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PEDIS Classification in Diabetic Foot Ulcers Patients

Article in Journal of Indonesian Society for Vascular and Endovascular Surgery · July 2020
DOI: 10.36864/jinasvs.2020.2.012

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Journal of Indonesian Society for Vascular and Endovascular Surgery Original Article
Vol. 1, No. 2, June 2020
pISSN 2715-1204 - eISSN 2715-1239

PEDIS Classification in Diabetic Foot Ulcers Patients

Radi Noorsyawala, Fahmi Jaka Yusufa, Kemas Dahlan*a, Ratna Maila Dewib

Copyright © 2020, The

Introduction: Diabetic foot ulcer are one of several serious complications of diabetes Indonesian Society for
Vascular and Endo-
progression. Up to 15% of patients with diabetes have diabetic foot ulcer and these ulcers vascular Surgery
lead to more than 80,000 amputations per year in the United States. Many DFU
classification systems have been proposed to predict clinical outcome; however, almost of JINASVS 2020;1(2):50-54
these systems have limitations. To categorize and define DFU objectively, the International
Working Group of the Diabetic Foot (IWGDF) developed the PEDIS classification system.
These collective findings and because of there is no findings of characteristic of DFU based
on PEDIS classification in Mohammad Hoesin Hospital indicate that this research is needed
to do.

Method: This is a prospective study at Mohammad Hoesin hospital, Palembang. The aim is
to describe the characteristic of diabetic foot ulcers based on PEDIS classification. There
were 41 cases evaluated under this study.

Results: Peripheral arterial disease is the most problem in perfusion. 1-3 cm2 is the most
happen in extent. Wound depth on fascia or muscle or tendon is the most happen. Abscess
or fascitis is the most problem in infection. Loss of sensation is the most happen. PEDIS
score ≥ 7 is the most happen.

Conclusion: Early prevention and treatment from vascular and endovascular surgery can be
considered as the most important for the management of diabetic foot ulcers patient.

Keywords: Diabetic Foot Ulcer, PEDIS classification, Peripheral Arterial Disease

https://doi.org/10.36864/jinasvs.2020.2.012

*Correspondence: [email protected]
aM.D., General Surgery Department of Dr. Mohammad Hoesin Hospital, Palembang, Indonesia
bM.D., Internal Medicine Department of Dr. Mohammad Hoesin Hospital, Palembang, Indonesia

INTRODUCTION disabilities, decrease quality of life, and incur

significant costs.10
Diabetic Foot Ulcer (DFU) is one of the few There are many DFU classifications that have
serious complications of diabetes mellitus. The main been used to predict clinical manifestation; However,
causes of DFU are peripheral neuropathy and almost all of these systems have limitations. First,
peripheral arterial disease.1-3. The number of DFU most classification systems only focus on local
patient in the world was around 55 million people in pathology of DFU and cannot adequately assess all
2011, and this number is expected to increase to 83 important parameters related to ulcer healing. For
million by 2030.4. In Indonesia, DFU patient example, the Wagner system specifically assesses the
numbered 1.095 million in 2011, predicted to increase depth of ulcers without comorbidities such as
to 1,770 million in 2030.4 Based on these data, the ischemia and neuropathy.11 Second, some
increase in the number of DM patient in Indonesia is classification systems do not standardize the
higher (23.6%) than at the world level (20.26%).4 definition of ischemia, infection and systemic
The number of DFU patient is estimated to be around variables important for wound healing. Finally, some
15% of the number of people with diabetes mellitus DFU classification systems have been validated, and
and causes more than 80,000 cases of amputations none of the classifications have received worldwide
per year in the United States5,6 As a result of the recognition.12 To classify and determine DFU
development of DFU, the risk of amputation in objectively and facilitate communication between
patients has also increased, almost 84% of patient of health care providers, the International Working
lower limb amputations due to diabetes mellitus.7 Group of the Diabetic Foot (IWGDF) developed a
Estimation of the annual cost expenditures due to DFU classification system Perfusion, Extent, Depth,
treatment in patients with diabetes mellitus is 10.91 Infection and Sensation (PEDIS), where DFU is
million US dollars.8 Foot ulcers significantly contribute classified according to five categories: perfusion, area
on the morbidity and mortality of patients with / size, depth, infection and sensation. This category is
diabetes mellitus. Diabetic patients with foot ulcers considered to be able to explain the pathogenesis
require long-term hospitalization.9 From these relevant in the development of DFU. In addition, each
findings, it indicates that DFU can cause serious subcategory is defined according to criteria obtained

© 2020 Noorsyawal et al. The Indonesian Society for Vascular and Endovascular Surgery. This is an Open Access
Journal distributed under the terms of the Creative Commons Attribution Non-Commercial License
JINASVS (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution,
and reproduction in any medium, provided the original work is properly cited.
50
Noorsyawal et. al, JINASVS 2020;1(2):50-54 PEDIS Classification in Diabetic Foot Ulcers Patients

based on objective techniques that apply throughout range of 30-79 years, the majority of patients with
the world.12 The PEDIS classification system was age ≥ 45 years were 18 patients (86%) and <45
developed primarily for research and has not been years as many as 3 patients (14%). 17 patients were
validated in clinical practice in terms of prognosis.12 smoked, while the other 24 patients did not smoke.
Based on the fact, it is deemed necessary to The result of body mass index of diabetic foot
conduct further research on the characteristics of ulcer patients is that there are no patients in the
patients with diabetic foot ulcers based on the PEDIS underweight category, 11 peoples in the normoweight
classification which has never been examined at RSUP category, 28 peoples in the overweight category, 2
Dr. Mohammad Hoesin and is expected to be used as peoples in the obesity category. 14 patients have
a reference for medical personnel and related parties diabetes mellitus less than 5 years and 27 peoples
in taking action in order to improve health services have diabetes mellitus for more than 5 years. 17
more effectively. peoples have no history of hypertension, 7 peoples
with pre hypertension, 11 peoples with first grade
METHOD hypertension, 6 peoples with second grade
hypertension. There are 20 peoples without chronic
This type of research is a prospective study kidney failure, 2 peoples with first grade kidney
with a descriptive research design. Took place in failure, 4 peoples with second grade kidney failure, 8
January 2018 to March 2018. The population in this peoples with third grade kidney failure, 4 peoples with
study were all patients with diabetic foot ulcers who fourth grade kidney failure, 3 peoples with fifth grade
came to the sub-division of vascular and endovascular kidney failure. The results of X-ray pedis examination
surgery Dr. RSUP. Mohammad Hoesin Palembang showed that 16 peoples were diagnosed with
from 1 January 2018 to 31 March 2018. The sample osteomyelitis and 25 peoples were diagnosed with no
in this study was all populations that met the criteria osteomyelitis. LDL examination results obtained 26
inclusion. peoples with LDL results ≤ 100 and 15 peoples with
The criteria inclusion of this study were all LDL results >100.
patients with diabetic foot ulcers and obtained all the In this study, perfusion examination showed
variables studied in full, while the exclusion criteria of that 6 peoples did not suffer from PAD, 23 peoples
this study were patients with diabetic foot ulcers with suffered from PAD, 12 peoples suffered from CLI,
other comorbidities. from the results of examination of the extent obtained
Characteristics of patients with diabetic foot results of 1 peoples with skin contact, 4 peoples with
ulcers divided into gender, age, smoking habits, body injuries less than 1cm2, 19 peoples with injuries 1cm2
mass index, duration of diabetes, hypertension, to 3cm2, 17 peoples with more than 3cm2, from depth
kidney failure, osteomyelitis, LDL values and PEDIS examination found that there were no people with
score are described descriptively and data are skin intact wound depths, 8 peoples with superficial
presented in tabular form and analyzed with the SPSS wound depths, 24 peoples with deep fascia or muscle
version program 21. or tendon depths, 9 peoples with bone depths or
joints, from examination of infection obtained results
RESULTS of 2 peoples not infected, 17 peoples with infection on
the wound surface, 19 peoples with abscess
Based on gender, there were 20 male and 21 infections, 3 peoples with SIRS infection, from
female. Based on age, the average age of patients sensation examination results obtained 9 peoples with
with diabetic foot ulcer was 54.1 years with an age still has sensation, 32 people with loss of sensation.

Table 1. General Characteristics Of Research Subjects (n=41)

Characteristics N %
Gender Male 20 49
Female 21 51
Age ≥ 45 years old 38 92
< 45 years old 3 8
Smoking Habit Yes 17 41
No 24 59
Body Mass Index Underweight 0 0
Normoweight 11 27
Overweight 28 68
Obesity 2 5
Duration of diabetes ≤ 5 years old 14 34
> 5 years old 27 66
Hypertension No 17 41
Pre Hypertension 7 17
First Grade Hypertension 11 27
Second Grade Hypertension 6 15
Chronic Renal Failure No 20 49
First Grade 2 5
Second Grade 4 10
Third Grade 8 20
Fourth Grade 4 10
Fifth Grade 3 6
Pedis X-Ray No osteomyelitis 25 61
Osteomyelitis 16 39
LDL values ≤ 100 26 63
> 100 15 37

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Noorsyawal et. al, JINASVS 2020;1(2):50-54 PEDIS Classification in Diabetic Foot Ulcers Patients

Table 2. Characteristics of PEDIS Classification Research Subjects (n=41)

Characteristics N %
Perfusion No PAD 6 15
PAD 23 56
CLI 12 29
Extent Skin intact 1 2
< 1 cm2 4 11
1 cm2–3 cm2 19 46
>3 cm2 17 41
Depth Skin intact 0 0
Superficial 8 20
Fascia, muscles, 24 58
tendons
Bones or joints 9 22
Infection No infection 2 5
Surface 17 41
Abscess or fascitis 19 47
SIRS 3 7
Sensation Yes 9 22
No 32 78

With a PEDIS score of more than 7, 28 were found, compared to those who were of normal weight [AOR
and a PEDIS score of less than 7 was obtained 13 = 2.1; 95% CI: 1.15, 3.10] .20 This is consistent with
peoples research conducted in Ethiopia, Kenya and Nigeria.21-
23
Possible reasons for higher foot pressure in heavier
DISCUSSION bodies and with diabetic patients with a higher body
mass index (BMI) as well as obesity and being
The results of this study are not in overweight can intensively decrease the normal blood
accordance with the study of Fauci et al (2008) circulation patterns in the lower extremities; As a
mentioning one of the risk factors that can cause foot result, this can cause diabetic foot ulcers.
ulcers and amputations is male.13 Results of research The results of this study are consistent with
conducted by Decroli et al in RSUP Dr. M. Djamil a study in India by Shahi in 2012 on 678 patients with
Padang also mentioned that diabetic foot ulcer patient diabetes melltius showing the results of long-standing
were male more than female.14 But according to the diabetes mellitus ≥ 5 years is a risk factor for diabetic
results of research conducted by Kahuripan et al in ulcers. The results of this study are in accordance with
RSUD dr. H. Abdul Moeloek Lampung using a cross the research of Shahi et al., Who stated that diabetic
sectional method retrospectively from the medical foot ulcer patients were more common in patients
record data of diabetic ulcer patients treated from with DM duration of ≥ 5 years.
January 1, 2005 to May 30, 2009 reported that The results of this study are not in
diabetic foot ulcer patient suffered the most by accordance with the study of Chuan et al in 364 DFU
women (65.3%). patients showing the results of patients with
In the United States alone, cases of diabetic hypertension there are 179 people and patients
foot ulcers who are older than 60 years have a greater without hypertension there are 185 people.24
percentage than age less than equal to 60 years. In Hyperlipidemia in people with DM is one of
line with the results of Utami's study which reported the causes of endothelial dysfunction and increases
that patient of diabetic foot ulcers were mostly found oxygen free radical production which inactivates nitric
in respondents aged 55-60 years.15 According to the oxide, so LDL-C will be buried in the intima layer
Agency for Healthcare Research and Quality (AHRQ) where the endothelial permeability is increased.
in 2008, diabetic foot ulcers were most commonly The accumulation of LDL-C in the vascular
found in the 45-54 year age category.16 According to wall in the intima layer coupled with chemical changes
Gupta et al, Decades 4 and 5 are the most common in fat triggered by free radicals in the arterial wall will
age group of diabetics with foot implications.17 produce oxidized LDL-C that plays a role and
The results of this study are not in accelerates the emergence of atheromatous
accordance with Norwood (2011) which states that plaque.25,26
smoking history is one of the risk factors causing Growth factors and growth hormones
diabetic foot ulcer.18 The results of this study are also stimulate the proliferation and migration of
not in accordance with Baker et al (2005), patients macrophages and vascular smooth muscle cells to
with diabetes mellitus who have a history or risk of form atherosclerotic plaques. The proliferation of
smoking 10 -16 times greater occurrence of smooth muscle cells and the deposition of extra cell
peripheral arterial disease. Blockage of blood vessels matrix in the intima converts fatty patches to mature
results in a decrease in the amount of blood fibrofatty atheroma and contributes to the growth of
circulation in the legs and decreases the amount of atherosclerotic lesions and forms atherosclerotic
oxygen sent to the tissues and causes ischemia and plaque.26,27
ulceration or diabetic foot ulcers.19 This causes the process of macroangiopathy
The results of this study are consistent with in blood vessels so that tissue circulation decreases
research findings of Mariam et al., Which showed that marked by loss or reduction of the pulse in the
diabetic patients who were overweight were 2.1 times dorsalis pedis, tibialis and poplitea arteries, feet
more at risk of developing diabetic foot ulcers become atrophy, cold and thickened nails.

www.journal.vascular.co.id 52
Noorsyawal et. al, JINASVS 2020;1(2):50-54 PEDIS Classification in Diabetic Foot Ulcers Patients

Subsequent abnormalities occur in tissue necrosis, curve analysis to assess the accuracy of different
resulting in ulcers which usually begin at the tip of the diagnostic systems for diagnostic diabetic foot ulcers
foot or leg. and considered it the best method for measuring the
The results of this study are in accordance diabetic foot ulcer scoring system.30,31 In addition to
with the research of Rodrigues et al who identified risk ROC curve analysis, Monteiro et al also used AUC
factors for Lower Limb Amputation (LLB) in patients values to ensure the diagnostic accuracy of the
with diabetic foot ulcers, one of which is a history of system PEDIS score to predict the results of diabetic
osteomyelitis.28 So osteomyelitis can be used as a foot ulcers. The results of the Monteiro et al study
consideration for determining the prognosis of showed that the PEDIS score system also has a very
diabetic foot ulcers. good ability to predict the results of diabetic foot
The results of this study are not in ulcers. In addition, the research of Chuan et al.
accordance with the results of the study Chuan et al Showed that the value of the PEDIS category with a
explain from the examination of perfusion of patients score of 7 or more was associated with a much greater
with diabetic foot ulcers who do not PAD is the most likelihood of healing difficulties. Chuan et al explained
cases, followed by those experiencing PAD and CLI. that the PEDIS score system must be widely applied
The results of this study are in accordance with the in clinical practice.24
results of the study Chuan et al. Explained that from
examination of the extent obtained wound area 1cm2- CONCLUSION
3cm2 is the most cases, followed by wound area of
more than 3cm2, less than 1cm2, skin contact. The PEDIS score system is a good predictor for
results of this study are consistent with the results of the results of diabetic foot ulcers. Early prevention
the study by Chuan et al. Explaining that from depth and treatment from vascular and endovascular
examination it was found that the depth of the fascia surgery can be considered as the most important for
or muscle or tendon wound was the most cases, the management of diabetic foot ulcers patient.
followed by bone or joint, superficial, skin contact.
The results of this study are not in accordance with CONFLICT OF INTEREST
the results of the study Chuan et al. explained that
examination of infections found infection of the wound The author states the original work, and
surface was the most cases, followed by abscess there is no conflict of interest in doing this research.
infection, SIRS infection, and did not experience
infection. From the sensation examination the results ORCID ID OF AUTHORS
of sufferers with lost sensation are the most cases,
followed by those with sensation.24 Radi Noorsyawal
The results of the study by Chuan et al. https://orcid.org/0000-0003-4705-8106
Explain the Extent Larger (OR, 2,461, 95% CI, 1,373-
4,412, P = 0.002), Deeper wound (OR, 12,494, 95% Fahmi Jaka Yusuf
CI, 4,076-38,297, P <0,001), Severe Infection (OR, https://orcid.org/0000-0003-0260-0571
7,202, 95% CI, 3,407-15,224, P <0,001), and Loss
Sensation (OR, 9,545, 95% CI, 3,184-28,611, P Kemas Dahlan
<0.001) have an effect on increasing the incidence of https://orcid.org/0000-0002-0153-4384
diabetic foot ulcer.24
Many diabetic foot ulcer scoring systems Ratna Maila Dewi
have been used with the aim of facilitating fast and https://orcid.org/0000-0002-1560-6115
accurate clinical decisions. Monteiro et al29 used ROC

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