Introduction

Diabetes mellitus-related foot ulceration is very common. As a result of neuropathy, peripheral vascular disease, and infection, patients with diabetes are prone to develop diabetic foot problems that may eventually require a lower-extremity amputation. Of all individuals with diabetes mellitus, 15 percent will be affected by ulceration at least once in their lifetime.1,2 The presence of foot ulceration increases the hospitalization duration by 59 percent in people with diabetes mellitus. Because diabetic foot ulceration is a serious problem and because ulcers are heterogeneous in terms of etiology, anatomic location, depth of tissue involvement, and associated circumstances, including the presence or absence of infection, classification is needed in order to predict ulcer outcome and conduct clinical trials.1

In the literature, several classification systems for diabetic foot ulcers have been proposed. These classification systems have to comply with certain characteristics, such as precision, flexibility, specificity, and simplicity. They also must be applicable for education and communication between all care providers, including nurses, general practitioners, and specialists. They can be of great help for the assessment of treatment schemes. Classifications are also useful in standardization and analysis of multicenter research. The classification most frequently used analyzes one or more of the following elements: infection, neuropathy, vasculopathy, and the extent (surface and depth) of the ulcer.

The best known and widely available classifications are the following: Meggit/Wagner, Gibbon’s, Frykberg’s and Coleman’s, Forrest’s, Knighton’s, the Texas Diabetic Wound Classification, and the Ten-Level Seattle Wound Classification System.2–11 Each of these classifications was developed to accomplish a particular objective, utilizes different criteria, and categorizes lesions according to different rationales. Only a few of these classifications were evaluated for the assessment of the prognosis on salvage of the ulcerated or dysvascular diabetic limb.

The aim of this study was to evaluate a new classification, the Van Acker/Peter classification (VA/P). This is a two-dimensional classification on the vertical axis parameters of physiopathology and on the horizontal axis parameters of depth of the ulcer and the presence or absence of infection. Outcome measures studied are healing with or without amputation and the time until healing.

Patients and Methods

Study population. Patients were selected in the Antwerp Diabetic Foot Clinic. All patients who visited the diabetic foot clinic during the period of January, 1992, and December, 1997, were selected on the basis of having a specific health insurance file code. This code is the identifying mark of the health insurance organization LCM, the most important insurance system in Belgium. The reason of this selection was that this group of patients received follow up in an economical evaluation in a long-term study in our clinic. All files contained photographic images of the ulcers and careful clinical descriptions according to the standard procedure of the foot clinic. In order to eliminate interpretation bias by different investigators, the same investigator (KVA) coded all ulcers. The total number of ulcers with a Wagner classification greater than 0 was 303. Only the files with data on healing outcome were used for analysis (n = 253).

The Meggit-Wagner classification. This system is based on three features: depth of the ulcer, the degree of infection, and the presence or absence of gangrene and its extent. Grades 1 to 3 are mainly based on neuropathy, while grade 4 and 5 represent mainly ischemic lesions.

The Van Acker/Peter classification. This classification is based upon the Texas Wound Classification, the first bidimensional classification.