Diabetic foot classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Daniel A. Gerber, M.D. [2] Anahita Deylamsalehi, M.D.[3]

Overview

Diabetic foot is classified based on ulcer's features in order to assist with clinical decision-making regarding the need for oral or parenteral antibiotics, outpatient management, hospitalization, and surgical intervention. There are multiple methods of classification for diabetic foot. One of them that has been published by The Infectious Disease Society of America (IDSA) in their 2004 guideline and mainly has been focused on the extent of infection and inflammation of the ulcer. In addition another similar classification system has been released by The International Working Group on the Diabetic Foot (IWGDF) in 2012. The aforementioned systems were externally validated in a longitudinal study to assess prognostic value, which demonstrated increased risk for amputation among patients with infections classified as severe. Another widely accepted diabetic foot ulcer classification is Wagner ulcer classification system, which uses some ulcer's features such as depth, in addition to presence of osteomyelitis or gangrene.

Classification

• Diabetic foot infections are classified according to the severity of involvement to assist with clinical decision-making regarding the need for oral or parenteral antibiotics, outpatient management, need for hospitalization, and surgical intervention.
• The Infectious Disease Society of America (IDSA) introduced a classification scheme for these infections in their 2004 guidelines, broadly categorized as mild, moderate, and severe infections based upon the extent of infection and inflammation.
• The International Working Group on the Diabetic Foot (IWGDF) published a similar classification system in 2012.
• The aforementioned systems were externally validated in a longitudinal study to assess prognostic value, which demonstrated increased risk for amputation among patients with infections classified as severe.

Clinical Manifestation PEDIS Grade IDSA Severity No symptoms or signs of infection 1 Uninfected Local infection involving only the skin and the subcutaneous tissue without involvement of deeper tissues and without signs of SIRS If erythema, must be >0.5 cm to ≤2 cm around the ulcer. Exclude other causes of an inflammatory response of the skin (eg, trauma, gout, acute charcot neuro-osteoarthropathy, fracture, thrombosis, venous stasis). 2 Mild Local infection with erythema >2 cm or involving structures deeper than skin and subcutaneous tissues (eg, abscess, osteomyelitis, septic arthritis, fasciitis) without signs of SIRS 3 Moderate Local infection with the signs of SIRS, as manifested by ≥2 of the following: Temperature >38 °C or <36 °C Heart rate >90 beats/min Respiratory rate >20 breaths/min or PaCO2 <32 mm Hg White blood cell count >12,000 or <4,000 cells/μL or ≥10% immature (band) forms 4 Severe

• Another widely accepted diabetic foot ulcer classification is Wagner ulcer classification system, which uses some ulcer's features such as depth, in addition to presence of osteomyelitis or gangrene.
  • Unfortunately Wagner ulcer classification system does not address important factors such as ischemia and infection.
  • The following table is a summary of Wagner ulcer classification system:

Grade	Ulcer's Features
0	Not an obvious open lesion
1	Superficial ulcer with partial or full-thickness
2	Extension of ulcer to other structures such as tendon, ligament, joint capsule, or deep fascia (without abscesses or osteomyelitis)
3	Extension of ulcer to other structures such as tendon, ligament, joint capsule, or deep fascia with abscesses, osteomyelitis or septic arthritis
4	Presence of gangrene, but localized to forefoot or heel
5	Presence of extensive gangrene