Macfarlane and Jeffcoate (1999) correctly identify wound classification as both an important and vexatious topic. They argued cogently in the last issue of The Diabetic Foot about the aspects of diabetic foot disease that continue to defeat the objective of a practical taxonomy to support research and quality improvement. And they describe with some clarity many of the features that would characterise such a classification. There follows a commendable attempt to move this important topic forward, but I doubt that it has yet reached its destination.
They suggest that ‘systems designed for the purpose of studying methods of care must be different from those used for departmental record keeping’ because lesions are dynamic and sequential charting may result in multiple classifications of a single lesion. Surely, however, it is not incompatible to use one system both to define the presenting lesion and to record its progress. Indeed, elsewhere, they argue for minimising complexity and providing a ‘basis upon which observations can be made of an ulcer’s management and/or outcome either in one centre or several’, both of which probably warrant having a single system. So, would the S(AD) SAD classification meet these objectives and is it superior to previous attempts?
Macfarlane and Jeffcoate have adopted and adapted features of existing systems, particularly the San Antonio group’s proposals. They extend the concept of size to include area as well as depth. The need for this increased complexity needs testing but clinical experience suggests it will be validated. Their categories of infection have clinical ‘face validity’ but depart from their commendable ambition to use only terms that are unequivocal because they fail to define ‘cellulitis’ and ‘osteomyelitis’. Ischaemia is categorised using pulses, which have been validated as a clinical sign, and ‘signs suggestive of reduced perfusion’ which are neither defined nor validated.
The exclusion of temperature, the other validated clinical sign of ischaemia (McGee and Boyko, 1998), needs to be defended. The addition of neuropathy, its subclassification and definition of the terms seems appropriate and practical, but requires validation. The recent paper by Reiber et al (1999) is supportive. But this same paper, allied to everyday experience, might also question why deformity, oedema, and possibly callus have been omitted. The authors might argue that these are important only as descriptors but since they ‘are variously associated with anticipated outcome, and also determine broad strategies for management’ they should, perhaps, be seriously considered as candidates for inclusion notwithstanding the inevitable increase in complexity.
This is a valuable contribution to an important debate. Ultimately, however, a widely adopted classification must fulfil the authors’ correctly defined requirements of being ‘simple enough to be remembered and yet precise enough to be useful’. Simplicity can only really be evaluated in practice. Precision depends both on the consistent use of unequivocal terms between observers and centres and on the ability of those terms to describe adequately the factors that determine the natural history and treatment responsiveness of the ulcers. The time has come for more to follow the San Antonio lead by testing the practicability and validity of classifications and basing further refinements on experience derived from practice.
Macfarlane and Jeffcoate (1999) correctly identify wound classification as both an important and vexatious topic. They argued cogently in the last issue of The Diabetic Foot about the aspects of diabetic foot disease that continue to defeat the objective of a practical taxonomy to support research and quality improvement. And they describe with some clarity many of the features that would characterise such a classification. There follows a commendable attempt to move this important topic forward, but I doubt that it has yet reached its destination.
They suggest that ‘systems designed for the purpose of studying methods of care must be different from those used for departmental record keeping’ because lesions are dynamic and sequential charting may result in multiple classifications of a single lesion. Surely, however, it is not incompatible to use one system both to define the presenting lesion and to record its progress. Indeed, elsewhere, they argue for minimising complexity and providing a ‘basis upon which observations can be made of an ulcer’s management and/or outcome either in one centre or several’, both of which probably warrant having a single system. So, would the S(AD) SAD classification meet these objectives and is it superior to previous attempts?
Macfarlane and Jeffcoate have adopted and adapted features of existing systems, particularly the San Antonio group’s proposals. They extend the concept of size to include area as well as depth. The need for this increased complexity needs testing but clinical experience suggests it will be validated. Their categories of infection have clinical ‘face validity’ but depart from their commendable ambition to use only terms that are unequivocal because they fail to define ‘cellulitis’ and ‘osteomyelitis’. Ischaemia is categorised using pulses, which have been validated as a clinical sign, and ‘signs suggestive of reduced perfusion’ which are neither defined nor validated.
The exclusion of temperature, the other validated clinical sign of ischaemia (McGee and Boyko, 1998), needs to be defended. The addition of neuropathy, its subclassification and definition of the terms seems appropriate and practical, but requires validation. The recent paper by Reiber et al (1999) is supportive. But this same paper, allied to everyday experience, might also question why deformity, oedema, and possibly callus have been omitted. The authors might argue that these are important only as descriptors but since they ‘are variously associated with anticipated outcome, and also determine broad strategies for management’ they should, perhaps, be seriously considered as candidates for inclusion notwithstanding the inevitable increase in complexity.
This is a valuable contribution to an important debate. Ultimately, however, a widely adopted classification must fulfil the authors’ correctly defined requirements of being ‘simple enough to be remembered and yet precise enough to be useful’. Simplicity can only really be evaluated in practice. Precision depends both on the consistent use of unequivocal terms between observers and centres and on the ability of those terms to describe adequately the factors that determine the natural history and treatment responsiveness of the ulcers. The time has come for more to follow the San Antonio lead by testing the practicability and validity of classifications and basing further refinements on experience derived from practice.
