Validation of a system of foot ulcer classification in diabetes mellitus

Treece, K. A.; Macfarlane, R.M.; Pound, Nicholas; Game, Frances; Jeffcoate, William

doi:10.1111/j.1464-5491.2004.01275.x

Cited by 122 publications

(110 citation statements)

References 12 publications

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“…The details of all patients and all lesions presenting to the specialist multidisciplinary outpatient diabetic foot service are recorded at the time of first attendance, with ulcers being classified according to the Size (Area, Depth) Sepsis, Arteriopathy, Denervation [S(AD)SAD] system as previously described [8]. The S(AD)SAD system allows definition of ulcer area, depth, limb ischaemia and neuropathy and the distinction of infection of soft tissue and of bone.…”

Section: Methodsmentioning

confidence: 99%

Primarily non-surgical management of osteomyelitis of the foot in diabetes

2008

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Aims/hypothesis We examined the use of surgery and assessed the response to non-surgical management of osteomyelitis of the foot in diabetic patients. Methods We reviewed the records of all patients presenting to a single specialist centre with osteomyelitis complicating a diabetic foot ulcer over a 5 year period. Details were extracted on antibiotic choice and treatment duration, hospital admission, incidence of minor and major amputation, and 12 month outcomes. Results There were 147 patients, with mean age 64.7 years (66% men). Of these, 26 (18%) were admitted to hospital at the time of presentation and managed with intravenous antibiotics; the remainder were managed with oral antibiotics as outpatients. Surgery was undertaken because of life-or limb-threatening infection, or failure to respond, in 34 (23%) patients (minor amputation 28, major amputation six patients). The remaining 113 were managed non-surgically. Remission was induced in 66 (58.4% of 113), while 35 (31%) had a relapse. Of those experiencing relapse, 27 (77%) achieved apparent arrest of the infection with a further course of antibiotics; six underwent minor and two underwent major amputation. Of all 113 whose infection was initially managed without surgery, apparent remission was achieved with antibiotics alone in 93 (82.3%). Conclusions/interpretation As these observations were made in an unselected case series, they give more insight into the respective roles of surgical and non-surgical management.The results confirm that although urgent surgery is indicated in some patients, non-surgical management of those without limb-threatening infection is associated with a high rate of apparent remission.

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Section: Methodsmentioning

confidence: 99%

Primarily non-surgical management of osteomyelitis of the foot in diabetes

2008

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“…Our confounders also included subject age at the time of entering our cohort, duration of diabetes as noted in the medical record, practice site, diagnosis of history of myocardial infarction (myocardial infarction or unstable angina), sex, and history of hypertension. A subject was assumed to have PAD if he or she had an absence of pulses of both lower extremities (screening test frequently used in U.K. clinical practice and epidemiological studies) or had a medical diagnosis consistent with lower-extremity atherosclerotic disease (16). It is possible that this diagnosis of PAD lacks validity and therefore could result in an underestimate of the true association between CKD and LEA/DFU.…”

Section: Research Design Andmentioning

confidence: 99%

Association Between Renal Failure and Foot Ulcer or Lower-Extremity Amputation in Patients With Diabetes

2008

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OBJECTIVE -The objective of this study was to evaluate the association between foot ulcers (DFU) and lower-extremity amputation (LEA) and chronic kidney disease (CKD) in patients with diabetes. RESULTS -The presence of DFU or LEA and estimated glomerular filtration rate (eGFR) were evaluated in 90,617 individuals with a median time of observation of 2.4 years. Of these individuals 378 had an LEA and 2,619 had a DFU. CKD (eGFR Ͻ60 ml/min per 1.73 m 2 ) was noted in 23,350 (26%) individuals in our cohort. For the development of DFU compared with our reference group (group 1 [eGFR Ն60 ml/min per 1.73 m 2 ]), the hazard ratio (HR) for group 2 (eGFR Ն30 and Ͻ60 ml/min per 1.73 m 2 ) was 1.85 (95% CI 1.71-2.01) and for group 3 (eGFR Ͻ30 ml/min per 1.73 m 2 ) was 3.92 (3.23-4.75) (all P Ͻ 0.001). For LEA, the HR for group 2 was 2.08 (1.68 -2.58) and for group 3 was 7.71 (5.29 -11.26) (all P Ͻ 0.001). RESARCH DESIGN AND METHODSCONCLUSIONS -In this observational study, there is a strong association between stage of CKD and DFU or LEA that is probably not just related to the presence of peripheral arterial disease. Individuals with even moderate CKD (eGFR Ͻ60 ml/min per 1.73 m 2 ) have an increased risk for DFU and LEA.

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“…The use of this database was approved by the Nottingham University Hospitals National Health Service Trust, and it has previously been established that analysis of the effectiveness of routine care does not require approval by the local research ethics committee. Details of all patients are recorded at the time of first clinic attendance, and their foot lesions are classified according to the S(AD)SAD system, which is a classification based on subcategorization of cross-sectional area, depth, sepsis, arteriopathy, and neuropathy (11). Ulcer area was estimated simply by measuring the two greatest diameters at right angles and multiplying them as if the ulcer was rectangular.…”

Section: Research Design Andmentioning

confidence: 99%

Rate of Healing of Neuropathic Ulcers of the Foot in Diabetes and Its Relationship to Ulcer Duration and Ulcer Area

2007

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OBJECTIVE -To examine the outcome of neuropathic foot ulcers and to seek associations between healing and features of the ulcers at baseline.RESEARCH DESIGN AND METHODS -Data were collected prospectively during the course of routine management. All patients were selected who presented to a single unit between 1 January 2000 and 31 December 2004 with neuropathic foot ulcers and without evidence of either peripheral arterial disease or infection. Associations were sought between ulcer characteristics at baseline and clinical outcome.RESULTS -A total of 154 patients (66.9% male) presented with 410 ulcers. Age was 57.4 Ϯ 12.0 years (means Ϯ SD). A total of 178 (43.4%) ulcers were on the plantar aspect of the foot; 73.7% of ulcers had a cross-sectional area of Ͻ1 cm 2 . Median ulcer duration at referral was 15 days (range 1-1,046). Healing without amputation was observed in 91.7%. The percentage of ulcers healed at 12, 20, and 52 weeks were 59.3, 70.5, and 86.6%, respectively. Significant associations were observed between area at referral and outcome type ( 2 P Ͻ 0.0001), prior ulcer duration (Kruskal-Wallis P ϭ 0.006), and time to healing (Kruskal-Wallis P ϭ 0.014), as well as between ulcer duration and time to healing (Spearman , r ϭ 0.104, P ϭ 0.047). There was no difference between plantar and nonplantar ulcers.CONCLUSIONS -The rate of healing in this cohort provides a benchmark for comparison with other centers. While further work is needed to determine how outcomes can be improved in unselected series such as these, the confirmation of close relationships between ulcer duration at referral, ulcer area, and outcome emphasizes the importance of early expert assessment of newly occurring neuropathic ulcers. Diabetes Care 30:660 -663, 2007W hile there is evolving consensus on the best management of different types of diabetic foot disease, there remain differences in clinical practice between different expert centers, and it is important to determine whether these differences are associated with better or worse clinical outcomes. If different outcomes can be identified, it should add to the evidence base underlying current consensus and serve as a spur to planning further research. However, one major barrier to effective comparison lies in the fact that studies in expert centers are necessarily undertaken in populations that are selected by referral. It follows that the results of comparison are only meaningful when the populations (of both people and ulcers) are well characterized. This is the rationale for the drive to develop simple but robust classifications, as has been argued elsewhere (1). Nevertheless, there is one group of foot ulcers in which case definition is less problematic-the neuropathic ulcer, whether on the plantar surface of the foot or elsewhere. The classic neuropathic ulcer is readily recognized in clinical practice, being associated with surrounding callus and occurring on a foot with loss of protective sensation but relative preservation of peripheral arterial blood supply. The relative hom...

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Validation of a system of foot ulcer classification in diabetes mellitus

Cited by 122 publications

References 12 publications

Primarily non-surgical management of osteomyelitis of the foot in diabetes

Primarily non-surgical management of osteomyelitis of the foot in diabetes

Association Between Renal Failure and Foot Ulcer or Lower-Extremity Amputation in Patients With Diabetes

Rate of Healing of Neuropathic Ulcers of the Foot in Diabetes and Its Relationship to Ulcer Duration and Ulcer Area

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