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Comparison of three systems of classification in predicting outcome of diabetic foot ulcers in a Brazilian population

M Parisi, Endocrinology Division, Internal Medicine Department, Medical School of the State University of Campinas, Campinas, Brazil
D Zantut-Wittmann, Endocrinology Division, Internal Medicine Department, Medical School of the State University of Campinas, Campinas, Brazil
E Pavin, Endocrinology Division, Internal Medicine Department, Medical School of the State University of Campinas, Campinas, Brazil
H Machado, Statistical Nucleus of Research Commission of Medical School, State University of Campinas, Campinas, Brazil
M Neri, Endocrinology Department, Medical School of the State University of Sao Paulo, Sao Paulo, Brazil
W Jeffcoate, Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals Trust, Nottingham, United Kingdom

Correspondence: Maria Parisi, Email: emaildacandida{at}uol.com.br

Abstract

Objective: The aim was to compare three ulcer classification systems as predictors of the outcome of diabetic foot ulcers: the Wagner, the University of Texas (UT) and the S(AD)SAD system in a specialist clinic in Brazil.

Methods: Ulcer area, depth, appearance, infection, and associated ischaemia and neuropathy were recorded in a consecutive series of 94 subjects. A novel score, the S(AD)SAD score, was derived from the sum of individual items of the S(AD)SAD system, and was evaluated. Follow-up was for at least 6 months. The primary outcome measure was the incidence of healing.

Results: Mean age was 57.6 years; 57 (60.6%) were male. 48 ulcers (51.1%) healed without surgery; 11 (12.2%) subjects underwent minor amputation. Significant differences in terms of healing were observed for depth (p=0.002), infection (p=0.006) and denervation (p=0.002) using the S(AD)SAD system, for UT Grade (p=0.002) and Stage (p=0.032), and for Wagner grades (p=0.002). Ulcers with a S(AD)SAD score of 9 (total possible 15) were 7.6 times more likely to heal than scores 10 (p<0.001).

Conclusions: All three systems predicted ulcer outcome. The S(AD)SAD score of ulcer severity could represent a useful addition to routine clinical practice routine. The association between outcome and ulcer depth confirms earlier reports. The association with infection was stronger than reported from centres in Europe or N America. The very strong association with neuropathy has only previously been observed in Tanzania. Studies designed to compare outcome in different countries should adopt systems of classification which are valid for the populations studied.