CLINICAL STUDY Comparison of three systems of classification in predicting the outcome of diabetic foot ulcers in a Brazilian population Maria Ca ˆndida R Parisi 1,3 , Denise E Zantut-Wittmann 1 , Elizabeth J Pavin 1 , Helymar Machado 2 , Ma ´rcia Nery 3 and William J Jeffcoate 4 1 Endocrinology Division, Internal Medicine Department and 2 Statistical Nucleus of Research Commission, Medical School of the State University of Campinas, Campinas, SP, Brazil, 3 Endocrinology Department, Medical School of the State University of Sa ˜o Paulo, Sa ˜o Paulo, Brazil and 4 Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals Trust, City Hospital Campus, Nottingham, UK (Correspondence should be addressed to M C R Parisi at Disciplina de Endocrinologia, Departamento de Clı ´nica Me ´dica, Faculdade de Cie ˆncias Me ´dicas, Universidade Estadual de Campinas, PO Box 6111, Rua Tessa ´lia Vieira de Camargo, 126, Bara ˜o Geraldo, 13084-971 Campinas, SP, Brazil; Email: emaildacandida@uol.com.br) Abstract Objective: The aim was to compare three ulcer classification systems as predictors of the outcome of diabetic foot ulcers: the Wagner, the University of Texas (UT) and the size (area, depth), sepsis, arteriopathy, denervation system (S(AD)SAD) systems in a specialist clinic in Brazil. Methods: Ulcer area, depth, appearance, infection and associated ischaemia and neuropathy were recorded in a consecutive series of 94 subjects. A novel score, the S(AD)SAD score, was derived from the sum of individual items of the S(AD)SAD system, and was evaluated. Follow-up was for at least 6 months. The primary outcome measure was the incidence of healing. Results: Mean age was 57.6 years; 57 (60.6%) were male. Forty-eight ulcers (51.1%) healed without surgery; 11 (12.2%) subjects underwent minor amputation. Significant differences in terms of healing were observed for depth (PZ0.002), infection (PZ0.006) and denervation (PZ0.002) using the S(AD)SAD system, for UT grade (PZ0.002) and stage (PZ0.032) and for Wagner grades (PZ0.002). Ulcers with an S(AD)SAD score of %9 (total possible 15) were 7.6 times more likely to heal than scores R10 (P!0.001). Conclusions: All three systems predicted ulcer outcome. The S(AD)SAD score of ulcer severity could represent a useful addition to routine clinical practice. The association between outcome and ulcer depth confirms earlier reports. The association with infection was stronger than that reported from the centres in Europe or North America. The very strong association with neuropathy has only previously been observed in Tanzania. Studies designed to compare the outcome in different countries should adopt systems of classification, which are valid for the populations studied. European Journal of Endocrinology 159 417–422 Introduction Foot ulcers are a common complication of diabetes and represent a major source of morbidity (1–9). Early expert assessment and treatment are required to reduce the impact of the condition and to reduce the incidence of major amputation. The incidence of major amputa- tion has been described, as ‘a marker not just of disease but also of disease management’ (10). A number of foot ulcer classification systems have been devised in an attempt to categorize ulcers more effectively, and thereby allow effective comparison of the outcome of routine management in different centres and treatment strategies. These systems are variously based on the site of ulcer, depth, presence of neuropathy, infection and peripheral arterial disease, and have been used to compare the outcomes (10–14). To be useful, a system should be easy to apply, and robust enough to permit reliable classification of all ulcers encountered in routine practice (10–14). The two most widely used ulcer classification systems are: the Wagner (15) and the University of Texas (UT) systems (16). The size (area, depth), sepsis, arteriopathy, denervation system (S(AD)SAD) was described more recently (17). The S(AD)SAD system differs from the earlier ones by including reference to both ulcer area and neuropathy, and has been validated by demonstrating differences between different baseline variables and clinical out- come in a single centre in the UK (18). The International Working Group on the Diabetic Foot has also suggested a classification for the purposes of prospective research which is based on the same five elements as S(AD)SAD (19), but this system is potentially more complex and is primarily intended for selecting populations for prospective research, and was also not available when this study was planned. European Journal of Endocrinology (2008) 159 417–422 ISSN 0804-4643 q 2008 European Society of Endocrinology DOI: 10.1530/EJE-07-0841 Online version via www.eje-online.org