Diabetic foot surgery: Classifying patients to predict complications

The purpose of this article is to describe a classification of diabetic foot surgery performed in the absence of critical limb ischaemia. The basis of this classification is centred on three fundamental variables that are present in the assessment of risk and indication: (1) presence or absence of neuropathy (the loss of protective sensation); (2) presence or absence of an open wound; (3) presence or absence of acute limb-threatening infection. The conceptual framework for this classification is to define distinct classes of surgery in an order of theoretically increasing risk for high-level amputation. These include: Class I: elective diabetic foot surgery (procedures performed to treat a painful deformity in a patient without the loss of protective sensation); Class II: prophylactic (procedure performed to reduce the risk of ulceration or reulceration in a person with the loss of protective sensation but without an open wound); Class III: curative (procedure performed to assist in healing an open wound); and Class IV: emergency (procedure performed to limit the progression of acute infection). The presence of critical ischaemia in any of these classes of surgery should prompt a vascular evaluation to consider (1) the urgency of the procedure being considered and (2) possible revascularization prior to or temporally concomitant with the procedure. It is our hope that this system begins a dialogue amongst physicians and surgeons which can ultimately facilitate communication, enhance perspective, and improve care.