Guidelines on the classification of foot ulcers in people with diabetes (IWGDF 2023 update).
Open accessAbstract
BACKGROUND: This publication represents a scheduled update of the 2019 guidelines of the International Working Group of the Diabetic Foot (IWGDF) addressing the use of systems to classify foot ulcers in people with diabetes in routine clinical practice. The guidelines are based on a systematic review of the available literature that identified 28 classifications addressed in 149 articles and, subsequently, expert opinion using the GRADE methodology. METHODS: First, we have developed a list of classification systems considered as being potentially adequate for use in a clinical setting, through the summary of judgements for diagnostic tests, focussing on the usability, accuracy and reliability of each system to predict ulcer-related complications as well as use of resources. Second, we have determined, following group debate and consensus, which of them should be used in specific clinical scenarios. Following this process, in a person with diabetes and a foot ulcer we recommend: (a) for communication among healthcare professionals: to use the SINBAD (Site, Ischaemia, Bacterial infection, Area and Depth) system (first option) or consider using WIfI (Wound, Ischaemia, foot Infection) system (alternative option, when the required equipment and level of expertise is available and it is considered feasible) and in each case the individual variables that compose the systems should be described rather than a total score; (b) for predicting the outcome of an ulcer in a specific individual: no existing system could be recommended; (c) for characterising a person with an infected ulcer: the use of the IDSA/IWGDF classification (first option) or consider using the WIfI system (alternative option, when the required equipment and level of expertise is available and it is considered as feasible); (d) for characterising a person with peripheral artery disease: consider using the WIfI system as a means to stratify healing likelihood and amputation risk; (e) for the audit of outcome(s) of populations: the use of the SINBAD score. CONCLUSIONS: For all recommendations made using GRADE, the certainty of evidence was judged, at best, as being low. Nevertheless, based on the rational application of current data this approach allowed the proposal of recommendations, which are likely to have clinical utility.
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Approximately 40% of people with Charcot arthropathy have concomitant tissue loss; a unilateral red, hot, swollen foot without a wound or diagnosis of deep vein thrombosis may indicate Charcot arthropathy.
“Although approximately 40% of people with Charcot arthropathy have concomitant tissue loss, a unilateral red, hot, swollen foot without a wound or diagnosis of deep vein thrombosis may indicate Charcot arthropathy.32”
From Diabetic Foot Ulcers (2023) · cites this paper as [32]
The Clinical question section (Table 3, p. 8) lists acute Charcot neuro-osteoarthropathy and thrombosis as possible causes of skin inflammation, alongside swelling, erythema and warmth. It does not report that approximately 40% of people with Charcot arthropathy have tissue loss or state the proposed diagnostic rule involving a unilateral foot without a wound or deep vein thrombosis. (LLM, conf=0.81)
Experimental — accuracy not yet measuredCharcot arthropathy affects approximately 0.3% of people with diabetes, can lead to significant deformity, and increases the risk of a diabetic foot ulcer, particularly in the midfoot and ankle/hindfoot.
“Charcot arthropathy, defined as a foot fracture with possible joint dislocation in people with peripheral neuropathy, affects approximately 0.3% of people with diabetes, can lead to significant deformity, and increases the risk of a diabetic foot ulcer, particularly in the midfoot and ankle/hindfoot.32”
From Diabetic Foot Ulcers (2023) · cites this paper as [32]
The Clinical question section mentions acute Charcot neuro-osteoarthropathy only as a possible cause of skin inflammation, and the Rationale section lists foot deformity as a variable in a separate ulcer score (page numbers not supplied). Searches for Charcot, 0.3%, and midfoot/ankle/hindfoot found no passage supporting the claimed prevalence, definition, deformity, or ulcer risk. (LLM, conf=0.76)
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- Authors
- Monteiro‐Soares, M., Hamilton, E. J., Russell, D. A., Srisawasdi, G., Boyko, E. J., Mills, J. L., Jeffcoate, W., & Game, F.
- Affiliations
- Universidade do Porto (PT)
- The University of Western Australia (AU)
- University of Leeds (GB)
- Siriraj Hospital (TH)
- University of Washington (US)
- Baylor College of Medicine (US)
- Nottingham University Hospitals NHS Trust (GB)
- University Hospitals of Derby and Burton NHS Foundation Trust (GB)
- Corresponding author
- Game, Frances
- ORCID
- Venue
- Diabetes/Metabolism Research and Reviews
- Publisher
- Wiley
- Published
- 2023-05-14
- Volume
- 40
- Issue
- 3
- Pages
- e3648-e3648
- ISSN
- 1520-7552 (ISSN-L)
- 1520-7560
- OpenAlex
- W4376507548
- Cited by
- 152
- References
- 34
- Citations by year
- 2026: 56 · 2025: 46 · 2024: 30 · 2023: 20
- FWCI
- 30.99
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Diabetes/Metabolism Research and Reviews (publishedVersion)
- PubMed (publishedVersion)
- UWA Profiles and Research Repository (UWA) (submittedVersion)
- Funders
- National Institute for Health and Care Research (NIHR300633)
- Raine Medical Research Foundation
- Fundação para a Ciência e a Tecnologia (LA/P/0053/2020)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetic Foot Ulcer Assessment and Management
- Health Sciences › Medicine › Dermatology › Skin Diseases and Diabetes
- Health Sciences › Medicine › Rehabilitation › Wound Healing and Treatments
- Keywords
- diabetic foot ulcer, peripheral arterial disease, wound infection, amputation risk
- MeSH terms
- Diabetes Mellitus, Humans, Diabetic Foot
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