Classification Systems

• The Meggitt-Wagner classification is the most well-known and validated system for foot ulcers, and is shown in Table 2.1. The advantages and disadvantages of this classification system are described in Table 2.2.

• 'The University of Texas classification system for diabetic foot wounds',

Table 2.1 Meggitt-Wagner classification of foot ulcers

Grade

Description of the ulcer

Grade 0

Pre- or post-ulcerative lesion

completely epithelialized

Grade 1

Superficial, full thickness ulcer

limited to the dermis, not

extending to the subcutis

Grade 2

Ulcer of the skin extending

through the subcutis with

exposed tendon or bone and

without osteomyelitis or

abscess formation

Grade 3

Deep ulcers with osteomyelitis

or abscess formation

Grade 4

Localized gangrene of the toes

or the forefoot

Grade 5

Foot with extensive gangrene

Table 2.3 'The University of Texas

Table 2.2 Advantages and disadvantages of the Meggitt-Wagner classification system

Advantages

• It is simple to use and has been validated in a number of studies

• Higher grades are directly related to increased risk for lower limb amputation

• It provides a guide for planning treatment

• It is considered the gold-standard, against which other systems should be validated

Disadvantages

• Although the presence of infection and ischemia are related to poor outcome, ischemia in patients classified into grades 1-3 and infection in grade 1, 2 and 4 patients is not taken into account

• The location of the ulcer is not described

• Patient-related factors (poor foot care, emotional upset, denial) and foot deformities are not evaluated

(Table 2.3) has recently been proposed and validated by the University of Texas. This system evaluates both depth of the ulcer — as in Meggitt-Wagner classification system — and presence of infection and ischemia. Uncomplicated ulcers are classified as stage A, infected ulcers as stage B, ulcers with ischemia as system for diabetic foot wounds'

Table 2.3 'The University of Texas system for diabetic foot wounds'

Stage

Grade

0

1

2

3

A

Pre- or

Superficial wound not

Wound

Wound penetrating to

post-ulcerative

involving tendon,

penetrating to

bone or joint

lesion

capsule or bone

tendon or

completely

capsule

epithelialized

B

With infection

With infection

With infection

With infection

C

With ischemia

With ischemia

With ischemia

With ischemia

D

With infection

With infection and

With infection

With infection and

and ischemia

ischemia

and ischemia

ischemia

Table 2.4 Advantages and disadvantages of

'The University of Texas classification system'

Advantages

• It is simple to use and more descriptive

• It has been evaluated and shown to predict more accurately the outcome of an ulcer (healing or amputation) than the Meggitt-Wagner classification.

• Cases with infection and/or ischemia are taken into account in this system

• It provides a guide for planning treatment

Disadvantages

• Patient-related factors (poor foot care, emotional upset, denial) and foot deformities are not evaluated

• The location of the ulcer is not described stage C and ulcers with both infection and ischemia as stage D. Grades 1 and 2 are similar to the Meggitt-Wagner classification. Grade 3 ulcers are ulcers penetrating the bone or joint. The higher the grade, and the stage of an ulcer, the greater the risk for non-healing or amputation. The advantages and disadvantages of 'The University of Texas classification system' are described in Table 2.4. In addition to these two classification systems, other systems have been proposed:

• Edmonds and Foster have proposed a simpler classification. According to this system, based on clinical tests and determination of the ankle brachial pressure index, foot ulcers are classified into neuropathic and neuro-ischemic.

• Brodsky suggested the 'depth-ischemia' classification, which is a modification of the Meggitt-Wagner classification. According to this proposal, ulcers are classified into four subgroups (A, not ischemic; B, ischemic without gangrene; C, partial gangrene of the foot; and

D, complete foot gangrene) with grades 0-3 (similar to the Meggitt-Wagner classification). • Macfarlane and Jeffcoate proposed the S(AD)SAD classification for diabetic foot ulcers. According to this system, ulcers are classified on the basis of size (area and depth), presence of sepsis, arteriopathy, and denervation. This system awaits clinical validation.

Any valid classification system of foot ulcers should facilitate appropriate treatment, simplify monitoring of healing progress and serve as a communication code across specialties in standardized terms. Despite its disadvantages, the 'University of Texas classification system' offers many advantages over the Meggitt-Wagner system and is the most appropriate system devised to date. In addition, inclusion in a classification system of other parameters such as location of the ulcer, foot deformities and other factors which may be related to the outcome of an ulcer, makes the system more complex and cumbersome. 'The University of Texas classification system' is expected to be widely adopted in the future.

CLINICAL PRESENTATION OF NEUROPATHIC, ISCHEMIC AND NEURO-ISCHEMIC ULCERS

• Neuropathy is present in about 85-90% of foot ulcers in patients with diabetes.

• Ischemia is a major factor in 38-52% of cases of foot ulcers.

NEUROPATHIC ULCERS (FIGURES 2.1-2.3)

• Develop at areas of high plantar pressures (metatarsal heads, plantar aspect of

Ischemic Ulcer
Figure 2.1 Typical neuropathic ulcer with callus formation on the first metatarsal head before debridement
Ulcur Site Metatarsal Heads

Figure 2.2 Neuropathic ulcer on the first metatarsal head with healthy granulating tissue on its bed

Stage Iii Metatarsal Head Pressure Ulcer

Figure 2.3 Neuropathic ulcer on the first meta-tarsal head with healthy granulating tissue on its bed and callus formation

Figure 2.2 Neuropathic ulcer on the first metatarsal head with healthy granulating tissue on its bed

Figure 2.3 Neuropathic ulcer on the first meta-tarsal head with healthy granulating tissue on its bed and callus formation the great toe, heel or over bony prominences in a Charcot-type foot). Are painless, unless they are complicated by infection.

There is callus formation at the borders of the ulcer.

Its base is red, with a healthy granular appearance.

On examination evidence of peripheral neuropathy (hypoesthesia or complete loss of sensation of light touch, pain, temperature, and vibration, absence of Achilles tendon reflexes, abnormal vibration perception threshold, often above 25 V, loss of sensation in response to 5.07 monofilaments, atrophy of the small muscles of the feet, dry skin and distended dorsal foot veins) is present. However, the pattern of sensory loss may vary considerably from patient to patient.

Figure 2.4 Ischemic ulcer under the heel in a patient with severe peripheral vascular disease

Phlegmon Heel

The foot has normal temperature or may be warm.

Peripheral pulses are present and the ankle brachial pressure index is normal or above 1.3.

ISCHEMIC ULCERS (FIGURES 2.4-2.8)

Develop on the borders or the dorsal aspect of the feet and toes or between toes. They are usually painful.

Wagner Diabetic Foot

Figure 2.5 Ischemic ulcer on the dorsum of the second toe in a patient with critical limb ischemia. Case discussed in Chapter 7

Critical Limb Ischemia

Figure 2.6 Dry gangrene of the fifth right toe. Redness, and edema, which are typical signs of infection involving the forefoot, are present

Figure 2.5 Ischemic ulcer on the dorsum of the second toe in a patient with critical limb ischemia. Case discussed in Chapter 7

Figure 2.6 Dry gangrene of the fifth right toe. Redness, and edema, which are typical signs of infection involving the forefoot, are present

• There is usually redness at the borders of the ulcer.

• Its base is yellowish or necrotic (black).

• There is a history of intermittent claudication.

• On examination indications of peripheral vascular disease (skin is cool, pale or cyanosed, shiny and thin, with loss of hair, and onychodystrophy; peripheral pulses are absent or weak; the ankle brachial index is <0.9) are present.

• Non-invasive vascular testing (duplex or triplex ultrasound examination,

Neuro Ischemic UlcerArterial Ischemic Ulcers
Figure 2.8 Ischemic ulcer on the tip of the third right toe, with necrotic center

segmental pressures measurement, ple-thysmography), and angiography confirm peripheral vascular disease. • There are no findings of peripheral neuropathy.

MIXED ETIOLOGY ULCERS (NEURO-ISCHEMIC ULCERS) (FIGURES 2.9 AND 2.10)

Neuro-ischemic ulcers have a mixed etiology, i.e. neuropathy and ischemia, and a mixed appearance.

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Responses

  • joyce
    Where is ulcer of the foot classified?
    3 years ago
  • ava
    How many diabetic foot grading classification?
    3 years ago
  • TOM
    Is an ankle classified in diabetic foot?
    1 year ago
  • kenneth
    Is a grade four diabetic foot gangrene?
    1 year ago
  • gerontius
    How diabetic foot wounds are classified?
    1 year ago
  • diana
    Does a Wagner Grade 4 have to be on the forefoot?
    1 year ago
  • Tewelde
    How are diabetic ulcers classified?
    11 months ago
  • tristan reid
    What is a meggitt wagner grade 1 ulcer?
    5 months ago
  • keira
    Is callous considered epithelialized?
    3 months ago
  • Asmara
    How to grade wagner wounds?
    1 month ago

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