The Journal of Diabetic Foot Complications

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A NEW CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS:

A SIMPLE AND EFFECTIVE TEACHING TOOL
Authors:

Dr Amit Kumar C Jain*

*MBBS, D.DIAB, F.DIAB, DNB[Gen Surgery], FPS[Podiatric Surgery]

The Journal of Diabetic Foot Complications, 2012; Volume 4, Issue 1, No. 1, Pages 1-5 All rights reserved.

Abstract:

The prevalence of diabetes mellitus is growing at epidemic proportions world wide. Of the many complications
affecting the person with diabetes, none are more devastating than those involving the foot. The incidence
of diabetic foot complications is increasing in developing countries as the disease is often neglected both
by patients and treating doctors. Various classifications have been used in the West since the last 30 years
to describe diabetic foot lesions. Wagners and University of Texas are two well established classifications.
However, most of these classifications are difficult to understand and they do not include various common
diabetic foot complications. The author proposes a new classification of diabetic foot complications that is easy
to remember and includes all the common complications of the diabetic foot. This classification system can be
used as a teaching tool to disseminate the knowledge of diabetic foot complications among various health care
professionals, especially in developing countries.

Key words: diabetic foot, classification, Wagners, teaching tool

Corresponding author:

Affiliations:

Dr Amit Kumar C Jain

Consultant General, Diabetic Lower Limb and Podiatric Surgeon
Department of Surgery
St Johns Medical College
Bangalore -560034
Ph :- 09731717134

1. Department of Surgery, St. Johns Medical College, Bangalore

Email: dramit_ak47@yahoo.co.in

ntroduction

Diabetes mellitus has become an epidemic

worldwide. In the United States, the incidence
of diabetes is increasing 1% per year. (1) In the
U.S, diabetes is the seventh leading cause of
death, mainly secondary to cardiovascular complications. It was estimated in 2000 that there
were 32million people with diabetes in India, a
number that is predicted to increase to nearly 80
million by 2030.(2) Foot problems are an associated complication and an increasing problems
among individuals with diabetes. Diabetic foot
ulcers will complicate the disease in more than
15% of these people during their lifetime. (3) Foot
ulcers precede more than 80% of non traumatic
lower limb amputations. (4) The most common

sites for ulcer are toes, followed by the plantar

metatarsal heads and the heel. Foot risk factors
include peripheral neuropathy, peripheral arterial
disease and foot deformities. Arterial disease
was present in 48% of foot ulcers in Germany,
but only 11% in Tanzania and 10% in India. (5)
Treatment of infected foot wounds comprises
up to one quarter of all diabetic hospital admissions in the US and Britain, making this the most
common reason for diabetes related hospitalization in these countries. The estimated cost for
foot ulcer care in the US ranges from $4,595 per
ulcer episode to nearly $28,000 for the 2 years
after diagnosis. (6)

The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 1, No. 1, Pages 1-5

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LASSIFICATION OF DIABETIC FOOT LESIONS

Classification of diabetic foot wounds

is needed for many purposes. Among the most
important is our need to adequately describe
the lesions that we treat in order to study patient
outcome as well as to further our understanding
of the diabetic foot. Clinicians and researchers
have used various classification schemes for foot
related complications of diabetes for 30 years.
The usefulness of these systems is attested by

the fact that over a dozen have been devised

since the original Meggitt-Wagner grading
system. Some of the classifications include
Kings College Hospital classifications, University
of Texas classification, PEDIS classification, etc.
However, the two most well established classification systems are the Meggitt-Wagner and
University of Texas systems.

WAGNER- MEGGITTS CLASSIFICATION :

This classification [Table 1], which was developed
in the 1970s, has been the most widely accepted
and universally used grading system for lesions of
the diabetic foot. (7) The original system has six
grades of lesions. The first four grades (grade 0,
1, 2, and 3) are based on the physical depth of the
lesion in and through the soft tissues of the foot.
The last two grades (grade 4 and5) are completely
distinct because they are based on the extent of
gangrene and lost perfusion in the foot. Grade 4

refers to partial foot gangrene and Grade 5 refers

to a completely gangrenous foot. The problem with
Wagners classification is that this classification does
not adequately address all diabetic foot ulcerations
and infections. (8) Only one of the six grades (Grade
3) infers infection. (9) Further, the system is limited in
its ability to identify and describe vascular disease
as an independent risk factor. In addition, superficial
wounds that are infected or dysvascular are not able
to be classified by this system.

Table 1 - WAGNER-MEGGITT CLASSIFICATION OF DIABETIC FOOT

Grade 0

Foot symptoms like pain,only

Grade 1

Superficial ulcers

Grade 2

Deep ulcers

Grade 3

Ulcer with bone involvement

Grade 4

Forefoot gangrene

Grade 5

Full foot gangrene

UNIVERSITY OF TEXAS WOUND CLASSIFICATION :

The University of Texas classification (7) represents
an advance in the treatment of the diabetic foot. This
system [Table 2] uses four grades, each of which
is modified by the presence of infection (Stage B),
ischaemia (Stage C), or both (Stage D). This system

has been validated and is generally predictive

of outcome, since increasing grade and stage of
wounds are less likely to heal without revascularization or amputation. It is now widely used in many
clinical trials and diabetic foot centres.

Table 2 - UNIVERSITY OF TEXAS CLASSIFICATION OF DIABETIC FOOT

GRADE-0

GRADE-1

GRADE-2

GRADE-3

STAGE-A

Preulcerative or postulcerative lesion completely

epithelialized

Superficial wound, not

involving tendon, capsule
or bone

Wound penetrating to
tendon or capsule

Wound penetrating to
bone or joint

STAGE-B

Infection

Infection

Infection

Infection

STAGE-C

Ischemia

Ischemia

Ischemia

Ischemia

STAGE-D

Infection and Ischemia

Infection and Ischemia

Infection and Ischemia

Infection and Ischemia

The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 1, No. 1, Pages 1-5

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EED FOR NEWER CLASSIFICATION

Since there are a multiple classification schemes, it is understood that each has
its own set of advantages and drawbacks. The

advantage of the Meggitt-Wagner and University

of Texas classifications is that both systems have
been shown to be predictive of poor outcomes.

However, there are certain drawbacks of all current classifications:

These classifications do not include all the diabetic foot complications.

They are difficult to remember, especially University of Texas classification and PEDIS classification.

They cannot be used as a teaching tool, as these classifications are difficult to be understood
by undergraduate, postgraduates, specialists of different medical fields and paramedics involved in
diabetic foot care.

PROPOSED CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS :

The author proposes a new classification [Table
3] for diabetic foot problems that addresses the
deficits of the current classifications. The primary
advantage [Table 4] of this classification lies in its

simplicity. It allows for an easier understanding of

diabetic foot complications and it is also easy to
remember.

Table 3 Proposed CLASSIFICATION OF DIABETIC FOOT COMPLICATIONS

TYPES
TYPE 1 (INFECTIVE)
TYPE 2 (NON INFECTIVE)

LESIONS
Cellulitis, abscess, necrotizing fasciitis, wet gangrene, osteomyelitis and tinea pedis.
Skin and soft tissue
Nerve

Neuropathies

Bones and joints

Vessel

TYPE 3 (MIXED)

Nonhealing ulcer, callosity, diabetic bullae.

Charcot foot, hammertoes, claw toes

Peripheral arterial disease (mild, moderate and severe)

Includes infective and non infective complications

Table 4 - ADVANTAGES OF THE NEW CLASSIFICATION

1

Very simple to understand

Easy to remember

Useful as a teaching tool

Practical

Includes all the common complications affecting diabetic foot

The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 1, No. 1, Pages 1-5

According to this classification, diabetic foot lesions can be divided into 3 types:
Type 1- Diabetic foot complications that are infective: this includes cellulitis, abscess, necrotizing fasciitis, etc.
Type 2- Diabetic foot complications that are non
infective. Based on the structure affected they
have been categorized into 4 subtypes. The
diabetic Charcot foot, peripheral arterial disease,
neuropathy, etc. belong to this group.
Type 3- Diabetic foot complications that are
mixed, where both type 1 and type 2 complications can occur in combination. A common example might be a callus ulcer with underlying
osteomyelitis.

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This system could be used as an effective tool

for teaching and is not meant to be a replacement to any existing classifications. It would be
more helpful in developing countries because
complications like necrotizing fasciitis [Fig 1],
plantar abscess and Charcot foot are more common due to bare foot walking and poor health
care. The major disadvantage of this classification is that it does not predict the clinical outcome. It does not guide in instituting specific
therapy and hospitalization. It also cannot be
used for research purposes. Nonetheless, since
it is not just a wound classification system, it can
provide for a more thorough assessment and
categorization of diabetic foot complications.

Figure 1: showing a case of necrotizing fasciitis in a diabetic lower limb. Note that the infection has spread up to
the upper thigh. It belongs to Type 1 diabetic foot complications according to the new classification.

The Journal of Diabetic Foot Complications 2012; Volume 4, Issue 1, No. 1, Pages 1-5

ONCLUSION

As the incidence of diabetes is increasing, so is the prevalence of diabetic foot

complications. The new classification which
includes various common diabetic foot complications could be used as an effective teaching
tool as it is simple to understand and easy to
remember. The Diabetic foot has been largely
neglected both by the patient and physicians in
developing countries. None of the curriculum
in developing countries like India describes the
common diabetic foot complications appro-

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priately. Wagners classification is frequently

mentioned but least understood by undergraduates and postgraduates of various medical
specialties. The new classification proposed by
the author would probably help in disseminating
the knowledge of diabetic foot complications,
especially in developing countries where this
disease is frequently neglected. Further studies
will be required to determine its usefulness in
this regard.

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