Risk factors for diabetes amputation

NewsBot · Jun 13, 2022

Validation of a Simple Scoring System predicting Amputation in Patients with Diabetic Foot
S. Shaikh et al
Source

Background: Diabetic foot disease (DFD) is one of the most serious complications of diabetes with high mortality and reduction in quality of life. Diabetics are 10-30 times more prone to have lower limb amputation compared to non-diabetics and nearly 70% amputation occur in diabetics. Lower extremity amputation (LEA) is always preceded by poorly healing foot ulceration in 85% cases. There is wide variability in prevalence of lower extremity amputation in patients with diabetic foot ulcer (DFU) ranging from 0.86% in USA to 12-48% in Pakistan. Many risk factors predicting amputation has been cited in literature but several inconsistencies in results between these studies has been observed. If the risk factors are assessed, scored and then aggregated to a final sum so that a large overall score correlates with higher risk of amputation.
Method:
2.1. Study Area and Period. This study was conducted in Liaquat Medical University Hospital from 06-08-2017 to 07 – 09-2019.
2.2. Study Design. Cross-Sectional Descriptive.
2.3. Inclusion Criteria: This study included 113 consecutive patients > 18 years of age of either sex with DFU attending outpatient department or admitted through emergency department.
2.4. Exclusion Criteria: Foot with peripheral artery disease not associated with diabetes mellitus, traumatic foot ulcers, patients with psychiatric illness, gestational diabetes.
Results: Among 114 diabetic patients 90 (78.9 %) were male and 24 (21.1%) female. Sensory neuropathy of varying degrees was present in 107 (93.8%) patients. Amputation was performed in 36 (31.6%) whereas 78 (68.4%) patients improved. A strong relationship was found between rate of amputation with score system as higher rate of amputation was found in patients with score > 16. The other factors, age duration of diabetes and HBA1c, depth of ulcer, ABI and infection whereas poor relation with sex.
Discussion: According to abhijet et.al 68.1% had sensory neuropathy who had amputation.
Uysal S, et al in prospective study comprising 379 patients with DFU observed amputation in 126 (33.2%) cases.
Alder Al et al in their review consisting of 14 studies comprising 94640 patients found a strong association between hyperglycemia and for each one percentage increment in HBA1c risk of amputation increases by 1.3 times.
Oyibo et al in their study observed a significant correlation between Wagner grade and risk of amputation. Armstrong et al observed a 11 fold increment in major amputation in Wagner grade 3 to 5 compared to grade 1 and 2.
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NewsBot · Aug 14, 2022

Amputation of the Foot or Toe
Jorge Berlanga Acosta
Clin Res Foot Ankle 2022, 10:7

The aim of this study is to determine the predictors for reulceration, reamputation and mortality in patients with
diabetes following toe amputation, and the impact of activities of daily living on clinical outcomes. This prospective
cohort study included 245 patients who had undergone toe amputation (202 healing and 43 non-healing) and was
followed for a 5-year period. Data regarding new foot ulceration, reamputation and mortality were recorded, and the
patients' activities of daily living were evaluated. The rate of wound healing was 82·4%. The rate of follow-up in the
healed group was 91·6%. In years 1, 3 and 5, the cumulative incidence of patients who developed a new foot ulcer
was 27·3%, 57·2% and 76·4%, respectively, leading to reamputation in 12·5%, 22·3% and 47·1%, respectively. The
cumulative mortality was 5·8%, 15·1% and 32·7% at 1, 3 and 5years, respectively. Multivariate analysis showed
that GHbA1c>9% (75mmol/mol) was identified as an independent predictor of impaired wound healing, reulceration
and reamputation. An age of >70years was identified as an independent predictor of reamputation, mortality and
impairment of activities of daily living. Despite a satisfactory initial healing rate after the first toe amputation, with the
extension course after the toe amputation, the long-term outcomes are not optimistic. In developing countries like
China, taking measures to prevent reulceration and reamputation is very important for patients with diabetic foot minor
amputations, especially following toe amputation.
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NewsBot · Aug 30, 2022

Predicting Amputation in Patients With Diabetic Foot Ulcers: A Systematic Review
Zahraa Mansoor, Ali Modaweb
Cureus. 2022 Jul 25;14(7):e27245

Foot ulcers are a leading cause of morbidity in diabetics. One of the known complications of diabetic foot ulcers is lower limb amputation which makes it a major socioeconomic problem. Currently, there's a lack of knowledge on the predictors of amputations in diabetics with foot ulcers. We performed a systematic review of studies that identified risk factors of amputation in patients with diabetic foot ulcers. This systematic review aims to identify the predictors of amputation in order to optimize the management strategy and care plan. Medline database was searched and inclusion criteria were implemented for the selection of studies. The risk factors extracted were part of four categories: (i) history and physical examination, (ii) ulcer characteristics, (iii) lab results, and (iv) co-morbidities. The data extracted were in the form of odds ratios, 95% confidence intervals, and predictive values. The mean values with standard deviations of the included risk factors were recorded, and the incidence of risk factors among the amputation groups was identified or calculated when the data were sufficient. Seven articles were selected reporting on 3481 patients. This review identified peripheral arterial disease, neuropathy, high Wagner's grade, osteomyelitis, postprandial glucose level, white cell count, c-reactive protein, erythrocyte sedimentation rate, low hemoglobin, and albumin as the most significant predictors of amputation.
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NewsBot · Sep 5, 2022

Prevalence and determinants of lower extremity amputations among type I and type II diabetic patients: A multicenter-based study
Lawrence Sena Tuglo
Int Wound J. 2022 Aug 23

The incidence of diabetes-related lower-extremity complications is increasing globally, yet the condition in developing countries, particularly those in sub-Saharan Africa, is unclear. This study determined the prevalence and determinants of lower extremity amputations among type I and type II diabetic patients at health facilities in the Volta Region, Ghana. This was a multicenter-based study involving 473 diabetic patients. Sociodemographic, lifestyle, medical, biochemical, and anthropometric data were obtained systematically with a pretested structured questionnaire. The prevalence rate of lower extremity amputations (LEAs) was 1.9%. LEAs were linked to the male gender (unadjusted odds ratio [UOR] = 5.86; 95% confidence interval [CI] = 1.44-23.82; P = 0.013), smokers (UOR = 10.12; 95% CI = 2.63-38.91; P = .001), type I diabetic patients (UOR = 4.74; 95% CI = 1.24-18.10; P = .023), family history of diabetes mellitus (UOR = 9.18; 95% CI = 2.25-37.46; P = .002), diabetic foot ulcers (adjusted odds ratio [AOR] = 8.62; 95% CI = 1.58-47.62; P = .013) and obesity (AOR = 6.20; 95% CI = 1.00-38.04; P = .049). This study showed a relatively low prevalence rate compared to previous studies within Ghana. However, it is a major concern in public health that needs to be addressed since diabetes-related LEAs are connected to global major morbidity and mortality.
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NewsBot · Oct 18, 2022

Analysis of risk factors for amputation in patients with diabetic foot ulcers:
a cohort study from a tertiary center
Denizhan Demirkol et al
Acta Orthop Traumatol Turc 2022

Objective: This study aimed to analyze risk factors for amputation (overall, minor and major) in patients with diabetic foot ulcers (DFUs).
Methods: 407 patients with DFUs (286 male, 121 female; mean age = 60, age range = 32-92) who were managed in a tertiary care centre
from 2009 to 2019 were retrospectively identified and included in the study. DFUs were categorized based on the Meggit-Wagner, PEDIS,
S(AD)SAD, and University of Texas (UT) classification systems. To identify amputation risk-related factors, results of patients with DFUs
who underwent amputations (minor or major) were compared to those who received other adjunctive treatments using Chi-Square, oneway analysis of variance (ANOVA) and Spearman correlation analysis.
Results: The mean C-reactive protein (CRP) and White Blood Cell (WBC) values were significantly higher in patients with major or minor
amputation than in those without amputation. The mean Neutrophil (PNL), Platelets (PLT), wound width, creatinine and sedimentation
(ESR) values were significantly higher in patients with major amputation compared to other groups of patients. Elevated levels of Highdensity lipoprotein (HDL), Hemoglobin (HGB) and albumin were determined to be protective factors against the risk of amputation.
Spearman correlation analysis revealed a positive-sided, strong-levelled, significant relation between Wagner grades and amputation
status of patients.
Conclusion: This study has identified specific factors for major and minor amputation risk of patients with DFUs. Especially infection
markers such as CRP, WBC, ESR and PNL were higher in the amputation group. Most importantly, Meggit Wagner, one of the four different classification systems used in the DFUs, was determined to be highly associated with patients’ amputation risk.
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NewsBot · Nov 24, 2022

Clinical characteristics and risk factors of lower extremity amputation in patients with diabetic foot
Linru Wang et al
Pak J Med Sci. 2022 Nov-Dec;38(8):2253-2258

Objectives: To investigate the risk factors of lower limb amputation, and help physicians better understand the clinical characteristics of patients with diabetic foot, and make treatment strategies for these patients correctly.

Methods: In this study, the inpatients with diabetic foot treated in our hospital form January 2013 to February 2021 were reviewed retrospectively. The patients were divided into amputation and conservative treatment groups. The variables of the patients, consisting of age, gender, smoking history, alcohol use, diabetes and ulcer duration, ulcer size, Wagner classification, ankle brachial index, previous amputation history, laboratory data, and medical comorbidities including hypertension, coronary artery disease, peripheral arterial disease, chronic renal insufficiency, retinopathy, and sequelae of cerebral infarction were selected for analysis to determine the risk factors of lower limb amputation.

Results: In this study, a total of 856 patients with diabetic foot were enrolled, in which 487 patients received amputation surgeries, and the amputation rate was 56.9%. There were significant differences between the two groups in gender (p=0.014), smoking history (p=0.011), ulcer duration (p=0.023), ulcer size (p=0.000), Wagner classification (p=0.000), ABI (p=0.031), peripheral arterial disease (p=0.000), HDL-C (p=0.013), osteomyelitis (p=0.000), and fibrinogen (p=0.001). A stepwise multiple logistic regression analysis revealed that male gender (p=0.003), larger ulcer size (p=0.001), higher Wagner classification grades (p=0.002), higher rate of peripheral arterial disease (p=0.02) and osteomyelitis (p=0.0001), and increased fibrinogen level (p=0.004) were independent risk factors of lower limb amputation in patients with diabetic foot.

Conclusion: The diabetic foot patients with male sex, larger ulcer size, higher grade of Wagner classification, peripheral arterial disease or higher fibrinogen level may face higher risk of lower limb amputation.
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NewsBot · Jan 18, 2023

Status and influencing factors of lower limb amputation in patients with diabetic foot ulcer
Xiaofeng Peng et al
Int Wound J. 2023 Jan 18

To investigate the influencing factors of lower limb amputation in patients with diabetic foot ulcers. Patients with diabetic foot ulcers who were hospitalised in a tertiary general hospital in Guizhou Province from January 2019 to March 2022 were retrospectively collected. Sociological information of the general population, comorbidities, laboratory-related indicators, and information on the specialty situation, using univariate analysis and multifactor analysis, compared the influencing factors of amputation and non-amputee patients. A total of 205 patients with diabetic foot and 69 ampute patients (33.7%) were enrolled. The univariate analysis found that the decrease in HDL cholesterol levels was associated with the occurrence of lower extremity amputation, and logistic stepwise regression analysis showed that HDL-C was inversely correlated with the amputation rate of patients with diabetic foot ulcers, and the risk of amputation at low levels of HDL-C was 2.452 times higher than that of high-level HDL-C (95% CI: 1.105-5.846). Decreased HDL cholesterol levels are an independent predictor of amputation in patients with diabetic foot ulcers.
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NewsBot · Jan 30, 2023

Does a shorter residual first metatarsal length after first ray amputation in diabetic patients leads to poorer outcomes - a risk factor study
Choon ChietHONGSouraSAHAChristopher JonPEARCE
Foot and Ankle Surgery 27 January 2023

Background
The first ray plays a vital role in the normal function of the foot and the gait cycle where in its absence can lead to abnormal changes in weight distribution to the residual first metatarsal stump and lesser metatarsals with predisposition to developing lesser toe deformities reulcerations and reamputations particularly in diabetic patients. This study aims to characterize the outcomes after first ray amputation and its associated risk factors with focus on the impact of residual first metatarsal length.

Methods
All diabetic patients with first ray amputations from January 2012 to December 2016 were reviewed. Residual first metatarsal length was measured using postoperative radiographs. Risk factors for outcomes such as readmission, reulceration and/or reamputation, transfer ulceration and/or amputation of lesser toes, proximal amputations, ulcer-free duration (UFD) and mortality were analysed using bivariate logistic/linear regression followed by multiple logistic/linear regression models adjusting for confounding factors.

Results
Among 89 patients with first ray amputations, 65.3% needed readmission for further treatment. Although only 10.1% had reulceration at the first ray which all led to reamputation, there were 56.2% with transfer ulceration and 40.4% with transfer amputation of the lesser toes in this cohort. The prevalence of transmetatarsal amputation was 18% and proximal amputations at 12.4% while the average UFD was 27 months. Mortality rate was 31.5% with an average of 3-year survival. Preservation of the first metatarsal length via metatarsophalangeal joint disarticulation independently reduced likelihood of readmissions and residual metatarsal length of > one third when compared to < one third after first ray amputations had lower likelihood of transfer amputation of lesser toes.

Conclusion
First ray amputation in diabetic patients leads to significant morbidities and mortality. Preservation of the residual first metatarsal length independently reduced the likelihood of readmissions and transfer amputation to the lesser toes.
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NewsBot · Apr 4, 2023

Clinical characteristics and risk factors of lower extremity amputation in the diabetic inpatients with foot ulcers
Hongping Gong et al
Front. Endocrinol., 31 March 2023

Objectives: To analyze clinical characteristics of the diabetic inpatients with foot ulcers and explore the risk factors of lower extremity amputation (LEA) in West China Hospital of Sichuan University.

Methods: A retrospective analysis was performed based on the clinical data of the patients with diabetic foot ulcer (DFU) hospitalized in West China Hospital of Sichuan University from January 1, 2012 to December 31, 2020. The DFU patients were divided into three groups: non-amputation, minor amputation, and major amputation groups. The ordinal logistic regression analysis was used to identify the risk factors for LEA.

Results: 992 diabetic patients (622 males and 370 females) with DFU were hospitalized in the Diabetic Foot Care Center of Sichuan University. Among them, 72 (7.3%) (55 minor amputations and 17 major amputations) cases experienced amputation, and 21(2.1%) refused amputation. Excluding the patients who refused amputation, the mean age and duration of diabetes of and HbA1c the 971 patients with DFU, were 65.1 ± 12.3 years old, 11.1 ± 7.6 years, and 8.6 ± 2.3% respectively. The patients in the major amputation group were older and had longer course of diabetes for a longer period of time than those in the non-amputation and minor amputation groups. Compared with the non-amputation patients (55.1%), more patients with amputation (minor amputation (63.5%) and major amputation (88.2%)) suffered from peripheral arterial disease (P=0.019). The amputated patients had statistically lower hemoglobin, serum albumin and ankle brachial index (ABI), but higher white blood cell, platelet counts, fibrinogen and C-reactive protein levels. The patients with amputation had a higher incidence of osteomyelitis (P = 0.006), foot gangrene (P < 0.001), and a history of prior amputations (P < 0.001) than those without amputation. Furthermore, a history of prior amputation (odds ratio 10.194; 95% CI, 2.646-39.279; P=0.001), foot gangrene (odds ratio 6.466; 95% CI, 1.576-26.539; P=0.010) and ABI (odds ratio 0.791; 95% CI, 0.639-0.980; P = 0.032) were significantly associated with LEAs.

Conclusions: The DFU inpatients with amputation were older with long duration of diabetes, poorly glycemic control, malnutrition, PAD, severe foot ulcers with infection. A history of prior amputation, foot gangrene and a low ABI level were the independent predictors of LEA. Multidisciplinary intervention for DFU is essential to avoid amputation of the diabetic patients with foot ulcer.
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NewsBot · Apr 18, 2023

Clinical characteristics and risk factors of lower extremity amputation in the diabetic inpatients with foot ulcers
Hongping Gong et al
Front Endocrinol (Lausanne). 2023 Mar 31;14:1144806

Objectives: To analyze clinical characteristics of the diabetic inpatients with foot ulcers and explore the risk factors of lower extremity amputation (LEA) in West China Hospital of Sichuan University.

Methods: A retrospective analysis was performed based on the clinical data of the patients with diabetic foot ulcer (DFU) hospitalized in West China Hospital of Sichuan University from January 1, 2012 to December 31, 2020. The DFU patients were divided into three groups: non-amputation, minor amputation, and major amputation groups. The ordinal logistic regression analysis was used to identify the risk factors for LEA.

Results: 992 diabetic patients (622 males and 370 females) with DFU were hospitalized in the Diabetic Foot Care Center of Sichuan University. Among them, 72 (7.3%) (55 minor amputations and 17 major amputations) cases experienced amputation, and 21(2.1%) refused amputation. Excluding the patients who refused amputation, the mean age and duration of diabetes of and HbA1c the 971 patients with DFU, were 65.1 ± 12.3 years old, 11.1 ± 7.6 years, and 8.6 ± 2.3% respectively. The patients in the major amputation group were older and had longer course of diabetes for a longer period of time than those in the non-amputation and minor amputation groups. Compared with the non-amputation patients (55.1%), more patients with amputation (minor amputation (63.5%) and major amputation (88.2%)) suffered from peripheral arterial disease (P=0.019). The amputated patients had statistically lower hemoglobin, serum albumin and ankle brachial index (ABI), but higher white blood cell, platelet counts, fibrinogen and C-reactive protein levels. The patients with amputation had a higher incidence of osteomyelitis (P = 0.006), foot gangrene (P < 0.001), and a history of prior amputations (P < 0.001) than those without amputation. Furthermore, a history of prior amputation (odds ratio 10.194; 95% CI, 2.646-39.279; P=0.001), foot gangrene (odds ratio 6.466; 95% CI, 1.576-26.539; P=0.010) and ABI (odds ratio 0.791; 95% CI, 0.639-0.980; P = 0.032) were significantly associated with LEAs.

Conclusions: The DFU inpatients with amputation were older with long duration of diabetes, poorly glycemic control, malnutrition, PAD, severe foot ulcers with infection. A history of prior amputation, foot gangrene and a low ABI level were the independent predictors of LEA. Multidisciplinary intervention for DFU is essential to avoid amputation of the diabetic patients with foot ulcer.
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NewsBot · Apr 26, 2023

Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis
Huiling Zhang et al
Int Wound J. 2023 Apr 24

A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.
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NewsBot · May 16, 2023

An index to prevent major limb amputations in diabetic foot
Bugra Zengin et al
Endocr Regul. 2023 May 15;57(1):80-91

Objective. Besides the early detection and treatment of diabetic foot ulcers, being aware of the risk factors for major amputation plays a crucial role in preventing the major lower limb amputations. Major lower limb amputations are not just mentally and physically hard for patients, but also have an effect on patient's survival and are a financial burden on both patients and healthcare systems. Subjects and Methods. We defined 37 potential risk factors for major amputation and these risk factors were investigated among 507 patients who had ulcers in their feet and were seen by the diabetic foot ulcer council at Ege University Faculty of Medicine. In our study, 106 (20.9%) patients ended up undergoing major lower limb amputation. Results. The univariate analysis showed that 24 defined risk factors were statistically significant. In the multivariate analysis using the Cox regression model, 6 risk factors remained statistically significant. Multivariate-adjusted hazard ratios were 4.172 for hyperlipidemia, 3.747 for albumin <3.365 g/dL, 3.368 for C-reactive protein (CRP) >2.185 mg/L, 2.067 for presence of gangrenous Wagner stage, 1.931 for smoking tobacco >30 pack/year, and 1.790 for hematocrit (HCT) <31.5%. Most patients with major amputation presented with a neuroischemic foot (58%). Gender and age were not found to be risk factors for major amputation. Having less than 7% of hemoglobin A1c (HbA1c) levels had a direct proportion with major amputation numbers. The mortality rates in one year, two and three years after the major amputation operations were 24.6%, 30%, and 35.9%, respectively. Conclusion. Being familiar with these risk factors for major amputation is crucial for multi-disciplinary teams to take good care of patients with diabetic foot ulcers and to lower the need for major amputations
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NewsBot · May 29, 2023

Assessment of the risk factors determining the prognosis of major and minor limb amputations in patients with diabetic foot ulcers
Kürşat Tuğrul Okur et al
Adv Clin Exp Med. 2023 May 22

Background: Diabetes mellitus (DM) is a major global health problem, and its incidence is growing. Depending on this increase, the number of diabetes-related complications will also rise.

Objectives: This study aimed to determine the risk factors associated with major and minor amputations resulting from diabetes.

Material and methods: Patients diagnosed with diabetic foot complications (n = 371) and hospitalized between January 2019 and March 2020 were retrospectively evaluated using information obtained from the database of Diabetic Foot Wound Clinic. Examination of the data identified 165 patients for inclusion in the study, who were stratified into major amputation (group 1, n = 32), minor amputation (group 2, n = 66) and non-amputation (group 3, n = 67) groups.

Results: Of the 32 patients who underwent major amputations, 84% had a below-knee amputation, 13% had an above-knee amputation and 3% had knee disarticulation. At the same time, 73% of 66 patients who underwent minor amputation had a single-finger amputation, 17% had a multiple-finger amputation, 8% had a transmetatarsal amputation, and 2% had Lisfranc amputation. Laboratory results showed high acute phase protein and low albumin (ALB) levels in patients from group 1 (p < 0.05). Although Staphylococcus aureus was found to be the most common infectious agent, Gram-negative pathogens were dominant (p < 0.05). Also, there was a significant cost difference between the groups (p < 0.05). Furthermore, those aged over 65 had a high Wagner score, high Charlson Comorbidity Index (CCI), long diabetic foot ulcer (DFU) duration, and high white blood cell (WBC) count, all of which were risk factors for major amputation (p < 0.05).

Conclusions: This study demonstrated an increased Wagner staging and incidence of peripheral neuropathy (PN) and peripheral arterial disease (PAD) in major amputation patients. In addition, the rate of distal vessel involvement was high in major amputation patients, with elevated acute phase proteins and low ALB levels crucial in laboratory findings.
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NewsBot · Jun 5, 2023

Risk factors for reamputation in patients with diabetic foot: A case-control study
Carlos Alberto Sánchez Correa et al
Foot and Ankle Surgery; June 2023

Background
Reamputation as a complication of diabetic foot ulcers presents a high economic burden and represents a therapeutic failure. It is paramount to identify as early as possible patients in whom a minor amputation may not be the best option. The purpose of this investigation was to do a case-controlled study to determine risk factors associated with re-amputation in patients with DFU (diabetic foot ulcers) at two University Hospitals.

Methods
Multicentric, observational, retrospective, case-control study from clinical records of 2 university hospitals. Our study included 420 patients, with 171 cases (re-amputations), and 249 controls. We performed a multivariate logistic regression analysis and time-to-event survival analysis to identify re-amputation risk factors.

Results
Statistically significant risk factors were artery history of tobacco use (p =0.001); male sex (p = 0.048); arterial occlusion in Doppler ultrasound (p = 0.001); percentage of stenosis in arterial ultrasound > 50% (p = 0.053); requirement of vascular intervention (p = 0.01); and microvascular involvement in photoplethysmography (p = 0.033). The most parsimonious regression model suggests that history of tobacco use, male sex, arterial occlusion in ultrasound, and percentage of stenosis in arterial ultrasound > 50% remained statistically significant. The survival analysis identified earlier amputations in patients with larger occlusion in arterial ultrasound, high leukocyte count, and elevated ESR.

Conclusion
Direct and surrogate outcomes in patients with diabetic foot ulcers identify vascular involvement as an important risk factor for reamputation.
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NewsBot · Jun 15, 2023

An Overview of Risk Factors for Diabetic Foot Amputation: An Observational, Single-centre, Retrospective Cohort Study
Burak Yuzuguldu et al
touchREV Endocrinol. 2023 May;19(1):85-93

Introduction: Not only are early detection and treatment of diabetic foot ulcers important, but also acknowledging potential risk factors for amputation gives clinicians a considerable advantage in preventing amputations. Amputations impact both healthcare services and the physical and mental health of patients. This study aimed to investigate the risk factors for amputation in patients with diabetic foot ulcers.

Methods: The sample for this study was patients with diabetic foot ulcers who were treated by the diabetic foot council at our hospital between 2005 and 2020. A total of 32 risk factors for amputation were identified and investigated among 518 patients.

Results: Our univariate analysis showed that 24 of 32 defined risk factors were statistically significant. In the multivariate analysis using the Cox regression model, seven risk factors remained statistically significant. The risk factors most significantly associated with amputation were Wagner grading, abnormal peripheral arteries, hypertension, high thrombocyte levels, low haematocrit levels, hypercholesterolaemia and male sex, respectively. The most common cause of death in patients with diabetes who have undergone amputation is cardiovascular disease, followed by sepsis.

Conclusion: To enable optimum treatment of patients with diabetic foot ulcers it is important for physicians to be aware of the amputation risk factors, and thus avoid amputations. Correcting risk factors, using suitable footwear and routinely inspecting feet are crucial factors for preventing amputations in patients with diabetic foot ulcers.
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NewsBot · Jul 27, 2023

Predictive Factors for Lower Limb Amputation in
Type 2 Diabetics
Sawsen Nouira , Taïeb Ach , Foued Bellazreg , Asma Ben Abdelkrim
Cureus

Introduction: Type 2 diabetes mellitus (T2DM) is a major public health problem. Foot-related complications
are common in diabetic patients. The aim of this study is to identify predictive factors for lower limb
amputation (LLA) in order to better identify this at-risk population.
Methods: This was a cross-sectional study involving 134 patients who were hospitalised for the management
of T2DM complicated by diabetic foot, in the department of endocrinology and diabetology. We included
patients with T2DM whose diabetes was diagnosed 10 years ago or more, and who had a diabetic foot
problem. Statistical differences between predictors of amputations were tested using: t-tests for numerical
variables and chi-square tests for categorical variables. Significant variables were analysed by logistic
regression to determine significant predictors.
Results: The mean duration of diabetes was 17±7 years. We found that 70% of patients with LLA were older
than 50 years (p<10-3). The prevalence of LLA was higher (p=0.015) in patients with diabetes for more than
20 years. We noted that 58% of patients who underwent LLA were hypertensive (p<10-3). The majority of
patients with LLA (58%) had abnormal micro-albuminuria (p<10-3). We found that 70% (n=12) of patients
with LLA had low-density protein cholesterol levels above the target value (p<10
-3
). Diabetic foot grade ≥4 (4
or 5) according to Wagner's classification, was present in 24% of amputee patients. Based on a 95%
confidence interval level, the independent significant predictive factors for LLA in our patients were: T2DM
for more than 20 years, hypertension and diabetic foot grade ≥4.
Conclusions: After multivariate analysis, the significant independent predictive factors associated with LLA
were: T2DM for more than 20 years, hypertension, and diabetic foot grade ≥4. Early management of diabetic
foot problems is therefore recommended to avoid amputations.
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NewsBot · Aug 3, 2023

Risk factor analysis for diabetic foot ulcer-related amputation including Controlling Nutritional Status score and neutrophil-to-lymphocyte ratio
Yandan Zhu, Hongtao Xu, Yuzhen Wang, Xia Feng, Xinyu Liang, Liying Xu, Zhiqiang Liang, Zhongjia Xu, Yawen Li, Yi Le, Manchen Zhao, Jianfei Yang, Ji Li, Yemin Cao
4 July 2023

Diabetic foot ulcer often leads to amputation, and both nutritional status and immune function have been associated with this process. We aimed to investigate the risk factors of diabetic ulcer-related amputation including the Controlling Nutritional Status score and neutrophil-to-lymphocyte ratio biomarker. We evaluated data from hospital in patients with diabetic foot ulcer, performing univariate and multivariate analyses to screen for high-risk factors and Kaplan–Meier analysis to correlate high-risk factors with amputation-free survival. Overall, 389 patients underwent 247 amputations over the follow-up period. After correction to relevant variables, we identified five independent risk factors for diabetic ulcer-related amputation: ulcer severity, ulcer site, peripheral arterial disease, neutrophil-to-lymphocyte ratio and nutritional status. Amputation-free survival was lower for the moderate-to-severe versus mild cases, for the plantar forefoot versus hindfoot location, for the concomitant peripheral artery disease versus without and in the high versus low neutrophil-to-lymphocyte ratio (all p < 0.01). The results showed that ulcer severity (p < 0.01), ulcer site (p < 0.01), peripheral artery disease (p < 0.01), neutrophil-to-lymphocyte ratio (p < 0.01) and Controlling Nutritional Status score (p < 0.05) were independent risk factors for amputation in diabetic foot ulcer patients and have predictive values for diabetic foot ulcer progression to amputation.
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NewsBot · Aug 3, 2023

Predictive Factors for Lower Limb Amputation in Type 2 Diabetics
Sawsen Nouira et al
Cureus. 2023 Jun 5;15(6):e39987

Introduction: Type 2 diabetes mellitus (T2DM) is a major public health problem. Foot-related complications are common in diabetic patients. The aim of this study is to identify predictive factors for lower limb amputation (LLA) in order to better identify this at-risk population.

Methods: This was a cross-sectional study involving 134 patients who were hospitalised for the management of T2DM complicated by diabetic foot, in the department of endocrinology and diabetology. We included patients with T2DM whose diabetes was diagnosed 10 years ago or more, and who had a diabetic foot problem. Statistical differences between predictors of amputations were tested using: t-tests for numerical variables and chi-square tests for categorical variables. Significant variables were analysed by logistic regression to determine significant predictors.

Results: The mean duration of diabetes was 17±7 years. We found that 70% of patients with LLA were older than 50 years (p<10-3). The prevalence of LLA was higher (p=0.015) in patients with diabetes for more than 20 years. We noted that 58% of patients who underwent LLA were hypertensive (p<10-3). The majority of patients with LLA (58%) had abnormal micro-albuminuria (p<10-3). We found that 70% (n=12) of patients with LLA had low-density protein cholesterol levels above the target value (p<10-3). Diabetic foot grade ≥4 (4 or 5) according to Wagner's classification, was present in 24% of amputee patients. Based on a 95% confidence interval level, the independent significant predictive factors for LLA in our patients were: T2DM for more than 20 years, hypertension and diabetic foot grade ≥4.

Conclusions: After multivariate analysis, the significant independent predictive factors associated with LLA were: T2DM for more than 20 years, hypertension, and diabetic foot grade ≥4. Early management of diabetic foot problems is therefore recommended to avoid amputations.
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NewsBot · Nov 6, 2023

Association between the diabetic foot amputation index and metabolic compensation in diabetes mellitus
Francisca Kuschel et al
Rev Med Chil. 2022 Jul;150(7):912-918

Background: Diabetic foot amputation is a public health challenge due to the increasing prevalence of type 2 diabetes mellitus (T2D). Although there are many health indicators aimed at the management and control of T2D and its complications, amputations persist.

Aim: To evaluate the association between diabetic foot amputation index and indicators of care and management of T2D in primary care centers of the eastern section of Santiago, Chile.

Material and methods: We conducted a mixed ecological study and included information from the Monthly Statistical report of different public health centers from 2014 to 2018. We also analyzed the hospital discharge records from an individual tertiary public health center. The annual index for diabetic foot amputation per 100,000 diabetic patients was used as a response variable. The diabetic compensation percentage was calculated as the proportion of adults with a glycosylated hemoglobin below 7% or the proportion of older people with a value below 8%. The diabetic decompensation percentage was calculated as the proportion of people with a glycosylated hemoglobin over 9%.

Results: A high variability in demographic and management indicators was observed between communes and centers in the study period. Bivariate analysis showed a significant correlation between the amputation index, decompensation, and insulin use. In a regression analysis, the amputation index was significantly associated with the diabetic compensation percentage (β = -3.5; p < 0.05) and a high decompensation percentage (β = 12.3; p < 0.005).

Conclusions: The diabetic foot amputation index was associated with diabetic compensation and decompensation indicators.
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NewsBot · Nov 15, 2023

“I know what I'm supposed to do, but I don't do it”: patient-perceived risk factors that lead to their lower extremity amputations
Marcelle Ben chmo, Lisa Matricciani, Saravana Kumar & Kristin Graham
Journal of Foot and Ankle Research volume 16, Article number: 79 (2023)

Background
The purpose of this study is to extend on our previous research by exploring patient-perceived factors that lead to their Lower Extremity Amputations (LEA). LEA are a serious complication of Type 2 Diabetes Mellitus (T2DM), LEA are thought to be preventable with early detection and management of risk factors. Our previous study identified that these factors extend beyond the typical biological and modifiable risk factors and may also extend to patient awareness and competing priorities. Therefore, this research explored these issues in further detail, identifying patient-perceived factors that lead to their LEA.

Methods
A qualitative descriptive methodology involving non-probability purposive sampling was used to recruit inpatients at a tertiary metropolitan hospital in South Australia. Semi-structured interviews were conducted, and data were transcribed verbatim. Data from the interviews were analysed using thematic analysis and the constant comparison approach.

Results
A total of 15 participants shared their perspectives of risk factors for LEA. Two main themes emerged: intrinsic and extrinsic factors. Intrinsic factors identified in this study included identity, ambivalence, denial, inevitability, and helplessness. Extrinsic factors related to resources, rapport with healthcare professionals, and management of care.

Conclusions
Through identifying that a combination of perceived personal attributes (intrinsic) and system-level (extrinsic) factors likely contribute to LEA, this study highlights the complexity of factors that contribute to patients' perceptions of what led to their diabetes related LEA. These findings support the importance of a nuanced approach in managing patients with diabetes who are at risk of LEA as it's likely patients’ personal circumstances, day-to-day life’s requirements and responsibilities, their interaction with healthcare professionals all seemingly contribute to how risks are viewed and managed. Tackling this challenge will require reimagining diabetes care, acknowledgement of risk factors beyond the obvious and addressing persistent access and workforce issues.
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NewsBot · Nov 15, 2023

Ambulatory Status before Diabetic Foot Ulcer Development as a Predictor of Amputation and 1-Year Outcomes: A Retrospective Analysis
Devin J Clegg et al
Plast Reconstr Surg Glob Open. 2023 Nov 9;11(11)

Background: Up to 25% of people with diabetes develop a diabetic foot ulcer (DFU) during their lifetime, which precedes approximately 85% of nontraumatic lower limb amputations. Diabetic limb salvage has been at the forefront of recent research, as major amputation is associated with 5-year mortality rates of 52%-80%. We sought to determine if ambulatory status before DFU diagnosis is predictive of amputations and outcomes within 1 year, as no studies have directly examined this relationship.

Methods: A retrospective review of patients diagnosed with DFUs from January 2011 to December 2021 was performed. Patients aged 18 years or more with type II diabetes were included. Ambulatory status was defined as the primary form of mobility reported by the patient before development of DFU, and was categorized as independent ambulation, ambulatory with assisting device (AWAD), or nonambulatory (NA). Statistical analyses included χ2, multinomial, and multivariable logistic regressions.

Results: After review, 506 patients were included. NA (OR = 5.10; P = 0.002) and AWAD status (OR = 2.77; P = 0.01) before DFU development were predictive of major (below or above-knee) amputation during hospitalization, emergency department visits within 30-days (NA: OR = 4.19; P = 0.01, AWAD: OR = 3.09; P = 0.02), and mortality within one-year (NA: OR = 4.19; P = 0.01, AWAD: OR = 3.09; P = 0.02). AWAD status was also associated with increased risk of hospital readmission (OR = 2.89; P < 0.001) within 30-days and any amputation (OR = 1.73; P = 0.01) within 1 year.

Conclusions: In patients with DFUs, NA and AWAD status were predictive of major amputation during hospitalization and are associated with poorer 1-year outcomes, including mortality. Ambulatory status assessment may be used to inform DFU treatment approaches.
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NewsBot · Nov 27, 2023

Predictive Value of C-Reactive Protein to Albumin Ratio for Amputation Risk in Diabetic Foot Infection
Banu Karaca et al
Angiology. 2023 Nov 22

Diabetic foot infections are one of the complications of diabetes mellitus resulting in extremity amputation and mortality. This study aimed to examine the predictive value of the C-reactive protein (CRP) to albumin ratio (CAR) for amputation risk in diabetic foot infection. Data from 178 patients were retrospectively examined. We found the cut point value of 15.45 according to the receiver operating characteristic (ROC) curve to show the predictive value of CAR for amputation risk in the overall population. We then divided the patients into two groups low (<15.45, n = 96) and high risk (≥15.45, n = 82) according to their CAR value. Matching based on propensity scores produced 64 patients in each group and showed that the amputation rate was high in the high-risk groups (50 vs 25%, P = .003). In the multivariate analysis in the matching group, previous amputation, antibiotic therapy in the last 3 months, and CAR (Odds ratio [OR]: 1.30, 95%Confidence interval [CI]: 1.01-1.45, P < .001) were independent predictors of amputation. These parameters may be useful to predict amputation risk in these patient groups.
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NewsBot · Jan 31, 2024

Risk Prediction of Diabetic Foot Amputation Using Machine Learning and Explainable Artificial Intelligence
Chien Wei Oei et al
J Diabetes Sci Technol. 2024 Jan 30

Background: Diabetic foot ulcers (DFUs) are serious complications of diabetes which can lead to lower extremity amputations (LEAs). Risk prediction models can identify high-risk patients who can benefit from early intervention. Machine learning (ML) methods have shown promising utility in medical applications. Explainable modeling can help its integration and acceptance. This study aims to develop a risk prediction model using ML algorithms with explainability for LEA in DFU patients.

Methods: This study is a retrospective review of 2559 inpatient DFU episodes in a tertiary institution from 2012 to 2017. Fifty-one features including patient demographics, comorbidities, medication, wound characteristics, and laboratory results were reviewed. Outcome measures were the risk of major LEA, minor LEA and any LEA. Machine learning models were developed for each outcome, with model performance evaluated using receiver operating characteristic (ROC) curves, balanced-accuracy and F1-score. SHapley Additive exPlanations (SHAP) was applied to interpret the model for explainability.

Results: Model performance for prediction of major, minor, and any LEA event achieved ROC of 0.820, 0.637, and 0.756, respectively, with XGBoost, XGBoost, and Gradient Boosted Trees algorithms demonstrating best results for each model, respectively. Using SHAP, key features that contributed to the predictions were identified for explainability. Total white cell (TWC) count, comorbidity score and red blood cell count contributed highest weightage to major LEA event. Total white cell, eosinophils, and necrotic eschar in the wound contributed most to any LEA event.

Conclusions: Machine learning algorithms performed well in predicting the risk of LEA in a patient with DFU. Explainability can help provide clinical insights and identify at-risk patients for early intervention.
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NewsBot · Feb 9, 2024

Prediction of amputation risk of patients with diabetic foot using classification algorithms: A clinical study from a tertiary center
Denizhan Demirkol et al
Int Wound J. 2024 Jan;21(1):e14556

Diabetic foot ulcers can have vital consequences, such as amputation for patients. The primary purpose of this study is to predict the amputation risk of diabetic foot patients using machine-learning classification algorithms. In this research, 407 patients treated with the diagnosis of diabetic foot between January 2009-September 2019 in Istanbul University Faculty of Medicine in the Department of Undersea and Hyperbaric Medicine were retrospectively evaluated. Principal Component Analysis (PCA) was used to identify the key features associated with the amputation risk in diabetic foot patients within the dataset. Thus, various prediction/classification models were created to predict the "overall" risk of diabetic foot patients. Predictive machine-learning models were created using various algorithms. Additionally to optimize the hyperparameters of the Random Forest Algorithm (RF), experimental use of Bayesian Optimization (BO) has been employed. The sub-dimension data set comprising categorical and numerical values was subjected to a feature selection procedure. Among all the algorithms tested under the defined experimental conditions, the BO-optimized "RF" based on the hybrid approach (PCA-RF-BO) and "Logistic Regression" algorithms demonstrated superior performance with 85% and 90% test accuracies, respectively. In conclusion, our findings would serve as an essential benchmark, offering valuable guidance in reducing such hazards.
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NewsBot · Feb 24, 2024

Epidemiological Insights into Diabetic Foot Amputation and its Correlates: A Provincial Study
Maryam Aalaa et al
Clin Med Insights Endocrinol Diabetes. 2024 Jan 30

Background: Diabetic foot ulcer and potential subsequent lower extremity amputation are major complications of diabetes mellitus and are also prominent morbidity factors that could affect patients' quality of life.

Objectives: This study aimed to assess the prevalence of diabetic foot amputation and explore correlates of amputation cause and type among subjects with diabetes mellitus in Tehran, Iran.

Methods: A descriptive cross-sectional study was conducted to assess the demographic, sociological, and clinical characteristics of subjects who had undergone lower extremity amputation due to diabetic foot ulcers, from 2011 to 2020, in two educational medical centers in Tehran, Iran. We examined the medical records of 4676 individuals who were admitted to Shariati and Sina hospitals due to diabetic foot issues. Information related to patient demographics (age, gender, marital status), social factors (education level, insurance), and clinical data (medical history, laboratory results, and characteristics of diabetic foot ulcers) was collected for subjects who had undergone lower extremity amputation due to diabetic foot ulcer. The collected data was reported using average values, standard deviations and proportions and analyzed using statistical tests.

Results: During one decade, 882 out of 4676 (18.8%) patients with diabetic foot ulcers underwent lower extremity amputations of various types in Sina and Shariati hospitals in Tehran, Iran. Of these, 692 (14.5%) were included for further analysis in the study and the rest were excluded due to lack of sufficient recorded data. About 75.9% of the study population was male, and the average age including both sexes was 60 years. About 92.7% were married, and on average, subjects had been afflicted with diabetes mellitus for 15.1 years. Statistical analysis using Pearson's chi-square test showed there was a significant association between the treatment regimen for diabetes mellitus and the type of amputation (P = .01), as well as between the duration of the disease and the cause of amputation (P = .01) and its type (P = .04).

Conclusion: diabetes mellitus related treatment regimen and duration of disease are significantly associated with amputation cause and type.
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NewsBot · Apr 13, 2024 at 10:54 PM

Prediction model for lower limb amputation in hospitalized diabetic foot patients using classification and regression trees
C A Sánchez et al
Foot Ankle Surg. 2024 Mar 21

Background: The decision to perform amputation of a limb in a patient with diabetic foot ulcer (DFU) is not an easy task. Prediction models aim to help the surgeon in decision making scenarios. Currently there are no prediction model to determine lower limb amputation during the first 30 days of hospitalization for patients with DFU.

Methods: Classification And Regression Tree analysis was applied on data from a retrospective cohort of patients hospitalized for the management of diabetic foot ulcer, using an existing database from two Orthopaedics and Traumatology departments. The secondary analysis identified independent variables that can predict lower limb amputation (mayor or minor) during the first 30 days of hospitalization.

Results: Of the 573 patients in the database, 290 feet underwent a lower limb amputation during the first 30 days of hospitalization. Six different models were developed using a loss matrix to evaluate the error of not detecting false negatives. The selected tree produced 13 terminal nodes and after the pruning process, only one division remained in the optimal tree (Sensitivity: 69%, Specificity: 75%, Area Under the Curve: 0.76, Complexity Parameter: 0.01, Error: 0.85). Among the studied variables, the Wagner classification with a cut-off grade of 3 exceeded others in its predicting capacity.

Conclusions: Wagner classification was the variable with the best capacity for predicting amputation within 30 days. Infectious state and vascular occlusion described indirectly by this classification reflects the importance of taking quick decisions in those patients with a higher compromise of these two conditions. Finally, an external validation of the model is still required
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NewsBot · Apr 13, 2024 at 10:55 PM

Risk factors for amputation in diabetic foot ulcers: A retrospective analysis
Xiaoyu Zhang, Qiwei Li, Xianpei Zhou, Yu Xu, Zizhen Shu, Hongyu Deng
28 March 2024

Diabetic foot ulcers (DFUs) are chronic, difficult-to-heal wounds with a very high incidence of amputation. For patients with DFUs, prevention of amputation is crucial. However, the risk factors associated with DFU amputation and the extent to which different risk factors increase the risk of amputation are still uncertain. This study intends to provide a clinical basis for early intervention in DFU by retrospectively analysing the risk factors for DFU amputation. A retrospective analysis of 200 patients with DFUs admitted between October 2019 and October 2023 was conducted. Sixty-eight of the 200 underwent amputations. The overall amputation rate was 34%. Multiple logistic regression model showed that neutrophil/lymphocyte ratio (OR = 1.943; 95% CI:1.826–2.139), white blood cell (OR = 1.143; 95% CI:1.034–1.267), C-reactive protein (OR = 1.307; 95% CI:1.113–2.194) and Wagner grading (OR = 2.783; 95% CI: 1.751–4.302) were independent risk factors for amputation, while haemoglobin (OR = 0.742; 95% CI:0.638–0.965) and high density lipoprotein were independent protective factors for amputation (OR = 0.168; 95% CI:0.037–0.716), and further Receiver Operating Characteristic Curve curves showed that they showed high accuracy and were good predictors of amputation of DFUs.
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NewsBot · Apr 17, 2024 at 2:58 AM

Association of Demographic Characteristics and Laboratory Values in Diabetic Foot Infections Leading to Lower-Extremity Amputation
Allen J Kempf et al
J Am Podiatr Med Assoc. 2024 Jan-Feb;114(1):21-187

Background: Lower-extremity amputations are a common complication of poorly controlled diabetes and contribute to significant morbidity and mortality in diabetic patients. We sought to determine whether objective data points obtained on presentation or hospital admission, including white blood cell (WBC) count, hemoglobin A1c (HbA1c), C-reactive protein (CRP), and descriptive patient demographics allow for the ability to predict optimal amputation levels and outcomes of lower-extremity amputation in the diabetic population.

Methods: A retrospective analysis of 162 patients was performed evaluating laboratory and descriptive values on hospital presentation for lower-extremity infection during a 16-year period. Occurrence of multiple amputations and level of amputation were assessed against laboratory values to determine whether these objective values would provide clinicians with a better understanding of amputations in the diabetic patient.

Results: The mean patient age was 60.6 years. A significantly higher percentage of patients who underwent amputations through the tibia and fibula or of the foot midtarsal were male compared with patients who underwent amputations of the thigh through femur. Patients who had amputations through the tibia and fibula had a significantly higher WBC count compared with patients who had a transmetatarsal amputation (P = .03). There was no significant difference in type or quantity of amputations when analyzing HbA1c and CRP levels.

Conclusions: An admission WBC count may be used as a predictor of lower-extremity amputation level and outcomes in diabetic infections. Although a statistically significant difference was not found for CRP or HbA1c levels between amputation procedures and number of procedures performed, these values remain useful in managing lower-extremity infections in diabetic patients.
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Risk factors for diabetes amputation

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Risk factors for diabetes amputation

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Risk Factors for Fractures and Falls in Older Women with Type 2 Diabetes

Chronic diseases and allergies as risk factors for MTSS

Risk factors for ingrown toenails

Incidence and Risk Factors for Pin Site Infection of Exposed Kirschner Wires

The risk factors for diabetic peripheral neuropathy

Incidence and Risk Factors for Foot Fractures

Genetic risk factors for plantar fasciitis

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