April 22, 2010

Wagner’s Classification vs. Texas University Classification for Diabetic Foot Ulcer

Foot ulcer complicating 5-10% patient suffered from diabetes mellitus with up to 3% of them will need lower limb amputation. [Samson O. Oyibo et al]

Below is the grading of this two system.

1. Wagner’s classification

Grade 0 (Pre or post ulcerative lesion)

Grade 1 (partial/ full thickness ulcer, i.e. superficial ulcer)

Grade 2 (Probing to tendon or capsule, i.e. deep ulcer)

Grade 3 (Presence of osteomyelitis)

Grade 4 (Partial foot gangrene)

Grade 5 (Whole foot gangrene)

2. University Texas Classification

Grade 0 (pre or post ulcerative ulcer that has healed)

Grade 1 (Superficial wounds not involving tendon, capsule or bone)

Grade 2 (Wound penetrating to tendon or capsule)

Grade 3 (Wound penetrating bone or joint.

Within each grade, it got 4 stages

A (Clean wounds)

B (Non ischemic infected wounds)

C (Ischemic non infected wounds)

D (Ischemic infected wounds)


1) Increasing stage regardless of grade is associated with increased risk of amputation and prolongs healing ulcer time.

2) UT system’s inclusion of stage makes it a better predictor of outcome.

Extract from

1) Samson O. Oyibo, Edward B. Jude, Ibrahim Tarawneh, et al, “ A Comparison of Two Diabetic Foot Ulcer Classification Systems”, Diabetes Care 24:84-88, January 2001


  1. assalamu'alaikum.. hi, I'm Nisa from Jakarta, Indonesia..
    I wanna ask if diabetic patient who has foot diabetic grade IV (according to wagner classfctn) must undergo debridement and/or amputation as the treatment choices or is there any other alternatives for this??

  2. Wa'alaikum slm w.b.t

    dear Nisa,

    Management of diabetic foot ulcer mainly depends on it's severity, vascular status and whether there is presence of infection or not.

    when there is presence of deep infection, we can cosider bone resection and debridement without involving amputation plus good wound healing management and antibiotic coverage.

    there is also few study regarding the role of hyperbaric treatment but it is expensive and not readily available.

    However, once it reach stage IV and V, it is usually superimposed with both ischemic and infected element. therefore, amputation is always done in this patient. a retrospective study by pittet et al found that only 1% of patient with gangrene are succesfully treated conservatively.

    In choosing the type of amputation to be done (local, Below knee amputation or above knee aputation), evaluation of Ankle Brachial Systolic Index with/out angiography should be perform. BKA might be a best modality however we need to consider many factor such as the psychosocial of the patient. local amputation is associated with risk of recurrence within one year after operation. however, it still acceptable if the blood circulation to the periphery is good.

    location of the ulcer also determines the type of amputation. if the ulcer confined to the forefoot area, then local amputation can be considered. however, if it involves the hind foot, BKA is the best treatment as removal of hind foot will not improve the patient condition (stability and weight bearing is not possible)

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