Diabetic foot ulcers are the leading cause of hospitalization and amputation among diabetics today. In spite of contributing to the morbidity and mortality of diabetics in such a significant way, diabetic foot ulcers are not yet bound by a universally accepted classification system. A few systems of classification have been introduced, but they have not been accepted wholeheartedly and are used sporadically, at best.
Why is it important to classify diabetic foot ulcers?
Foot ulceration naturally calls for hospitalization. The ulcers are heterogeneous in terms of their depth and tissue involvement, etiology, intensity, depth and associated circumstances. The presence or absence of infection depends on a number of these factors. The treatment methods also differ accordingly. Sense classification is essential to predict the outcome of the ulcer. Classifications help communicate the depth and severity of the ulcer and offer an easy way to convey changes for the better or the worse.
Any classification system must have certain characteristics like flexibility, precision, specificity and simplicity. An easy-to-use classification system gives us a uniform description of the ulcer. The best known and widely accepted systems of classification include:
- Merck Manual
- University of Texas System
- Frykberg and Coleman
Wagner's classification is the most widely accepted system. It is based on the presence of gangrene, depth of penetration and the extent of tissue necrosis. According to this system, a grade-0 disease is one in which the skin shows signs of healed scars and also has pre-ulcerative lesion or exhibits the signs of bone deformity which will lead to the formation of calluses.
With this as the basis indication, the classification marks the different stages of the disease using four subdivisions in each category, Grade1-A, Grade 1-B, Grade 1-C and Grade 1-D, for instance. Generally, Grade-1 ulcers are superior ulcers in which the skin shows damage but the infection has not penetrated to the underlying tissues. Grade-2 ulcers go deeper since the infection has already penetrated the ligaments and the muscle but have not yet reached the bone. Grade-3 ulcers are deep abscesses that show the formation of cellulitis and osteomyelitis. Grade-4 and Grade-5 indicate the danger zones and have no categories. In Grade-4, the gangrene is localized. In Grade-5, gangrene has affected the entire foot.
There is however one major drawback to this system – it does not address two important facets of the disease – infection and ischemia.
Alternately, the second most widely accepted system of classification is the University of Texas diabetic wound classification. This system takes into account the depth of the ulcer, the presence of infection and the presence of ischemia. This system grades ulcers from 0-3 based on these factors. The UT (University of Texas) System combines grade and stage and is there before more intuitive.
Research shows that a good foot ulcer classification system helps in predicting clinical outcome. The higher the grade, the greater the risk and greater the number of amputations performed.
In case of foot ulcers adhering to a strict regimen of classification at the time of diagnosis can improve communication between the physician and the diabetic specialist. This team approach will absolutely lead to a decrease in complications and possibly avoid amputations.