Comparison of five systems of classification of diabetic foot ulcers and predictive factors for amputation

Abstract

Diabetes mellitus is a common metabolic disorder. Among various complications, diabetic neuropathy and peripheral vascular disorders are closely associated with diabetic foot ulcers (DFUs). Lower extremity ulcers and amputations are ongoing problems among individuals with diabetes. There are several classification systems for DFUs; however, no prognostic system has to date been accepted as the gold standard or the optimum prediction tool for amputations. A retrospective study was designed. Demographic data and baseline laboratory data were gathered and scored or evaluated using five representative DFU classification systems. These included (i) the diabetic ulcer severity score (DUSS); (ii) University of Texas (UT) diabetic wound classification; (iii) Meggitt-Wagner classification; (iv) depth of the ulcer, extent of bacterial colonisation, phase of ulcer and association aetiology (DEPA) scoring system; and (v) site, ischaemia, neuropathy, bacterial infection and depth (SINBAD) score. Finally, a statistical analysis was performed. A total of 137 patients were included in this study. During the follow-up, DFU had healed in 51·1% of subjects and 48·9% of the individuals underwent lower extremity amputations (LEAs). In a univariable logistic regression analysis, history of previous DFU, hypertension, neuropathy, haemoglobin, C-reactive protein (CRP) and ankle-brachial index (ABI) showed a statistically significant difference between the healed group and the LEA group. Moreover, the stages, grades or overall prognostic ability of all five classifications were highly associated with the overall occurrence of LEA. On multivariable logistic regression analysis of the risk of LEA, all classifications showed a significant positive trend with an increased number of amputations. All the five classification systems exhibited high sensitivity, specificity, classification accuracy, positive predictive, negative predictive and area under the curve (AUC) values. They showed substantial accuracy and their main variables were associated with LEA occurrence. The Wagner and UT systems, although they are relatively simple to assess, were better predictors of LEA.

Amputations in patients with diabetic foot ulcer: a retrospective study from a single centre in the Northern Territory of Australia

“…Wagner grade is a well‐known risk factor for LEA . In our study, Wagner grade 2 and 3 increased the risk of both minor and major LEA but not Wagner grade 4.…”

Factors Affecting Amputations in Patients with Diabetic Foot Ulcer Referring To the Emergency Units

“…In the study of Pemayun et al [19], HbA1c ≥8% and triglycerides ≥150 mg/dL were also found to have significant effects on amputation. Decreased Hb and elevated CRP were reported to have significant effects on amputation in another study [17]. In a study performed by Namgoong et al [16] in patients with DFU, WBC, CRP, ESR, Hb, and albumin levels were found to be the factors significantly affecting amputation, while HbA1c had no such effect.…”

“…In the study of Namgoong et al [16], renal, gastrointestinal, and pulmonary disease had a significant effect on amputation in patients with DFU, while no significant effect was found for comorbidities such as cardiac, hepatobiliary, opthalmologic, musculoskeletal system, nervous system, genitourinary, metabolic and malignant diseases, or hypertension. Hypertension and peripheral artery disease were shown to have significant effects on amputations in another study [17]. In the study of Beaney et al [18], hypertension was found to have a significant effect on amputation, while peripheral artery disease was not considered comorbidity affecting amputation.…”

Clinical and surgical characteristics of infected diabetic foot ulcers in a tertiary hospital of Mexico

“…This system must be used to guide physicians towards an adequate treatment of each wound, aside from a certain ability to predict prognosis in each case. Multiple classification systems for diabetic foot wounds have been put forward [13–16]. However, none are considered as the definite one.…”