A study of risk factors
amputation in diabetic foot
predicting
Introduction
Abstract
Introduction: Prevalence of Diabetes is increasing
rapidly worldwide. Foot complications are a major
cause of hospital admission for diabetes and they
cause a disproportionately high number of hospital
days because of repeated surgical procedures.
Amputations are one of the most disabling
complication of diabetes.
Material and methods:This is prospective study of
50 patients with diabetic foot lesions presented in
surgical OPD of our hospital. In all patients, a
detailed history and clinical examination was
carried out. All foot lesions were classified as per
Wagner’s grading system. Various risk factors were
evaluated that led to amputation.
Results: Of the 50 patients, 26(52%) patients had
peripheral vascular disease, 18 (36%) patients had
neuropathy of the foot whereas foot ulcers were
found in 37 (74%) patients. There were 24 (48%)
patients who had undergone amputations.
Conclusion: Male gender, trauma, poor glycemic
control were associated with higher amputation
rate. Peripheral neuropathy, peripheral vascular
disease, infection, foot deformity and prior ulcer
were other factors associated with an increased risk
of amputation. Patients presented in the late stage of
disease because of illiteracy, ignorance and poor
knowledge. Good diabetic control, improving
nutritional status, meticulous debridement, use of
broad-spectrum antibiotics and early control of
infection were found to be the main factors in
reducing the major amputations.
The prevalence of diabetes for all age-groups
worldwide is estimated to be 2.8% in 2000 and
which is likely to rise to 4.4% by the year 2030[1].
The total number of persons affected by diabetes is
also projected to rise from 171 million in 2000 to
366 million by 2030. Approximately 20% of all
diabetics who enter the hospital are admitted for the
foot problems [2]. The most common components
in the causal pathway leading to limb loss include
peripheral neuropathy, ulceration, infection, and
peripheral vascular disease. Annual incidence of
foot ulcers is 1% to 4% and prevalence 5% to 10%
in patients with diabetes [3]. Peripheral vascular
disease is present in 30% and 7% of all hospitalized
patients require surgery. Amputations are
considered as a very debilitating complication of
diabetes. Both the social impact of such
amputations for the patients and the financial
implications for the health care are grave [4].The
purpose of this study is to analyze the risk factors
Key words Diabetic foot, Risk factors, Lower
limb amputations
SrinivasVeerraju.G, (Department of Surgery)
Renu.V.Sulakhe (Dept. of Community Medicine)
Konaseema Institute of Medical Sciences,
Amalapuram
Andhra Pradesh,
India, 533201
for lower limb amputations in diabetic patients.
Material and Methods
Fifty patients of diabetes with foot lesion admitted
to our hospital were studied. In all patients, a
detailed history was taken with special attention to
age sex duration and severity of diabetes, nature
and regularity of anti diabetic treatment. Detailed
and meticulous clinical examination included
examination for peripheral pulses, trophic changes,
features of neuropathy like loss of ankle jerk,
reduced vibration perception and sensory loss. I.n
all 50 patients, the diagnosis of infection was made
on the basis of frank pus or two or more of
thefollowing local signs viz,a.Pain, erythema,
warmth lymphangitis, edema, Loss of function. Pus
was sent for culture and sensitivity before starting
initial debridement,Bloodsugar X-ray foot was done
in all cases to see bony involvement, soft tissue
infection, evidence of gas and any vessel wall
calcification. Fundoscopy was done in all cases to
detect retinopathy.Inout country
All patients were classified as per Wagner’s grading
system by,
1. Wound debridement / drainage followed by
wound care with or with out SSG
2. Dressing with or with out split thickness
skin grafting (SSG)
3. Local amputation – Ray, Toe, Fore
footabove knee.
4. Lower extremity amputation below or above
knee
Antibiotic protocol changes as per culture and
sensitivity, subsequently Diabetic control and
diabetic drugs.
Results
There were 38 male and 12 female patients with sex
ratio of 3.2:1. The average age was 56.2 years with
a range of 28 to 80 yrs.A total of 70% of patients in
the age group above 51 yrs and 48% in the age
group of 51-60yrs. 34 (68%) patients were known
diabetics at the time of admission. The average
duration of diabetes was 7.04 yrs and majority of
the patients had diabetes of more than 5 yrs. sixteen
(32%) patients were detected as diabetic for the first
time at the time of admission. Foot ulcers were
present in 37 (74%) patients. Infection was present
in all the cases. Staphylococcus aureus was the
commonest organism grown on culture although
most of the cultures had multiple
organisms. A total of 26(52%) patients had loss of
one or more peripheral pulses. Eighteen (69%) out
of 26 patients who had peripheral vascular disease
required
amputation. Peripheral neuropathy, either somatic
or autonomic was present in 18 (36%) patients, 10
(55.5%) of these patients underwent amputation.
Grading of the foot lesions was done by Wagner's
staging. The number of foot ulcers and lower limb
amputations in each grade of the Wagner’s method
are shown in Table 2. Of all patients, 24 (48%) had
lower limb amputations as a result of foot ulcers
and gangrene, These included minor amputations
(45.8% of total amputations), below knee
amputations (37.5% of total), and above knee
(16.6% of total).Splitthickness skin grafting was
done.
DISCUSION
Foot lesions are amongst the commonest indication
for hospitalization amongst diabetic patients. in
diabetics and there is fifteen fold risk In the study
by Armstrong et al [5], sixty to eighty percent of the
non traumatic amputations are performed
in
diabetic tumors and there is fifteen fold risk of
major amputations than non diabetics[6]. And there
is fifteen fold risk of Lower extremity amputations
are preventable to an extent of 45-85% if
aggressive, prompt and correct line of treatment is
followed[7]. Prevalence of diabetes is more in
patients over the age of 50 years. Of the patients
with foot lesions 76% were men with a definite
male preponderance similar to other studies.
Majority of patients gave history of trauma as
predisposing factor being positive in 38 cases
(76%). It was found to be the most common
precipitating factor which may be because of
walking bare foot, shoe bite and loss of sensation
due
to
neuropathy.
In the series by Stone et al [8]the duration
from the time of diagnosis to the first event of
amputation. varied in different studies from
14years[5] to 8 years[9]. In our study it was found
to be 7.3 years. Uncontrolled diabetes and habit of
walking bare foot could be contributory and
undetected factors towards need for early
amputation.
Infection which was present invariably in all
patients was a prime cause of lower extremity
morbidity and frequently leads to wet gangrene and
subsequent amputation. The data collected suggests
that,
patients
with
infections,
ischemia,
osteomyelitis and peripheral neuropathy were at a
higher risk for lower- extremity amputation. In the
present study, a total of 26(52%) patients have loss
of one or more peripheral pulses and 18 (69%) of
these patients had to be subjected to various types
of amputations. In the study by Moulik et al [3],
59% of the patients with peripheral vascular disease
had amputations. Tentouloris and associates [10]
had reported ischemia as a cause of amputation in
69.6% of the diabetic patients. Peripheral vascular
disease is the only single disease process that can,
by itself, necessitate an amputation, and that the
prevalence of amputation increases considerably
more in the presence of both ischemia and infection
[11].
Diabetic neuropathy is one of the most
debilitating and most common manifestation and
usually develops
after many years of
hyperglycemia. In present series, 18 (36%) patients
had neuropathy of the foot and 10(56%) of these
patients had amputations. Moulik et al [3] had
reported the incidence of peripheral neuropathy in
as much as 61% of diabetic patients. In a study by
Boyko and associates [12]. 60% of the patients who
developed diabetic foot ulcer had neuropathy.In
neuropathic foot, there is weakness of the small
muscles leading to the foot deformity resulting in
formation of new pressure points, callosities &
ultimately ulcer. In case of sensory neuropathy,
there will be loss of sensation, which predispose to
the trauma and ulcer formation.In autonomic
neuropathy, skin becomes dry as result of loss of
sweating. There will be cracking of skin and
impaired defense against infection. In a
retrospective case-control study, Mayfield et al.
[13] suggested that the risk of lower- extremity
amputation increases with the presence of sensory
neuropathy and peripheral vascular disease which
was found to be similar in our study
Table 1- Risk factors in patients with diabetic foot
lesions and patients with amputation
Patients
with
Patients who
foot
required
lesions
lower limb
amputation
Total number of 50
24
patients
Men/women
Age
3.2/1
(years) 56.2
5/1
55.2
Mean age
Duration
of 7.04
7.6
diabetes (years)
Uncontrolled
29 (58%)
15 (51.7%)
Controlled
5 (10%)
0
Detected
the
time
at 16 (32%)
9 (56.25%)
of
admission
Trauma
38 (76%)
22 (91.6%)
Bare foot
20(40%)
12 (50%)
Table 2 - Wagner’s stage and amputations:
Types of lesions
Gangrene
10(20%)
10 (100%)
Cellulitis
30 (60%)
14 (58.3%)
Foot ulcer
37 (74%)
12 (50%)
our study vs Ovibo etal
X-ray foot
Wagner’s
Foot ulcers
Amputations
Stage
(our study)
(%)
n=50
Osteomyelitis
9 (18%)
9 (100%)
Charcots joint
5 (10%)
5 (100%)
I
6
0
Subcutaneous
2 (4%)
2 (100%)
II
13
1 (8%)
III
23
16(69.5%)
IV
4
3(75%)
V
4
4(100%)
gas
Absent
26 (52%)
18 (69%)
peripheral pulses
Neuropathy
18(36%)
10 (55.5%)
Neuropathy
+ 12(24%)
10(83.3%)
PVD
peripheral vascular disease and infection were
significantly associated with an increased
prevalence of lower-extremity amputation [14].
Additionally, infection, gangrene, and ischemia
were the most common component for lowerextremity amputation in another study. In our study
as well common risk factors were illiteracy,
ignorance poor knowledge, walking with bare foot,
Male sex, trauma, poor glycemic control, Peripheral
neuropathy, peripheral vascular disease, infection,
foot deformity and prior ulcer were equally
associated with an increased risk of amputation.
were associated with higher amputation rate
Wagners wound classification system cannot be
used as an effective tool to predict patients need for
Amputation.Higher the staging, Higher the grade
and
the
no.of
amputations
,was
not
increased[14]was not observed in our study, in our
study where in diabetic patients who under go
amputation belonged to stage stage I
In the past, a longer hospitalization and a higher
prevalence of perioperative complications was
reported for diabetic amputees, [15]. The mean
hospital stay was 44 days in our diabetic patients
which was comparable with recent data from
Netherlands which was 42 days [16], less than the
mean in the Australia which was 24.3 days [17],
and in U.S. 15.9 days. It is of note that in
multicenter studies, large regional variations in
hospital stay have been reported, which probably
reflects variations in clinical practice and access to
health care system.
Wagner's Classification system.
Grade'0':
There is no open lesion but the break
down with high pressure deformities
and sensory neuropathy
Grade '1':
The lesion is superficial through the
skin only with or without underlying
bony prominences.
Grade '2':
Conclusions
The ulcer is deep penetrating to tendon, joint or
bone.
Grade'3':
There is deep abscess formation with
plantar space and tendon sheath
Grade '4':
gangrene is present locally in the
toes or more
diffuse
over
forefoot.
Grade '5':
gangrene has spread and involves the
hind foot resulting in need for higher
amputation. infection, osteomyelitis
or septic arthritis.
To conclude, diabetic foot lesions commonly result
from a combination of neuropathy, vasculopathy
and infection in lower extremity. Patients presented
in the late stage of disease may be because of and
illiteracy, ignorance poor knowledge. Male sex,
trauma, poor glycemic control were associated with
higher amputation rate. Peripheral neuropathy,
peripheral vascular disease, infection, foot
deformity and prior ulcer were equally associated
with an increased risk of amputation. Good diabetic
control, improving nutritional status, meticulous
debridement and use of broad-spectrum antibiotics
and early control of infection are the main steps in
reducing the major amputations. Hence, raising
awareness about the lethal complications of diabetic
foot and educating the patient regarding the foot
hygiene, use of well fitted closed foot wear,
Therapeutic footwear for diabetic foot patients aims
to reduce the risk of ulceration by relieving
mechanical pressure on the foot[18].early access to
healthcare system and satisfactory rehabilitation
might help in reducing the risk of amputations.
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