Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation.
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...• University of Texas (UT) ulcer classification [47]—This system has a combined matrix of 4 grades (related to the...
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...rate in wounds deeper than superficial ulcers [47]....
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1,006 citations
Cites background from "Validation of a diabetic wound clas..."
...Yes, cutoffs for CLI; Category 4: Resting AP <40 mm Hg; Flat or barely pulsatile ankle or forefoot PVR; TP <30 mm Hg Category 5/6: AP <60 mm Hg; flat or barely pulsatile ankle or forefoot PVR; TP <40 mm Hg No Pure ischemia model PAD classification system includes milder forms of PAD (categories 1-3); Categories 4-6 based on cutoff values for CLI; No spectrum of ischemia, does not acknowledge potential need for revascularization with <CLI cutoff depending on wound extent/infection; Not intended for patients with diabetes; Wound classes not sufficiently detailed; Omits infection as a trigger Cutoff values for CLI based on European consensus document: Ischemic rest pain >2 weeks with AP <50 mm Hg or TP <30 mm Hg ulcer and gangrene; AP <50 mmHg, TP <30 mmHg, absent pedal pulses in patient with diabetes No Pure ischemia model; No clear definitions of spectrum of hemodynamics; Minimal description of wounds; Infection omitted Yes, 3 grades; CLI cutoff Grade 1: no PAD symptoms, ABI >0.9, TBI >0.6, TcPO2 >60 mm Hg; Grade 2: PAD symptoms, ABI <0.9, AP >50 mm Hg, TP >30 mm Hg, TcPO2 30- 60 mm Hg; Grade 3: AP <50 mm Hg, TP <30 mm Hg, TcPO2 <30 mm Hg Yes, grades 1-4; see IDSA classification (Table II) Primarily intended for DFUs; Ulcer grades validated; Includes perfusion assessment, but with cutoff for CLI; Gangrene not separately categorized; Includes validated IDSA infection categories Yes 6 based on ABI <0.8 Yes, 6 wounds with frank purulence or >2 of the following (warmth, eythema, lymphangitis, edema, lymphadenopathy, pain, loss of function) considered infected Primarily intended for DFUs; Includes validated ulcer categories; PAD and infection included, but only as 6 with no grades/spectrum No No for soft tissue component; included only as osteomyelitis Orthopedic classification intended for diabetic feet; No hemodynamics; Gangrene from infection not differentiated from that due to ischemia; Osteomyelitis included; Soft tissue infection not separated from bone infection Pulse palpation only, no hemodynamics Yes, 1 ¼ no infection; 2 ¼ cellulitis; 3 ¼ osteomyelitis Intended for DFUs; Also includes neuropathy; Does not mention gangrene; No hemodynamic information; Perfusion assessment based on pulse palpation only Yes, grades 0-3; Grade 0: AP >80 mm Hg, ABI 0.9-1.2; Grade 1: AP 70-80 mm Hg, ABI 0.7-0.89, TP 55-80 mm Hg; Grade 2: AP 55-69 mm Hg, ABI 0.5-0.69, TP 30-54 mm Hg; Grade 3: AP <55 mm Hg, ABI <0.5, TP <30 mm Hg Yes, grades 0-3; Grade 0: none; Grade 1: mild. erythema 0.5-2 cm, induration, tenderness, warmth and purulence; Grade 2: moderate, erythema >2 cm, abscess, muscle tendon, joint, or bone infection; Grade 3: severe, systemic response (similar to IDSA) Detailed system intended only for DFUs; Detailed comprehensive ulcer classification system and hemodynamic categories for gradation of ischemia; Gangrene not considered separately Infection system similar to IDSA No Yes, uninfected, mild, moderate, and severe (Table II) Validated system for risk of amputation related to foot infection, but not designed to address wound depth/complexity or degree of ischemia Yes, ischemia grades 0-3; Hemodynamics with spectrum of perfusion abnormalities; No cutoff value for CLI; Grade 0: unlikely to require revascularization Yes, IDSA system (Table II) Includes PAD þ diabetes with spectrum of wounds, ischemia and infection, scaled from 0- 3; No cutoff for CLI....
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...8 are at lower risk for amputation and unlikely to require revascularization to achieve healing.(34,44,54) In these patients, wound and infection severity are the major determinants of amputation risk....
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...8), with no gradations for severity, or they mistakenly apply CLI hemodynamic criteria that were never intended to be applied to patients with DFUs.(34-49) The existing major wound classification systems (Table I) are primarily ulcer classifications, and generally do not distinguish ulcers from gangrene....
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...The diabetes prevalence was 58% in the Bypass vs Angioplasty in Severe Ischaemia of the Leg (BASIL) trial,24-26 64% in the Project of Ex-Vivo Vein Graft Engineering via Transfection III (PREVENT III) trial,27 and exceeds 70% to 80% in many specialized vascular centers.28,29 Although tradition teaches that the initiating cause of foot ulceration in patients with diabetes is primarily neuropathy (loss of protective sensation and foot deformity from motor neuropathy), DFUs may be broadly categorized into three groups: purely neuropathic, purely ischemic, and neuroischemic (mixed)....
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...Based on recent studies, the prevalence of neuroischemic ulcers has steadily risen from approximately 20%-25% in the 1990s to over 50% of patients currently.23 Thus, Rutherford8 Yes, category 4/6 Category 5, minor tissue loss, nonhealing ulcer, focal gangrene with diffuse pedal ischemia Category 6, major tissue loss extending above TM level, functional foot no longer salvageable (although in practice often refers to extensive gangrene, potentially salvageable foot with significant efforts) Fontaine14 Yes, class III/IV Class IV/IV, ulcer and gangrene grouped together Class IV/IV, ulcer and gangrene grouped together PEDIS43 No Yes, grades 1-3; Grade 1: superficial full-thickness ulcer, not penetrating deeper than the dermis; Grade 2: deep ulcer, penetrating below the dermis to subcutaneous structures involving fascia, muscle or tendon; Grade 3: All subsequent layers of the foot involved including bone and/or joint (exposed bone, probing to bone) No UT34 No Yes, grades 0-3 ulcers; Grade 0: pre- or postulcerative completely epithelialized lesion; Grade 1: superficial, not involving tendon, capsule, or bone; Grade 2: penetrating to tendon/capsule; Grade 3: penetrating to bone or joint No Wagner35,36 No Grade 0: pre- or postulcerative lesion; Grade 1: partial/full thickness ulcer; Grade 2: probing to tendon or capsule; Grade 3: deep ulcer with osteitis; Grade 4: partial foot gangrene; Grade 5: whole foot gangrene Ulcer and gangrene grouped together; gangrene due to infection not differentiated from gangrene due to ischemia; also includes osteomyelitis S(AD) SAD system40 No Yes, grades 0-3 based on area and depth; Grade 0: skin intact; Grade 1: superficial, <1 cm2; Grade 2: penetrates to tendon, periosteum, joint capsule, 1-3 cm2; Grade 3: lesions in bone or joint space, >3 cm2 No Saint Elian39 No Yes, grades 1-3 based on depth; Grade 1: superficial wound disrupting entire skin; Grade 2: moderate or partial depth, down to fascia, tendon or muscle but not bone or joints; Grade 3: severe or total, wounds with bone or joint involvement, multiple categories including area, ulcer number, location and topography No IDSA42 No No No SVS Lower Extremity Threatened Limb Classification Yes, wound/clinical class 0-3 Yes, grades 0-3; Grouped by depth, location and size and magnitude of ablative/wound coverage procedure required to achieve healing Yes, grades 0-3; Grouped by extent, location and size and magnitude of ablative or wound coverage procedure required to achieve healing ABI, Ankle-brachial index; AP, ankle pressure; CLI, critical limb ischemia; DFUs, diabetic foot ulcers; IDSA, Infectious Disease Society of America; PAD, peripheral artery disease; PEDIS, perfusion, extent/size, depth/tissue loss, infection, sensation; PVR, pulse volume recording; SAD, sepsis, arteriopathy, denervation; SVS, Society for Vascular Surgery; TcPO2, transcutaneous oxygen pressure; TP, toe pressure; UT, University of Texas....
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References
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"Validation of a diabetic wound clas..." refers background in this paper
...Furthermore, since ischemia is the only single disease process that can, by itself, necessitate an amputation (8), it comes as no surprise that the data reported in this study suggest a higher...
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...Ulceration is the most common single precursor to amputation and has been identified as a component in 85% of lower- extremity amputations (8)....
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...Additionally, infection, gangrene, and ischemia were the most common component causes of lower-extremity amputation (8)....
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855 citations
"Validation of a diabetic wound clas..." refers background in this paper
...Forefoot wounds have generally been associated with repetitive moderate pressure from walking rather than constant exposure to pressure (as is exemplified in decubitus wounds) (45-50)....
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557 citations
545 citations
"Validation of a diabetic wound clas..." refers background or methods in this paper
...For all wounds, depth was evaluated using a sterile blunt nasal probe (25)....
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...For instance, wounds that probe to bone have been associated with a high prevalence of osteomyelitis (25,29)....
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537 citations
"Validation of a diabetic wound clas..." refers background in this paper
...Most classification systems previously reported in the medical literature have primarily focused on the depth of the ulceration and have neglected or inconsistently included infection and peripheral arterial occlusive disease (9-16)....
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