SLR - April 2021 - Shazeb Rizvi

Independent Observational Analysis of Ulcer Outcomes for SINBAD and University of Texas Ulcer Scoring Systems

Reference: Graham P. Leese, Enrique Soto-Pedre, and Christopher Schofield. Independent Observational Analysis of Ulcer Outcomes for SINBAD and University of Texas Ulcer Scoring Systems. Diabetes Care. February 2021. doi: 10.2337/dc20-1817

Level of Evidence: Level III- Retrospective Series

Scientific Literature Review

Reviewed By: Shazeb Rizvi, DPM
Residency Program: Carl T. Hayden VA Medical Center – Phoenix, AZ

Podiatric Relevance: Diabetic foot ulcers are one of the most common conditions that a podiatrist will encounter in training and even throughout their careers. It is important to have a systematic approach with multiple tools to properly assess the condition and determine if conservative or more aggressive treatment is warranted. Although many classifications systems such as Wagner, SINBAD, UT are used and cited in the literature, it is not entirely clear if one is better than the other in predicting outcomes. The aim of this study was to compare University of Texas and SINBAD scoring systems in predicting outcome of ulcers. 

Methods: A retrospective cohort study was done comparing the effectiveness of UT and SINBAD grading systems in predicting the outcome of ulcers. Data from 1068 patients and 1645 ulcers was reviewed for Diabetic patients referred to Ninewells Hospital outpatient diabetic foot clinic between 2006-2018. All ulcers were graded based on both scales and then tracked for outcomes. Critical data for ulcers was collected such as vascular status, presence of infection, location, and depth. The following were the possible outcomes: 1) Healed without amputation 2) Healed after minor amputation (surgery distal to ankle) 3) Healed after major amputation (proximal to ankle) 4) Death 5) Chronic/non healing wound.  

Results: One thousand six hundred forty-five ulcers were tracked in 1068 patients. One thousand one hundred eight ulcers healed (67 percent), in 174 cases the patient died before healing occurred, 177 underwent minor amputation, 144 patients underwent a major amputation and 42 had chronic ulcers or were lost to follow up. Regarding the SINBAD system, 100 percent healed in category 0 and 49 percent in category six, moreover, a step wise decreased was noted in healing rate as the category progressed. A similar phenomenon was also noted with the UT system. With the use of ANOVA, Chi squared test, and C-statistic it was established that both classifications systems had similar prognostic ability in predicting foot ulcer outcomes. 

Conclusions: The authors of this study concluded that both the UT and SINBAD classifications have similar effectiveness in predicting the outcome of diabetic foot ulcers. This conclusion is consistent with the literature, which reports that both systems can be used appropriately to assess ulcers and guide treatments. Although both systems have differences, they essentially revolve around vital components of wound healing: vascular/infection status, and spatial dimensions. Although, larger studies are needed to definitively anoint one over the other, it is not surprising that they yield similar results. Overall, it is crucial that clinicians use these as adjunctive tools rather than ignoring clinical judgment based on compliance, social history, medical comorbidities and related factors.  

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