The following increase the risk of major complications in the diabetic foot:
- Previous ulceration
- Neuropathy (loss of pressure sensation to 10g neurofilament)
- Duration of diabetes
- Poor metabolic control
- Poor foot care
- Ill-fitting shoes
- Deformity
- Tight Achilles tendon
The International Working Group on the Diabetic Foot produced a risk stratification, which was studied in a prospective cohort of 225 patients followed for 3 years (Peters et al 2001).
Group |
Criteria |
Ulceration rate (%) |
Amputation rate (%) |
0 |
no neuropathy |
5 |
0 |
1 |
neuropathy, no deformity or vascular disease |
14 |
0 |
2 |
neuropathy and deformity or vascular disease |
19 |
3 |
3 |
previous ulcer or amputation |
55 |
21 |
This was modified in the light of further work on outcomes (Lavery 2008), reflecting the independently higher risk in patients with vascular disease:
- group 0 - no neuropathy or vascular disease
- group 1 - neuropathy, no vascular disease or deformity
- group 2A - neuropathy and deformity, no vascular disease
- group 2B - vascular disease
- group 3A - previous ulcer
- group 3B - previous amputation
Montero-Soares (2012) reported a prospective study of 364 diabetic patients without ulcers who were followed up for 1 year or until an ulcer occurred. The IWGDF risk stratification system and four other systems (the University of Texas, American Diabetic Association, SIGN and Seattle systems) were applied prospectively. Although there was no statistically significant difference in the power of the different systems to predict the occurrence of an ulcer, the area under the receiver operating characteristic curve was largest for the IWGDF system.