Previous classification systems by our group and others have used the concept of:


Neuropathy

Neuropathy + Deformity

Previous History of Ulceration or Amputation


As a paradigm of escalating risk. While this is a common sense approach and is based on previous evidence(1), recent data(2) suggest that vascular disease may be an important independent factor. While not part of the traditional pathway of neuropathy + repetitive stress = ulcer, vascular disease appears to play a significant role in risk for recurrence(3), hospitalization, and amputation.(4)


The evolution of risk now may be simplified to include (Figure 1):


Neuropathy +/- Deformity

Vascular Disease

Previous History of Ulceration of Amputation


This leads us to a new, slightly modified classification of risk (Figure 1).

Figure 1

  1. 1.Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG. Practical Criteria for Screening Patients at High Risk for Diabetic Foot Ulceration. Arch Intern Med. 1998;158:158-162.


  1. 2.Lavery LA, Peters EJ, Williams JR, Murdoch DP, Hudson A, Lavery DC. Re-evaluating How We Classify the Diabetic Foot: Restructuring the International Working Group's Diabetic Foot Risk Classification. Diabetes Care. 2007.


  1. 3.Peters EJ, Armstrong DG, Lavery LA. Risk factors for recurrent diabetic foot ulcers: Site matters. Diabetes Care. 2007.


  1. 4.Lavery LA, Peters EJ, Armstrong DG. What are the most important interventions in preventing diabetic foot ulcers? International Wound Journal. 2008:In Press.

Foot Risk Classification, 2.0

Risk Group

Definition

Treatment Recommendations

Follow Up

0

No LOPS, no PAD

Patient Education

Annually (by generalist and/or

specialist)

1

LOPS ± deformity

Consider prescriptive or accommodative footwear. 

Consider prophylactic surgery if deformity is not able to be safely accommodated in shoes.  Continue patient education.

Every 3-6 months (by specialist)

2

PAD ± LOPS

  1. Consider prescriptive or accommodative footwear.

  2. Consider vascular consultation for combined follow-up.

Every 2-3 months (by specialist)

3

History of Ulcer or Amputation

Same as category 1.

Consider vascular consultation for combined follow-up if PAD present.

Every 1-2 months (by specialist)

Lavery, Armstrong, et al, Arch Intern Med, 1998

Lavery, et al, Diabetes Care, 2007

LOPS = loss of protective sensation

PAD = peripheral arterial disease

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