article
Understanding diabetic foot complications:
in praise of Amit Jain’s classification
Huda Al Dhubaib
Diabetic foot complications are common in developing countries. It is important to
be able to classify a foot complication in a simple and easily repeatable way in order
to be able to understand and treat the foot. Amit Jain’s new three-tier classification
system for diabetic foot complications is proving to be both popular and effective.
Its use is beginning to show patterns of prevalence, with type 1 complications being
common in developing countries. The author considers the classification to be a good
training tool for healthcare professionals across disciplines and countries and suggests
that it will improve communication about diabetic foot care.
T
Author
Dr Huda Al Dhubaib is General
Surgeon and Diabetic Foot and
Wound Care Specialist, IIWCC
and GDFWG Executive
Member, Kuwait
10
he number of people with diabetes worldwide
was 131 million in 2000 and it is likely to
increase to 366 million by 2030[1]. Diabetic
foot is considered to be one of the most serious
complications of diabetes. It is estimated that about
15% of people with diabetes will develop foot ulcers
during their lifetime[2,3] and ulceration is considered
to be the most common precursor of amputation.
For years, various classifications have been used
to describe ulcers in the diabetic foot[1,4] such as
Wagner’s classification, University of Texas (UT),and
Sepsis (Area and Depth), Sepsis Arteriopathy
and Denervation (S[AD] SAD)[5,6]. Knowing the
classification in diabetic foot is considered essential
for multiple reasons. First and foremost is that
classification helps us to understand the disease
better. It also provides a common language that can
be used among health professionals[7]. It is important
that any kind of classification should be easy to
apply[6], be easy to reproduce and provide adequate
information about the ulcer.
Recently, Amit Jain’s classification for diabetic
foot complications has increased in popularity.
This classification was proposed to improve and
standardise practice when caring for the diabetic foot
around the world[8].
Amit Jain’s classification is one of the simplest
classifications in the field of diabetic foot.
Furthermore, it is the only classification to date
that includes all the common complications seen
in the diabetic foot[8,9]. This classification is easy to
understand and can be used as an effective teaching
tool to disseminate the knowledge about diabetic
foot complications around the world, especially
in developing and underdeveloped counties where
diabetic foot is often neglected[5,9].
Amit Jain’s classification divides diabetic foot
complications into three simple types[5,8,9] [Table 1].
• Type 1 diabetic foot complications are infections
of the foot and include wet gangrene [Figure 1],
cellulitis, abscess and necrotising fasciitis.
• Type 2 diabetic foot complications are not
infections and include Charcot foot [Figure 2],
trophic ulcers, peripheral arterial disease and toe
deformities.
• Type 3 diabetic foot complications are mixed
and include type 1 and type 2 diabetic foot
complications together [Figure 3]. Examples
include non-healing ulcers with osteomyelitis and
infected ulcers with ischaemia.
Amit Jain’s classification for diabetic foot
complications has changed our approach towards
this condition. In recent studies on the use of this
classification[10,11] in a developing country, it has
been found that the most common complications
seen in patients who need hospital care for diabetic
foot are of type 1, ranging from 86–91% of all
diabetic foot complications. In the study by Jain et
al[10], diabetic foot patients accounted for 6.95% of
all surgeries in one surgical unit. Of these patients,
diabetic foot abscesses were the most common type
1 complication seen, whereas in Kalaivani’s study[11],
wet gangrene was the most common type 1 lesion
encountered. In fact, in these two studies, it was seen
The Diabetic Foot Journal Middle East Vol 1 No 1 2015
understanding diabetic foot complications: in praise of using
Figure 1. Wet gangrene. Amit Jain’s type 1
diabetic foot complication.
Figure 2. Ulcer in a Charcot foot. Amit Jain’s type
2 diabetic foot complication.
that the most common reason for major amputation
in diabetic foot is Amit Jain’s type 1 diabetic foot
complications and not diabetic foot ulcers.
According to these two studies, Amit Jain’s type
1 diabetic foot complications may be the most
common reason for hospitalisation for people
with diabetic foot complications in developing
countries. It should be stressed that diabetic foot
problems differ in different regions and what is
seen in the West may not be the case in the eastern
part of the world.
Amit Jain’s classification for diabetic foot
complications has simplified our understanding
of diabetic foot and it invariably makes us look
beyond ulcers, to include abscesses, cellulitis, wet
gangrene, Charcot foot, necrotising fasciitis and
toe deformities, which are also quite common in
clinical practice. Indeed, it forms the most effective
teaching tool to communicate about diabetic foot
between different specialists. Since it incorporates
all the common foot complications seen in clinical
practice and is very simple to understand, it forms
an ideal classification system for disseminating the
knowledge of diabetic foot across countries and
disciplines to healthcare professionals interested in
caring for people with diabetes.
Another beneficial aspect of this classification
is the fact that it also incorporates conditions like
necrotising fasciitis and Charcot foot[9] which
are now increasingly seen in developed as well as
developing countries[8,10,11]. A few more studies on
this classification from different regions would add
to our knowledge about the prevalence and type of
foot problems in different areas. Its widening use will
The Diabetic Foot Journal Middle East Vol 1 No 1 2015
Amit Jain’s classification
Figure 3. Dry gangrene of great toe with abscess
underneath and ascending cellulitis in a patient
with peripheral vascular disease. This is Amit Jain’s
type 3 diabetic foot complication.
spread understanding of diabetic foot complications
and hopefully improve care for patients.
n
1. Clayton W, Elasy TA. A review of the pathophysiology,
classification and treatment of foot ulcers in diabetic patients. Clin
Diabetes 2009; 27(2): 52–8
2. Ahmed AA, Elsharief E, Alsharief A. The diabetic foot in the Arab
world. J Diab Foot Comp 2011; 3(3): 55–61
3.Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in
patients with diabetes. JAMA 2005; 293: 217–28
4. Oyibo SO, Jude EB, Tarawney I et al. A comparison of two diabetic
foot ulcer classification systems. Diabetes Care 2001; 24: 84–8
5. Jain AKC, Joshi S. Diabetic foot classifications: Review of literature.
Med Sci 2013; 2(3): 715–21
6. Parisi MCR, Wittmann DEZ, Pavin EJ et al. Comparison of three
systems of classifications in predicting the outcome of diabetic
foot ulcer in a Brazilian population. Eur J Endocrinol 2008; 159:
417–22
7. Satterfield K. A guide to understanding the various wound
classification systems. Podiatry Today 2006; 19(66): 20
8. Kalaivani V, Vijayakumar HM. Diabetic foot in India- Reviewing
the epidemiology and Amit Jain’s classifications. Sch Acad J Biosci
2013; 1(6): 305–6
9. Jain AKC. A new classification of diabetic foot complication: a
simple and effective teaching tool. J Diab Foot Comp 2012; 4(1):
1–5
10. Jain AKC, Viswanath S. Distribution and analysis of diabetic foot.
OA Case Reports 2013; 2(12): 117
11. Kalaivani V. Evaluation of diabetic foot complications according to
Amit Jain’s classification. J Clin Diagn Res 2014; 8(12): 7–9
Table 1. Amit Jain’s Classification of Diabetic Foot Complications
No
Type of diabetic foot complications Lesions
1
Type 1 (caused by infection)
Cellulitis, wet gangrene, abscess, necrotizing fasciitis,
osteomyelitis etc
2
Type 2 (not caused by infection)
Non-healing ulcers, peripheral arterial disease, hammer
toes, entrapment neuropathies, diabetic neuroosteoarthropathy etc
3
Type 3 (mixed)
Example: non-healing ulcer with osteomyelitis
11