Using DIRECT Wound Assessment to Predict Limb Salvage and Provide Prognosis of Diabetic Foot Ulcers

Abstract

Background: Many wound assessment systems including the Wagner classification and University of Texas (UT) grading system have been previously described. The authors of this study applied the DIRECT (Debridement of necrosis, Infection control, Revascularization, Exudate control, Chronicity, and Top surface) wound coding system for initial assessment of diabetic foot ulcers (DFUs) to predict limb salvage and prognosis.<br/>Methods: From January 2016 to February 2020, a total of 169 first-time DFU patients were retrospectively evaluated using the DIRECT wound coding assessment system. DFUs were followed up for at least 6 months, and scores in each component of the coding system according to final limb status were statistically evaluated. The coding assessment’s ability to predict major amputation was compared to those of the Wagner classification and the UT grading system.<br/>Results: Subjects were divided into complete healing (n=80, 47.3%), not healed (n=71, 42%), and amputation (n=18, 10.7%) groups. The mean values of each component of DIRECT assessment for the complete healing/amputation groups were D 0.86/1.56 (P<0.001), I 0.46/0.89 (P=0.001), R 0.65/0.94 (P=0.014), E 1.15/1.56 (P=0.049), C 0.69/0.89 (P=0.086), T 0.53/0.72 (P=0.13) and the sum was 3.140/4.741 (P<0.001). The area under the receiver operating characteristic curve of the DIRECT, Wagner, and UT grading systems was 0.722, 0.603, and 0.663, respectively.<br/>Conclusion: The DIRECT coding system shows a greater association with prediction of amputation or complete healing, compared with the Wagner and UT wound classification systems. This more accurate wound assessment system will be helpful in predicting prognosis and planning treatments.

The SHID wound classification system for diabetic foot ulcer patients: a validity study

“…The Wagner classification system was the early framework for classifying diabetic foot ulcers. It evaluates the depth of the ulcer and the existence of osteomyelitis or gangrene and divides the ulcers into six grades [ 10 ]. Although it is simple to apply and in a wide application, it does not recognize peripheral arterial disease and infection for the first three grades (0–2) [ 11 ].…”

Ray Amputation in a Traumatic Diabetic Foot

“…To aid in the diagnosis of DFUs, there are various scoring metrics or assessment systems available that help provides a promptly accurate diagnosis and guide treatment. These systems are namely the Wagner’s Classification; University of Texas (UT) Classification; PEDIS (Perfusion, Extent, Depth, Infection, and Sensation) grading classification system; and DIRECT wound coding system [ 6 ]. Amongst all, the Wagner classification system was the first one to categorize DFU.…”

“…This helps predict outcomes because infection and ischemia are included in the evaluation. However, neither system accounts for necrotic status, size of the ulcer, or vascular status [ 6 ].…”

“…As a result, none of these classification systems have been internationally recognized to guide the standard of care. To date, the DIRECT (Debridement of necrosis, Infection control, Revascularization, Exudate control, Chronicity, and Top surface) Classification System comprises various pathophysiological components of wound healing and shows a higher association with the prediction of amputation or complete healing compared to the Wagner and the UT wound classification systems [ 6 ].…”

“…Therefore, both wound experts and newer medical trainees would benefit from using a Classification system such as the DIRECT wound coding system in multifaceted cases of diabetic wounds as it would suggest the most practical treatment, simplify tracking progression or regression of wound healing, and thereby practitioners would have more accurate outcome predictions which included either revascularization, limb salvage, or amputation [ 6 ].…”