A new classification for surgical offloading–An extension and expansion

Abstract Ulcers in diabetic foot are one of the most common focal pathology that affects more than 15% of the patients in their lifetime. Loss of sensation in foot and biomechanical factors play essential role in it’s causation. One of the most common modality of management of diabetic foot ulcer is offloading. The offloading can be mechanical or surgical. This article aims at providing a new descriptive classification for surgical offloading for the first time and it is an extension of Amit Jain’s SCC classification. Keywords: diabetic foot, offloading, amit jain, classification

Amit Kumar C Jain

Consultant and Head, Amit Jain’s Diabetic Foot and Wound Research Unit, Amit Jain’s Institute of Diabetic
Foot and Wound Care, Brindhavvan Areion Hospital, Bengaluru, Karnataka, India

Abstract

Ulcers in diabetic foot are one of the most common focal pathology that affects more than 15% of the patients in their lifetime. Loss of sensation in foot and biomechanical factors play essential role in it’s causation. One of the most common modality of management of diabetic foot ulcer is offloading. The offloading can be mechanical or surgical. This article aims at providing a new descriptive classification for surgical offloading for the first time and it is an extension of Amit Jain’s SCC classification.

Keywords: diabetic foot, offloading, amit jain, classification

Introduction

It is projected that in the year 2045, there will be around 700 million people in the world living with diabetes
mellitus [1]. One of the most challenging problems of diabetes mellitus is the diabetic foot ulcer [2]. In fact, the
diabetic foot problems today are one of the leading causes of disability that results in financial burden in
healthcare system [3].
It is known that diabetic foot ulcer results in almost 85% of non-traumatic lower limb amputation [4]. The global
prevalence of ulcers in diabetic foot is around 6.3% and recurrence of foot ulcer is reported to be very high [2].
Offloading of diabetic foot ulcers is one of the most important treatment modality in management of these ulcers
[5]. There are numerous offloading methods that are available for healing the diabetic foot ulcers [6]. The
offloading could be external/mechanical (non-surgical) or surgical offloading [7].
Amit Jain’s ‘SCC classification’ is a new classification that was developed first for diabetic foot ulcer and later it
was extended and applied to Charcot foot, foot amputations, therapeutic footwear, callus, etc [8, 9]. All these
concepts belong to Amit Jain’s principle and practice of diabetic foot [10].

Amit Jain’s Classification for Surgical Offloading

The primary author proposes a new classification for surgical offloading, which is an expansion and extension of
his “SCC” classification in diabetic foot [9].
According to this new classification, surgical offloading can also be divided into 3 general classes (Table 1)
namely simple, complex and complicated surgical offloading. It can also be applied to non-diabetics.
The classification is based not just on expertise of performance of the procedure but also understanding the
pathology, mechanobiology/biomechanics and application of the procedure/case selection.
This is a simple, easy to remember, practical, descriptive, open classification wherein any new surgical
offloading developed in future can be placed in any one of the classes.

Class of surgical offloading	Description	Examples
Class 1 surgical offloading	Simple	Tenotomies, Tendoachillies lengthening, Gastronemius recession, etc
Class 2 surgical offloading	Complex	Osteotomies, Arthroplasty, Resection, etc
Class 3 surgical offloading	Complicated	Tendon transfers

Further, we can have triangle of surgical offloading in pattern similar to triangle of amputation and triangle of
offloading (non –surgical) wherein the 3 available options can be placed at the 3 corners of the triangle [10, 11].
This can also serve as a good teaching tool (Figure 1).

Conclusion

Distinct new concepts are being developed in diabetic foot and many of them have made the understanding of diabetic foot much easier. The Amit Jain’s principle and practice is one such new concept. The Amit Jain’s classification for surgical offloading is another new classification that divides surgical offloading into 3 classes which is very easy to remember.

References

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AUTHORS’ CONTRIBUTIONS

Dr Amit Kumar- Data collection, Conceptualization, design and preparation of manuscript. Dr
Viswanath – critical revision and data collection.