Hello my name is Julien Vouillarmet I am a diabetologist in Lyon
France and I will talk to you about classifications of the diabetic foot.
Why classifications?
How they can be used by us in our daily lives?
These are tools that allow us to predict the outcome of wounds
in order to better orient the care.
It is also a tool for standardize the description of wounds
that will allow to standardize data
for clinical research
but also for audits at the national and international level.
How are these classifications validated?
Most of the time they essentially watch the future
i.e. amputations and wound healing.
What are the main ones parameters that are used
to perform these classifications?
These are essentially wound measurement
surface and depth, location
the presence of neuropathy infection and ischemia.
The problem is that in recent years
many classifications on the diabetic foot have appeared
and that it is important to choose the right classification.
A small definition, it is necessary to separate this
which is of the order of classification which will only be descriptive
and which corresponds to a score
which is a descriptive numerical scale
but who's going to give an idea of the severity of the wound.
The classification that has been the most used in recent years
oldest one it's Wagner's classification.
which is rather inaccurate and that should not be used anymore.
The second classification
which is important to know it's the one from the University of Texas
which includes two parameters.
The first is rank, there are four ranks
looking at the depth of the wound
and four stages that will define the comorbidities
that are infection and arteriopathy.
Why the depth?
Because we know that more the wounds are deep
the more likely they are to become infected and they take longer to heal.
In addition, deep wounds are at higher risk of osteomyelitis
so we know that the risk of osteomyelitis is multiplied
by 69 times in case of bone contact when
is associated with signs of infection of the parties.
Why ischemia infection?
Because it's about two very important factors
that increase the delay in healing
but also the risk of amputation.
What are these four ranks?
Grade 0 corresponds to a lesion which is pre- or post-ulcerated
almost completely epithelialized.
Grades 1, a lesion affecting the whole epidermis
grades 2 with an extension at the tendon and/or capsule
and grades 3 with an extension in advance.
Concerning the four internships stage A for wounds
where there is no infection and no associated arteriopathy
stages B infected wounds
stage C ischemic wounds
and stages D wounds infected and ischemic.
We come to a painting like this where we have horizontal grades
and vertically the stadiums.
A bone lesion not infected will be classified 3A
a superficial lesion ischemic will be classified as 3C.
We know that depending on the University of Texas classification
the severity of the wound and the risk of amputation
will become more and more important
with wounds that are easy to heal
with a good prognosis in green
and wounds with a risk of significant amputation in red.
The second classification is the classification of SINBAD.
SINBAD is an acronym English with S for Site
I for Ischaemia, N for Neuropathy, B for Bacterial infection
A for Area and D for Depth.
When we look at the different items
they were simple in clinical use.
For the site, we're going to have a score of zero if it is
from the forefoot and to one for the wounds in the middle and hindfoot.
For ischemia, if at least one pulse
is perceived we'll be at a score of zero.
if there is an absence of pulse we'll be at a score of one.
For neuropathy the absence of neuropathy corresponds to
to a score of zero and his presence to one.
The same goes for infection with the presence
which corresponds to a score of one.
The surface of the wound if it is more than one square centimetre
we'll also have a point and for the depth
deep wounds will also have a score of one.
The interest of this classification
is that it has been validated about ten years ago now
on four different populations:
in England, Germany, Tanzania and Pakistan.
And we can already see on this photograph the degree
wound severity by country
with wounds with scores between two and three in England
and when you look at Pakistan and Karachi
wounds that are more like with a score of three or four.
This same study validated this score in different populations
and we can see very clearly that the more the score increases
the closer we get to the site
the longer the healing time in days here increases.
Here, we spend 77 days healing with a score of zero
in England at 577 days of healing time
for the six scores and this in all four populations.
There are of course other classifications
including classification of the international group
on the diabetic foot PEDIS which is rather positioned
for clinical research with a level of complexity
and more important information.
There are other classifications also as those of WiFi
very vascularly focused.
Which classification should be used?
To summarize, when you want to do clinical research
the PEDIS classification will be the most complete and it's the only one to favour.
When we're going to be in routine clinical care
and that we only want descriptive information
we can use either the university from Texas or SINBAD
and whenever we want to have a more prognostic assessment
you will have to use SINBAD instead.
For all audit, evaluation and evaluation purposes both national and international
the SINBAD classification is to be preferred.
The limits of these classifications
and that must be taken into account in patient management
is that the comorbidities
and age are not integrated in these classifications.
The second thing is validity
of these classifications are often carried out
on a small number of people and for the most severe wounds.
On the other hand, it should not be forgotten that
for healing and amputation data
it depends a lot on local practices
and as we can see when we saw about the healing times
that are different between the data from Pakistan in particular
from Karachi, and the English data.
Thank you very much.