Diabetic foot ulcers: Classification, risk factors and management

Table 5 Wound, Ischemia, and foot Infection system

Grade	Wound	Ischemia			Foot infection system
	Clinical features	ABI (mmHg)	ASP (mmHg)	Toe pressure, TcPO2 (mmHg)	Clinical manifestations
0	No ulcer no gangrene	≥ 0.80	> 100	≥ 60	No symptoms or signs of infection. Infection present, as defined by the presence of at least two of the following items: (1) Local swelling or induration; (2) Erythema 0.5 cm-2 cm around the ulcer; (3) Local tenderness or pain; (4) Local warmth; and (5) Purulent discharge (thick, opaque to white, or sanguineous secretion)
1	Small, shallow ulcer(s) on the distal leg or foot; no exposed bone, unless limited to the distal phalanx	0.6-0.79	70-100	40-59	Local infection involving only the skin and the subcutaneous tissue exclude other causes of an inflammatory response of the skin (e.g., trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis, and venous stasis)
2	Deeper ulcer with exposed bone, joint, or tendon generally not involving the heel; shallow heel ulcer without calcaneal involvement, gangrenous changes limited to digits	0.4-0.59	50-70	30-39	Local infection with erythema > 2 cm, or involving structures deeper than skin and subcutaneous tissues (e.g., abscess, osteomyelitis, septic arthritis, and fasciitis), and no systemic inflammatory response signs
3	Extensive, deep ulcers involving forefoot and/or midfoot; deep, full-thickness heel ulcers with or without calcaneal involvement, extensive gangrene involving the forefoot and/or midfoot; full-thickness heel necrosis with calcaneal involvement	≥ 0.39	< 50	< 30	Local infection with signs of SIRS, as manifested by two or more of the following: (1) Temperature > 38 °C or < 36 °C; (2) Heart rate > 90 beats/min; (3) Respiratory rate > 20 breaths/min or PaCO2 < 32 mmHg; and (4) White blood cell count > 12000 or < 4000 cu/mm or 10% immature bands

ABI: Ankle-brachial index; ASP: Ankle systolic pressure; TcPO2: Transcutaneous oxygen pressure; SIRS: Systemic inflammatory response syndrome.