Can A Diabetic Foot Surgery Classification System Help Predict Complications?

By Brian McCurdy, Associate Editor

Various classification systems categorize diabetic wounds and infections. One system, devised in 2003, categorizes different levels of non-vascular diabetic foot surgery. How effective is such a system? A recent study, the first to evaluate the system’s effectiveness, suggests including various risk factors in the system may better predict surgical complications. The study, presented as an abstract at the American College of Foot and Ankle Surgeons Annual Scientific Meeting, evaluates the classification system’s four categories: elective, prophylactic, curative and emergency surgery. Researchers from the Center for Lower Extremity Ambulatory Research (CLEAR) examined the records of 180 patients with diabetes without critical limb ischemia. There was an equal number of patients in the four categories. The study detected a “highly significant trend” toward increasing risks of ulceration and reulceration, peri-postoperative infection, amputation at all levels and major amputation that corresponded to the severity of the surgery. Researchers concluded that a non-vascular surgical classification system — including variables such as neuropathy, open wound and acute infection — may help predict peri- and postoperative complications. Such variables may help surgeons identify potential risk when selecting a surgical procedure for patients with diabetes, note the authors. As far as diabetic foot surgery, David G. Armstrong, DPM, PhD, the lead author of the study, cites a “tremendous rise in procedures being performed and what some of us believe is a real ill-defined melange of indications and contraindications. “When the patient asks the surgeon, ‘Doc, what are the chances my leg is still going to be on my body in six months?’, the surgeon should be able to offer at least a qualified answer, based not only on experience but also on some evidence,” notes Dr. Armstrong, the Director of CLEAR at the William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science. “A classification of risk simply helps direct thought and therapy into something that can be better communicated among all members of the team, especially the patient.” While Dr. Armstrong believes the non-vascular diabetic foot surgery classification system’s framework may predict risk for complications such as amputation and infection, it is important for the system to continually evolve. Dr. Armstrong has been involved with teams that have proposed overall classification systems for foot risk and wound classification, and maintains these systems have evolved over time. He also cautions clinicians against relying too much on one classification system. “Just as it is best for one to be conversant in more than one language, it is best to be fluent in numerous classification systems,” says Dr. Armstrong, an immediate past member of the National Board of Directors of the American Diabetes Association. “I do believe that some (systems) are more descriptive than others but that knowledge only comes from immersing oneself in as many as possible.” Transmetatarsal Amputations: What A New Study Reveals By Brian McCurdy, Associate Editor A new study in the Journal of Foot and Ankle Surgery (JFAS) tracks the mortality and morbidity of those who had undergone transmetatarsal amputations and investigates predictive factors for complications. As part of the retrospective study, researchers reviewed medical records of 90 patients who had undergone 101 transmetatarsal amputations. The mean follow-up period was 2.1 years. Eighty-eight patients developed post-op complications and two patients died within 30 days following the surgery, according to the study. As senior author Graham Hamilton, DPM, notes, the population of patients with diabetes has changed significantly since the last extensive study, done 50 years ago by McKittrick, on surgical outcomes with this procedure and complications. Although patients are living longer with the disease, Dr. Hamilton notes many are experiencing chronic complications such as chronic renal failure and peripheral vascular disease, which have had a great impact on healing potential. The study notes no significant difference in healing times between the 88 patients with diabetes and the 13 without the disease. While this finding is consistent with other studies, the JFAS study notes that some studies have noted a difference in healing times between the two populations.

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