Classification systems for lower extremity amputation prediction in subjects with active diabetic foot ulcer: a systematic review and meta-analysis

• Published in: Diabetes/metabolism research and reviews 2014-10, Vol.30 (7), p.610-622
• Main Authors: Monteiro-Soares, M., Martins-Mendes, D., Vaz-Carneiro, A., Sampaio, S., Dinis-Ribeiro, M.
• Format: Article
• Language: English
• Subjects: Amputation - statistics & numerical data; Classification - methods; classification systems; clinical prediction rules; diabetic foot; Diabetic Foot - classification; Diabetic Foot - diagnosis; diagnostic accuracy; foot ulcer; Humans; Lower Extremity - surgery; Models, Statistical; Prognosis; Reproducibility of Results; Risk Factors; systematic review
• ISSN: 1520-7552; 1520-7560
• DOI: 10.1002/dmrr.2535

Aim We systematically review the available systems used to classify diabetic foot ulcers in order to synthesize their methodological qualitative issues and accuracy to predict lower extremity amputation, as this may represent a critical point in these patients' care. Material and Methods Two investigators searched, in EBSCO, ISI, PubMed and SCOPUS databases, and independently selected studies published until May 2013 and reporting prognostic accuracy and/or reliability of specific systems for patients with diabetic foot ulcer in order to predict lower extremity amputation. Results We included 25 studies reporting a prevalence of lower extremity amputation between 6% and 78%. Eight different diabetic foot ulcer descriptions and seven prognostic stratification classification systems were addressed with a variable (1–9) number of factors included, specially peripheral arterial disease (n = 12) or infection at the ulcer site (n = 10) or ulcer depth (n = 10). The Meggitt–Wagner, S(AD)SAD and Texas University Classification systems were the most extensively validated, whereas ten classifications were derived or validated only once. Reliability was reported in a single study, and accuracy measures were reported in five studies with another eight allowing their calculation. Pooled accuracy ranged from 0.65 (for gangrene) to 0.74 (for infection). Conclusion There are numerous classification systems for diabetic foot ulcer outcome prediction, but only few studies evaluated their reliability or external validity. Studies rarely validated several systems simultaneously and only a few reported accuracy measures. Further studies assessing reliability and accuracy of the available systems and their composing variables are needed. Copyright © 2014 John Wiley & Sons, Ltd.