J Wound Manag Res.  2021 Feb;17(1):9-18. 10.22467/jwmr.2020.01368.

Using DIRECT Wound Assessment to Predict Limb Salvage and Provide Prognosis of Diabetic Foot Ulcers

  • 1Department of Plastic and Reconstructive Surgery, Konkuk University Medical Center, Seoul, Korea


Many wound assessment systems including the Wagner classification and University of Texas (UT) grading system have been previously described. The authors of this study applied the DIRECT (Debridement of necrosis, Infection control, Revascularization, Exudate control, Chronicity, and Top surface) wound coding system for initial assessment of diabetic foot ulcers (DFUs) to predict limb salvage and prognosis.

From January 2016 to February 2020, a total of 169 first-time DFU patients were retrospectively evaluated using the DIRECT wound coding assessment system. DFUs were followed up for at least 6 months, and scores in each component of the coding system according to final limb status were statistically evaluated. The coding assessment’s ability to predict major amputation was compared to those of the Wagner classification and the UT grading system.

Subjects were divided into complete healing (n=80, 47.3%), not healed (n=71, 42%), and amputation (n=18, 10.7%) groups. The mean values of each component of DIRECT assessment for the complete healing/amputation groups were D 0.86/1.56 (P<0.001), I 0.46/0.89 (P=0.001), R 0.65/0.94 (P=0.014), E 1.15/1.56 (P=0.049), C 0.69/0.89 (P=0.086), T 0.53/0.72 (P=0.13) and the sum was 3.140/4.741 (P<0.001). The area under the receiver operating characteristic curve of the DIRECT, Wagner, and UT grading systems was 0.722, 0.603, and 0.663, respectively.

The DIRECT coding system shows a greater association with prediction of amputation or complete healing, compared with the Wagner and UT wound classification systems. This more accurate wound assessment system will be helpful in predicting prognosis and planning treatments.


Amputation; Diabetic foot; Limb salvage; Wound healing
Full Text Links
  • JWMR
export Copy
  • Twitter
  • Facebook
Similar articles
Copyright © 2022 by Korean Association of Medical Journal Editors. All rights reserved.     E-mail: koreamed@kamje.or.kr