Review of Classification Systems

Recommendations

Identify and Treat the Cause
1 Conduct a foot inspection and examine for decreased sensation. Correct (if possible) risk factors for ulcer formation/amputation: - Vascular supply - Infection - Pressure (including bony deformity) Remember the mnemonic VIP Level of Evidence
Not Assessed
2 Assess and document healing with ulcer duration, location, size, and depth (probe to bone). Level of Evidence
Not Assessed


Address patient-centered Concerns
n/a


Provide Local Wound Care
3 Assess and document healing with ulcer duration, location, size, and depth (probe to bone). Level of Evidence
Not Assessed
4 Integrate the risk classification system into clinical protocols so that it is consistently applied. Level of Evidence
Not Assessed


Provide Organizational Support
5 Each clinic providing diabetic foot care should review the diabetic foot risk classification systems and select the one that best meets the needs of the population served. Level of Evidence
Not Assessed


Background

Classification systems have been developed to assist the clinician in gathering the appropriate information to stratify diabetic patients into risk categories. These systems are useful in promoting a consistent approach to clinical examination and in providing a common language to facilitate communication between the multiple specialties often involved in caring for a diabetic patient.

The University of Texas Diabetic Foot Classification System divides the diabetic foot into the following categories:

0: No pathology
1: Neuropathy, no deformity
2: Neuropathy with deformity
3: History of pathology
4A: Neuropathic wound
4B: Acute Charcot’s joint
5: Infected diabetic foot
6: Ischemic limb

Diabetic feet falling into categories 0–3 are at risk of ulceration, whereas diabetic feet with ulcers (categories 4–6) are at risk of amputation. History and the results of physical examination and specific investigations determine category. Each category is associated with a recommended frequency of monitoring or assessment, implementation of preventive strategies and medical and/or surgical treatment approaches.

The International Working Group on the Diabetic Foot Risk Classification System uses a simple four-point risk classification system associated with a recommended evaluation frequency:

0: Normal Annual
1: Peripheral neuropathy, with loss of protective sensation Semi-annual
2: Neuropathy, deformity and/or peripheral arterial disease Quarterly
3: Previous ulcer or amputation Monthly to quarterly

The Carville system classifies diabetic feet into the following risk categories and provides recommendations for appropriate footwear to prevent ulceration:

0: No loss of protective sensation.
1: Loss of protective sensation, no deformity or history of plantar ulceration
2: Loss of protective sensation and deformity, no history of plantar ulceration
3: History of plantar ulcer.

The Wagner Classification grades diabetic ulcers to assist with planning treatment, as follows:
1: Superficial ulcer with partial- or full-thickness skin loss
2: Probing to tendon or capsule with soft-tissue infection
3: Deep ulcer with osteomyelitis
4: Ulcer with forefoot gangrene
5: Ulcer with gangrene involving entire foot

References

Essential Publications
1 University of Texas Diabetic Wound Classification System Quality Indicator
 Type: Scale Description
Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg 1996;35:528-531
This well-known classification system for diabetic foot infections developed to guide future surgical treatment protocols, algorithms. The classification system grades depth, ischaemia and infection.
2 University of Texas Diabetic Wound Classification System - validation Quality Indicator
 Type: Retrospective Analysis
Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. Diabetes care 1998;21(5):855-858.
Validation of the University of Texas grading system based on retrospective analysis of medical records of 360 diabetic patients in multidisciplinary tertiary care diabetic foot clinic, illustrating that outcomes deteriorate with increasing grade and stage of wounds.
3 Wagner Grading System for the Dysvascular Foot Quality Indicator
 Type: Retrospective Analysis
Wagner FW. The Dysvascular Foot: A system for diagnosis and treatment. Foot & Ankle 1981;2(2):64-122.
This is the well-known Wagner foot grading system, devised by Dr. Wagner many years ago, through observing progression of diabetic foot lesions. The classification system was developed to guide future surgical treatment protocols. Grading system: Grade 0 - no open lesion Grade 1 - superficial ulcer Grade 2 - deep ulcer Grade 3 - absess osteitis Grade 4 - gangrene forefoot Grade 5 - gangrene entire foot
4 Wagner Classification - validation Quality Indicator
 Type: Retrospective Analysis
Calhoun JH, Cantrell J, Cobos J, Lacy J, Valdex RR, Hokanson J, Mader JT. Treatment of Diabetic Foot Infections: Wagner Classification, Therapy, and Outcome. Foot & Ankle 1988;9(3):101-106.
In retrospective analysis, use of the Wagner classification system and therapy algorithms was shown to be a reasonable approach.
5 Falanga Staging system for wound bed preparation Quality Indicator
 Type: Scale Description
Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair and Regeneration 2000;8(5):347-352.
This well-known staging system was proposed by Dr. Vincent Falanga based on his clinical experience. It is a scoring system for wound bed preparation for all types of chronic wounds, since optimal treatment requires that the wound bed be prepared. The system consists of: an appearance score, A – D, based on granulation tissue, fibrinous tissue, and eschar and a wound exudate score, 1 – 3, based on extent of control, exudates amount, and dressing requirement.
6 Diabetic foot surgery classification system - validation Quality Indicator
 Type: Retrospective Analysis
Armstrong DG, Lavery LA, Frykberg RG, Wu SC, Boulton AJM. Validation of a diabetic foot surgery classification. Int Wound J 2006;3:240-246.
Medical records of 180 patients were reviewed to evaluate the validity of a classification system for non vascular diabetic foot surgery, i.e., Elective, Prophylactic, Curative, and Emergency, by examining the association with postoperative outcome. With increasing class of foot surgery, there was increased risk of ulceration or reulceration (P=0.0001), peri-postoperative infection (P=0.0001), all level amputation (P=0.0001), and major amputation (P=0.003). This study provides evidence of the validity of this nonvascular diabetic foot surgery classification system for predicting postoperative complications.
7 SINBAD classification system Quality Indicator
 Type: Scale Description
Ince P, Abbas ZG, Lutale JK, Basit A, Ali SM, Chohan F, Morbach S, Möllenberg J, Game FL, Jeffcoate WJ. Use of the SINBAD classification system and score in comparing outcome of foot ulcer management on three continents. Diabetes Care. 2008 May;31(5):964-7. Epub 2008 Feb 25.
The purpose of this study was to evaluate the clinical effectiveness of the SINBAD scale in predicting ulcer outcome. The SINBAD scale requires assessment of site, ischemia, neuropathy, bacterial infection and depth, and these variables are used to generate a single score. The results showed that time to healing increased with increasing SINBAD score. Consequently, the SINBAD score can be effectively used as a clinical assessment tool to predict ulcer outcome and to compare across different centres.
8 Foot infection in diabetic patients Quality Indicator
 Type: Validation study
Lavery LA, Armstrong DG, Murdoch DP, Peters EJ, Lipsky BA.. Validation of the Infectious Diseases Society of America's diabetic foot infection classification system.. Clin Infect Dis. 2007 Feb 15;44(4):562-5. Epub 2007 Jan 17
Through a longitudinal study of 1666 diabetic patients, it was found that amputation, higher level amputation and lower extremity-related hospitalization all increase with increasing infection severity. Therefore, it is important to assess infection, and this can be achieved by using the Infectious Diseases Society of America's diabetic foot infection classification system.
9 Foot Ulcer Classification Quality Indicator
 Type: Scale Description
Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care. 2001 Jan;24(1):84-8.
The purpose of this study is to compare the Wagner and Texas Classification systems for diabetic foot ulcers with respect to their predictive abilities for outcomes. The results show that the Texas system is more effective, due to its inclusion of ulcer stage.


Enablers for practice

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