A NEW CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS: A SIMPLE AND EFFECTIVE TEACHING TOOL

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1 The Journal of Diabetic Foot Complications A NEW CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS: A SIMPLE AND EFFECTIVE TEACHING TOOL Authors: Dr Amit Kumar C Jain* *MBBS, D.DIAB, F.DIAB, DNB[Gen Surgery], FPS[Podiatric Surgery] The Journal of Diabetic Foot Complications, 2012; Volume 4, Issue 1, No. 1, Pages 1-5 All rights reserved. Abstract: The prevalence of diabetes mellitus is growing at epidemic proportions world wide. Of the many complications affecting the person with diabetes, none are more devastating than those involving the foot. The incidence of diabetic foot complications is increasing in developing countries as the disease is often neglected both by patients and treating doctors. Various classifications have been used in the West since the last 30 years to describe diabetic foot lesions. Wagner s and University of Texas are two well established classifications. However, most of these classifications are difficult to understand and they do not include various common diabetic foot complications. The author proposes a new classification of diabetic foot complications that is easy to remember and includes all the common complications of the diabetic foot. This classification system can be used as a teaching tool to disseminate the knowledge of diabetic foot complications among various health care professionals, especially in developing countries. Key words: diabetic foot, classification, Wagner s, teaching tool Corresponding author: Dr Amit Kumar C Jain Consultant General, Diabetic Lower Limb and Podiatric Surgeon Department of Surgery St Johns Medical College Bangalore Ph : Affiliations: 1. Department of Surgery, St. Johns Medical College, Bangalore Introduction Diabetes mellitus has become an epidemic worldwide. In the United States, the incidence of diabetes is increasing 1% per year. (1) In the U.S, diabetes is the seventh leading cause of death, mainly secondary to cardiovascular complications. It was estimated in 2000 that there were 32million people with diabetes in India, a number that is predicted to increase to nearly 80 million by (2) Foot problems are an associated complication and an increasing problems among individuals with diabetes. Diabetic foot ulcers will complicate the disease in more than 15% of these people during their lifetime. (3) Foot ulcers precede more than 80% of non traumatic lower limb amputations. (4) The most common sites for ulcer are toes, followed by the plantar metatarsal heads and the heel. Foot risk factors include peripheral neuropathy, peripheral arterial disease and foot deformities. Arterial disease was present in 48% of foot ulcers in Germany, but only 11% in Tanzania and 10% in India. (5) Treatment of infected foot wounds comprises up to one quarter of all diabetic hospital admissions in the US and Britain, making this the most common reason for diabetes related hospitalization in these countries. The estimated cost for foot ulcer care in the US ranges from $4,595 per ulcer episode to nearly $28,000 for the 2 years after diagnosis. (6) 1

2 CLASSIFICATION OF DIABETIC FOOT LESIONS Classification of diabetic foot wounds the fact that over a dozen have been devised is needed for many purposes. Among the most since the original Meggitt-Wagner grading important is our need to adequately describe system. Some of the classifications include the lesions that we treat in order to study patient Kings College Hospital classifications, University outcome as well as to further our understanding of Texas classification, PEDIS classification, etc. of the diabetic foot. Clinicians and researchers However, the two most well established classification systems are the Meggitt-Wagner and have used various classification schemes for foot related complications of diabetes for 30 years. University of Texas systems. The usefulness of these systems is attested by WAGNER- MEGGITT S CLASSIFICATION : This classification [Table 1], which was developed in the 1970s, has been the most widely accepted and universally used grading system for lesions of the diabetic foot. (7) The original system has six grades of lesions. The first four grades (grade 0, 1, 2, and 3) are based on the physical depth of the lesion in and through the soft tissues of the foot. The last two grades (grade 4 and5) are completely distinct because they are based on the extent of gangrene and lost perfusion in the foot. Grade 4 Table 1 - WAGNER-MEGGITT CLASSIFICATION OF DIABETIC FOOT Grade 0 Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 refers to partial foot gangrene and Grade 5 refers to a completely gangrenous foot. The problem with Wagner s classification is that this classification does not adequately address all diabetic foot ulcerations and infections. (8) Only one of the six grades (Grade 3) infers infection. (9) Further, the system is limited in its ability to identify and describe vascular disease as an independent risk factor. In addition, superficial wounds that are infected or dysvascular are not able to be classified by this system. Foot symptoms like pain,only Superficial ulcers Deep ulcers Ulcer with bone involvement Forefoot gangrene Full foot gangrene UNIVERSITY OF TEXAS WOUND CLASSIFICATION : The University of Texas classification (7) represents an advance in the treatment of the diabetic foot. This system [Table 2] uses four grades, each of which is modified by the presence of infection (Stage B), ischaemia (Stage C), or both (Stage D). This system STAGE-A has been validated and is generally predictive of outcome, since increasing grade and stage of wounds are less likely to heal without revascularization or amputation. It is now widely used in many clinical trials and diabetic foot centres. Table 2 - UNIVERSITY OF TEXAS CLASSIFICATION OF DIABETIC FOOT GRADE-0 GRADE-1 GRADE-2 GRADE-3 Preulcerative or postulcerative lesion completely epithelialized Superficial wound, not involving tendon, capsule or bone Wound penetrating to tendon or capsule Wound penetrating to bone or joint STAGE-B Infection Infection Infection Infection STAGE-C Ischemia Ischemia Ischemia Ischemia STAGE-D Infection and Ischemia Infection and Ischemia Infection and Ischemia Infection and Ischemia 2

3 NEED FOR NEWER CLASSIFICATION Since there are a multiple classification advantage of the Meggitt-Wagner and University schemes, it is understood that each has of Texas classifications is that both systems have its own set of advantages and drawbacks. The been shown to be predictive of poor outcomes. However, there are certain drawbacks of all current classifications: These classifications do not include all the diabetic foot complications. They are difficult to remember, especially University of Texas classification and PEDIS classification. They cannot be used as a teaching tool, as these classifications are difficult to be understood by undergraduate, postgraduates, specialists of different medical fields and paramedics involved in diabetic foot care. PROPOSED CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS : The author proposes a new classification [Table 3] for diabetic foot problems that addresses the deficits of the current classifications. The primary advantage [Table 4] of this classification lies in its simplicity. It allows for an easier understanding of diabetic foot complications and it is also easy to remember. Table 3 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 Bones and joints Vessel Neuropathies Charcot foot, hammertoes, claw toes Peripheral arterial disease (mild, moderate and severe) TYPE 3 (MIXED) Includes infective and non infective complications Table 4 - ADVANTAGES OF THE NEW CLASSIFICATION 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 3

4 According to this classification, diabetic foot lesions can be divided into 3 types: Type 1- Diabetic foot complications that are infective: this includes cellulitis, abscess, necrotizing fasciitis, etc. Type 2- Diabetic foot complications that are non infective. Based on the structure affected they have been categorized into 4 subtypes. The diabetic Charcot foot, peripheral arterial disease, neuropathy, etc. belong to this group. Type 3- Diabetic foot complications that are mixed, where both type 1 and type 2 complications can occur in combination. A common example might be a callus ulcer with underlying osteomyelitis. This system could be used as an effective tool for teaching and is not meant to be a replacement to any existing classifications. It would be more helpful in developing countries because complications like necrotizing fasciitis [Fig 1], plantar abscess and Charcot foot are more common due to bare foot walking and poor health care. The major disadvantage of this classification is that it does not predict the clinical outcome. It does not guide in instituting specific therapy and hospitalization. It also cannot be used for research purposes. Nonetheless, since it is not just a wound classification system, it can provide for a more thorough assessment and categorization of diabetic foot complications. Figure 1: showing a case of necrotizing fasciitis in a diabetic lower limb. Note that the infection has spread up to the upper thigh. It belongs to Type 1 diabetic foot complications according to the new classification. 4

5 CONCLUSION As the incidence of diabetes is increasing, so is the prevalence of diabetic foot complications. The new classification which includes various common diabetic foot complications could be used as an effective teaching tool as it is simple to understand and easy to remember. The Diabetic foot has been largely neglected both by the patient and physicians in developing countries. None of the curriculum in developing countries like India describes the common diabetic foot complications appropriately. Wagner s classification is frequently mentioned but least understood by undergraduates and postgraduates of various medical specialties. The new classification proposed by the author would probably help in disseminating the knowledge of diabetic foot complications, especially in developing countries where this disease is frequently neglected. Further studies will be required to determine its usefulness in this regard. REFERENCES 1] Gibbons WG. Lower extremity bypass in patients with diabetic foot ulcers. Surg Clin N Am 2003;83: ] Wild S, Roglic G, Green A, et al : Global prevalence of diabetes Estimates for 2000 and Projection for Diabetes Care 2004;27: ] Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293: ] Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 1990;13: ] Ramsey SD, Newton K, et al. Incidence, outcomes and cost of foot ulcers in patients with diabetes. Diabetes Care 1999;22: ] James WB. Classification of foot lesions in Diabetic patients. Levin and O Neals The Diabetic Foot. 2008;9: ] Mark AK, Warren SJ. Update of treatment of diabetic foot infections. Clin Podiatr Med Surg 2007;24: ] Wagner FW Jr. The diabetic foot and amputation of the foot. In Surgery of the Foot, Mosby, St Louis 1986: ] Morbach S, Lutale JK, Viswanathan V, et al : Regional differences in risk factors and clinical presentation of diabetic foot lesions. Diabet Med 2004;21(1):

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