Clinical Performance of the IWGDF Risk Stratification System for Diabetic Foot Ulceration: A Gender-Disaggregated Study of 713 Patients

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Abstract
Introduction Diabetic foot ulceration (DFU) is a major complication of diabetes and is a leading cause of lower-extremity amputation. This study evaluated the cross-sectional discriminative performance of the International Working Group on the Diabetic Foot (IWGDF) risk classification for prevalent active DFU, described gender-disaggregated ulcer prevalence, and identified factors independently associated with moderate/high IWGDF risk in a specialist diabetes center. Methods In this retrospective cross-sectional study, 713 adults with diabetes mellitus who attended the diabetic foot service of a university diabetes center were classified according to the IWGDF risk system. The prevalence of active DFU was compared across risk categories using the Cochran–Armitage trend test. Multivariable logistic regression was used to identify factors associated with moderate/high IWGDF risk and active DFU. Results Active DFU was present in 21 patients (2.9%), with no significant difference between men (3.8%) and women (2.1%). Overall, 17.3% of the patients were classified as having moderate or high risk. Ulcer prevalence increased progressively across the IWGDF categories, from 0.0% in the very-low-risk group to 38.5% in the high-risk group (p < 0.001). The IWGDF classification showed excellent cross-sectional discrimination for prevalent active DFU (c-statistic 0.938), with 90.5% sensitivity and 99.7% negative predictive value at the moderate/high-risk threshold. Older age and higher glycated hemoglobin (HbA1c) levels were independently associated with moderate/high IWGDF risk, whereas gender was not. Conclusion The IWGDF classification showed excellent cross-sectional discrimination for prevalent active DFU. Older age and poorer glycemic control, but not gender, were independently associated with moderate/high IWGDF risk. These findings support routine IWGDF-guided risk stratification in specialist diabetes care, although prospective studies are required to establish its performance in predicting future ulceration.

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