Reevaluating the Way We Classify the Diabetic Foot

Abstract

OBJECTIVE -To separately evaluate peripheral arterial occlusive disease (PAOD) and foot ulcer and amputation history in a diabetic foot risk classification to predict foot complications.RESEARCH DESIGN AND METHODS -We evaluated 1,666 diabetic patients for 27.2 Ϯ 4.2 months. Patients underwent a detailed foot assessment and were followed at regular intervals. We used a modified version of the International Working Group on the Diabetic Foot's (IWGDF's) risk classification to assess complications during the follow-up period.RESULTS -There were more ulcerations, infections, amputations, and hospitalizations as risk group increased ( 2 for trend P Ͻ 0.001). When risk category 2 (neuropathy and deformity and/or PAOD) was stratified by PAOD, there were more complications in PAOD patients (P Ͻ 0.01). When risk group 3 patients (ulceration or amputation history) were separately stratified, there were more complications in subjects with previous amputation (P Ͻ 0.01).CONCLUSIONS -We propose a new risk classification that predicts future foot complications better than that currently used by the IWGDF. Diabetes Care 31:154-156, 2008

Risk stratification systems for diabetic foot ulcers: a systematic review

“…An increase in the group risk was associated with more foot ulcerations (p<0.001, χ 2 test for association and trend) and more complications were observed in group 2B than in 2A (p<0.001). This did not occur when comparing group 1 with 2A or group 3A with 3B [20]. No diagnostic accuracy measures were presented in the paper and due to a lack of data, it was impossible to determine them.…”

“…In 2008, Lavery and colleagues included this modification in the stratification system and also proposed a subdivision for group 2 (Table 3). This prospective cohort study included 1666 consecutive participants followed for an average of 27 months [20]. An increase in the group risk was associated with more foot ulcerations (p<0.001, χ 2 test for association and trend) and more complications were observed in group 2B than in 2A (p<0.001).…”

“…No validity testing of the ADA system has ever been performed, while the SIGN and UTFRS systems have been validated once [18,21]. The IWGDF system suffered modifications twice and its validation was performed accordingly [19,20]. The Boyko et al system was the only one externally validated [24,25].…”

“…The number of variables included varied from four [18] to eight [21] and the number of risk groups varied from two in the original ADA system [22,23] to six in the IWGDF system modified by Lavery et al [20] ( Table 3).…”

“…In the studies where diagnostic accuracy measures or crude data were not displayed, they were calculated by or requested from the authors [18,20,24], respectively. Unfortunately, it was not possible to obtain these data.…”