Ischemia Infect ion and Ischemia

Table 1 - WAGNER-MEGGITT CLASSIFICATION OF DIABETIC FOOT

Table 2 - UNIVERSITY OF TEXAS CLASSIFICATION OF DIABETIC FOOT

CLASSIFICATION OF DIABETIC FOOT LESIONS


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NEED FOR NEWER CLASSIFICATION

The author proposes a new classication [Table3] for diabetic foot problems that addresses thedecits of the current classications. The primaryadvantage [Table 4]of this classication lies in its

simplicity. It allows for an easier understanding ofdiabetic foot complications and it is also easy toremember.

Since there are a multiple classica-tion schemes, it is understood that each hasits own set of advantages and drawbacks. The

advantage of the Meggitt-Wagner and Universityof Texas classications is that both systems havebeen shown to be predictive of poor outcomes.

However, there are certain drawbacks of all current classications:

These classications do not include all the diabetic foot complications. They are difcult to remember, especially University of Texas classication and PEDIS classi-cation. They cannot be used as a teaching tool, as these classications are difcult to be understoodby undergraduate, postgraduates, specialists of different medical elds and paramedics involved indiabetic foot care.

PROPOSED CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS :

TYPES LESIONS

TYPE 1 (INFECTIVE) Cellulitis, abscess, necrotizing fasciitis, wet gangrene, osteomyelitis and tinea pedis.

TYPE 2 (NON INFECTIVE) Skin and soft tissue Nonhealing ulcer, callosity, diabetic bullae.

Nerve Neuropathies

Bones and joints Charcot foot, hammertoes, claw toes

Vessel Peripheral arterial disease (mild, moderate and severe)

TYPE 3 (MIXED) Includes infective and non infective complications

1 Very simple to understand

2 Easy to remember

3 Useful as a teaching tool

4 Practical

5 Includes all the common complications affecting diabetic foot

Table 3 Proposed CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS

Table 4 - ADVANTAGES OF THE NEW CLASSIFICATION

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According to this classication, diabetic foot le-sions can be divided into 3 types:

Type 1- Diabetic foot complications that are in-fective: this includes cellulitis, abscess, necrotiz-ing fasciitis, etc.

Type 2-Diabetic foot complications that are noninfective. Based on the structure affected theyhave been categorized into 4 subtypes. Thediabetic Charcot foot, peripheral arterial disease,neuropathy, etc. belong to this group.

Type 3- Diabetic foot complications that aremixed, where both type 1 and type 2 complica-tions can occur in combination. A common ex-ample might be a callus ulcer with underlying

osteomyelitis.

This system could be used as an effective toolfor teaching and is not meant to be a replace-ment to any existing classications. It would bemore helpful in developing countries becausecomplications like necrotizing fasciitis [Fig 1],plantar abscess and Charcot foot are more com-

mon due to bare foot walking and poor healthcare. The major disadvantage of this classica-tion is that it does not predict the clinical out-come. It does not guide in instituting specictherapy and hospitalization. It also cannot beused for research purposes. Nonetheless, sinceit is not just a wound classication system, it canprovide for a more thorough assessment andcategorization of diabetic foot complications.

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Figure 1: showing a case of necrotizing fasciitis in a diabetic lower limb. Note that the infection has spread up tothe upper thigh. It belongs to Type 1 diabetic foot complications according to the new classication.


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1] Gibbons WG. Lower extremity bypass in patients withdiabetic foot ulcers. Surg Clin N Am 2003;83:659-669.

2] Wild S, Roglic G, Green A, et al : Global prevalenceof diabetes Estimates for 2000 and Projection for 2030.Diabetes Care 2004;27:1047-1053.

3] Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcersin patients with diabetes. JAMA 2005;293:217-228.

4] Pecoraro RE, Reiber GE, Burgess EM. Pathways todiabetic limb amputation. Basis for prevention. Diabetes Care1990;13:513-521.

5] Morbach S, Lutale JK, Viswanathan V, et al : Regionaldifferences in risk factors and clinical presentation of diabeticfoot lesions. Diabet Med 2004;21(1):91-95.

6] Ramsey SD, Newton K, et al. Incidence, outcomes andcost of foot ulcers in patients with diabetes. Diabetes Care1999;22:382-387.

7] James WB. Classication of foot lesions in Diabeticpatients. Levin and ONeals The Diabetic Foot.2008;9:221-226.

8] Mark AK, Warren SJ. Update of treatment of diabetic footinfections. Clin Podiatr Med Surg 2007;24:383-396.

9] Wagner FW Jr. The diabetic foot and amputation of thefoot. In Surgery of the Foot, Mosby, St Louis 1986: 421- 455.

CONCLUSION

REFERENCES

As the incidence of diabetes is in-creasing, so is the prevalence of diabetic footcomplications. The new classication which

includes various common diabetic foot compli-cations could be used as an effective teachingtool as it is simple to understand and easy toremember. The Diabetic foot has been largelyneglected both by the patient and physicians indeveloping countries. None of the curriculumin developing countries like India describes thecommon diabetic foot complications appro-

priately. Wagners classication is frequentlymentioned but least understood by undergradu-ates and postgraduates of various medical

specialties. The new classication proposed bythe author would probably help in disseminatingthe knowledge of diabetic foot complications,especially in developing countries where thisdisease is frequently neglected. Further studieswill be required to determine its usefulness inthis regard.


new clasification dm foot

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