Reducing lower extremity amputations due to diabetes: the application of diabetic-foot protocol in Chiang Mai University Hospital

The aim of this study was to determine whether intensive treatment and education strategies for diabetic patients with ulcers help in preventing leg amputation. From August 2005 to March 2007, a diabetic-foot protocol using a multidisciplinary approach was applied at our hospital. All the subjects were educated regarding diabetic-foot disease and its complications and prevention. This report compares the amputation rate in patients receiving the protocol care from August 2005 to March 2007 with those who had standard care from August 2003 to July 2005. Seventy-three and 110 diabetic-foot ulcer patients received protocol and standard foot care, respectively. The incidence of major amputations in the protocol and standard care groups was 4.1% and 13.6%, respectively (P= .03). Our protocol was associated with improved diabetic-foot care outcomes. It can be used by any hospital to improve outcomes for patients with diabetes.     

Seminar review: sociocultural practices and epidemiology of diabetic foot problem: lessons from a study in Chiang Mai University Hospital, Thailand

The data on sociocultural practices and epidemiology of diabetic foot problems are scarce in Thailand. This report used data found in a database with patients involved in multidisciplinary foot care. Of the 511 patients with diabetes, 475 (93.0%) patients had type 2 diabetes. The prevalence of foot ulcers in diabetic patients was 12.5% and the amputation rate was 1.4%. A total of 32.7% of patients suffered from neuropathic problems. Barefoot walking inside the house was found 55.4% of the time, and this seemed to link closely with Thai sociocultural practices. Improvement in foot care was a direct result of foot care education.     

Early predictors for lower extremity amputation in a diabetic population: results of a case-controlled study

Lower extremity amputation is devastating to any person and is a very real complication for a diabetic. Identifying early risk factors is tantamount to saving a limb. This study used the national hospital discharge survey to identify 2206 control patients and 2098 diabetic patients with a lower extremity amputation. These patients were not limited based on gender or race as in previous studies. The results show that nephropathy and retinopathy are early predictors.     

The diabetic foot: an alternative approach to major amputation.

Of the complications of diabetes mellitus, none is more devastating than gangrene of the foot and the threat of leg amputation. The pathophysiology of vascular insufficiency, neurotrophic changes, and infection leading to this gangrene have been reviewed. Based on this pathophysiology, an approach for conservative surgery of the diabetic foot has been outlined. Using known principles of wound healing and the management of soft tissue infection, obviously necrotic or infected tissue is debrided and the wound managed conservatively. The use of debriding adjuncts such as the pulsating jet lavage, topical antibacterials, and biologic dressings are suggested to control the infection so that the wounds can be closed with either skin grafts or local flaps. This method can result in salvage of many feet and the maintenance of biped ambulation since the outlook for the diabetic with a major amputation is markedly different from the nondiabetic amputee.     

Effect of lower extremity amputation on caregiving burden in caregivers of patients with diabetic foot: Prospective cohort study

Lower extremity amputation as a treatment of diabetic foot ulcer is probably a major burden for the patient's family and friends, who typically act as caregivers and support the patient in coping with the physical disabilities and emotional distress. In the present prospective study, we investigated the effects of different lower extremity amputation levels for diabetic foot ulcer treatment on caregivers of patients with diabetes using the Zarit Burden Interview (ZBI‐12) scale. Patients with diabetic foot ulcers who underwent unilateral major amputation (above‐below knee) and minor amputation of foot (heel sparing) and their caregivers were requested to volunteer to participate in this study from June 2016 to December 2018. The ZBI‐12 form was completed immediately preoperatively and 3 and 6 months after postoperatively. In the minor amputation group, the mean age of the 51 patients was 72.1 years. In the major amputation group, the mean age of the 88 patients was 73.7 years. Both groups of caregivers of patients with minor amputation and major amputations showed a significant improvement in ZBI‐12 score when compared preoperatively and at 3‐ and 6‐month follow‐up visits. The mean ZBI‐12 score was significantly higher in the major than in the minor amputation group in preoperative and all postoperative visits. The absence of the ankle joint in the below‐ or above‐knee amputation renders it more difficult for the amputee to quickly learn the use of prosthesis, thereby increasing the burden of the patient and caregivers. We found that lower extremity amputation for the treatment of chronic diabetic foot ulcers has significantly favourable effect on the caregiver burden, and thereby heel sparing was considerably more effective for the caregiver burden.     

Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: A case‐control study

Present guidelines recommend a multidisciplinary team (MDT) approach to diabetic foot ulcer (DFU) care, but relevant data from Asia are lacking. We aim to evaluate the clinical and economic outcomes of an MDT approach in a lower extremity amputation prevention programme (LEAPP) for DFU care in an Asian population. We performed a case‐control study of 84 patients with DFU between January 2017 and October 2017 (retrospective control) vs 117 patients with DFU between December 2017 and July 2018 (prospective LEAPP cohort). Comparing the clinical outcomes between the retrospective cohort and the LEAPP cohort, there was a significant decrease in mean time from referral to index clinic visit (38.6 vs 9.5 days, P < .001), increase in outpatient podiatry follow‐up (33% vs 76%, P < .001), decrease in 1‐year minor amputation rate (14% vs 3%, P = .007), and decrease in 1‐year major amputation rate (9% vs 3%, P = .05). Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86m (SGD $2.5m) for patients within the LEAPP cohort. In conclusion, similar to the data from Western societies, an MDT approach in an Asian population, via a LEAPP for patients with DFU, demonstrated a significant reduction in minor and major amputation rates, with annualised cost avoidance of USD $1.86m.     

Keeping an eye on the diabetic foot: The connection between diabetic eye disease and wound healing in the lower extremity

Diabetic eye disease is strongly associated with the development of diabetic foot ulcers (DFUs). DFUs are a common and significant complication of diabetes mellitus (DM) that arise from a combination of micro- and macrovascular compromise. Hyperglycemia and associated metabolic dysfunction in DM lead to impaired wound healing, immune dysregulation, peripheral vascular disease, and diabetic neuropathy that predisposes the lower extremities to repetitive injury and progressive tissue damage that may ultimately necessitate amputation. Diabetic retinopathy (DR) is caused by cumulative damage to the retinal mic-rovasculature from hyperglycemia and other diabetes-associated factors. The severity of DR is closely associated with the development of DFUs and the need for lower extremity revascularization procedures and/or amputation. Like the lower extremity, the eye may also suffer end-organ damage from macrovascular compromise in the form of cranial neuropathies that impair its motility, cause optic neuropathy, or result in partial or complete blindness. Additionally, poor perfusion of the eye can cause ischemic retinopathy leading to the development of proliferative diabetic retinopathy or neovascular glaucoma, both serious, vision-threatening conditions. Finally, diabetic corneal ulcers and DFUs share many aspects of impaired wound healing resulting from neurovascular, sensory, and immunologic compromise. Notably, alterations in serum biomarkers, such as hemoglobin A1c, ceruloplasmin, creatinine, low-density lipoprotein, and high-density lipoprotein, are associated with both DR and DFUs. Monitoring these parameters can aid in prognosticating long-term outcomes and shed light on shared pathogenic mechanisms that lead to end-organ damage. The frequent co-occurrence of diabetic eye and foot problems mandate that patients affected by either condition undergo reciprocal comprehensive eye and foot evaluations in addition to optimizing diabetes management.     

Impact of multidisciplinary foot care team on outcome of diabetic foot ulcer in term of lower extremity amputation at a tertiary care unit in Karachi,Pakistan

To compare the outcomes of diabetic foot ulcers (DFU) in terms of healing and lower extremity amputation (LEA) rate before and after training of multidisciplinary foot care team (MDFCT). Subjects were categorised into two groups; Group‐A cases seen between 1997 and 2006 (before upgrading of training and services of MDFCT) and Group‐B cases seen between 2007 and 2016 (after upgrading of training and services of MDFCT). Baseline demographic characteristics, biochemical results, and outcomes of DFU in terms of healing or amputation were analysed by using statistical package social science (SPSS) version 20. Total 7994 DFU cases seen, 888 in group A and 7106 in group B. Mean age of patients was 53.80 ± 10.40 years and mean haemoglobin (HbA1c) was 10.12 ± 2.44. Overall, decreasing trends of amputations were observed from baseline 27.5% to 3.92% during the period of 20 years. In group A, 479 (78.8%) subjects healed completely compared with 3806 (89.1%) in group B. Significant reduction in toe amputations ([13.81%] vs [8.11%]) and below knee amputations [(5.26%) vs (1.82%)] were seen. Similarly, rates of above knee amputation ([1.80%] vs [0.35%] P‐value 0.008) in two groups was also significant. Significant improvement was observed in outcomes of DFU in terms of amputation through multidisciplinary team approach.     

Factors associated with lower‐extremity amputation in patients with diabetic foot ulcers in a Chinese tertiary care hospital

Providing a better understanding of the risk factors for amputation in this particular region, Hunan province, in China might help patients with diabetic foot ulcers receive timely and appropriate medical care and help prevent amputation. Diabetic foot ulcer patients referred to the Third Xiangya Hospital during the period between December 2014 and September 2018 were enrolled. Participants who underwent amputations and received conservative treatments were compared using univariate and multivariate analyses to identify the independent predictors of amputation. Those who required amputation presented significantly higher levels of white blood cell counts, platelet counts, erythrocyte sedimentation rate, C‐reactive protein, and glycated haemoglobin (HbA1c) levels. However, levels of haemoglobin, postprandial plasma C‐peptide, triglyceride, high‐density lipoprotein cholesterol, albumin, and uric acid were decreased in patients with amputations. Patients with more advanced Wagner grades had much higher rates of amputation. Multivariable‐adjusted odds ratios in stepwise logistic regression model was 1.317 for HbA1c (95% CI: 1.015‐1.709), 0.255 for triglyceride (95% CI: 0.067‐0.975), and 20.947 for Wagner grades (95% CI: 4.216‐104.080). Independent risk factors for amputation in these Chinese diabetic foot ulcer patients included an elevated HbA1c level, lower triglyceride level, and higher Wagner grades.     

Trans-metatarsal amputation in patients with a diabetic foot: Reviewing 10 years experience

Considerable disagreement exists whether trans-metatarsal amputations are indicated in persons with diabetes. A previous study reported that statistically the success rate of Syme's amputation in diabetic patients over 65 years of age resulted in a very poor results. The purpose of this study was to investigate the results of trans-metatarsal amputations, in patients with diabetes and to seek markers which could shed light upon the advantages/disadvantages of this procedure.The records of 46 patients covering a 10-year period (1996–2006) were used as a database.Twelve needed higher amputation level and another 10 needed a wound revision. All the patients that maintained the original amputation level walk without a need for a prosthesis and kept their previous abode.TMA in diabetic patients, although at a high risk for an extrasurgical procedure, once successful, the patient will regain his previous lifestyle.     

Risk of amputation in patients with diabetic foot ulcers: a claims-based study

The objective of this study was to undertake a retrospective analysis of claims data of diabetic foot ulcer (DFU) patients to determine the rates of amputation and identify the risk and protective factors. Rates of amputation were calculated in patients diagnosed with DFU in the MEDSTAT Marketscan database between January 2000 and December 2002, who had prediagnosis coverage of 90 days. A nested case-control study was conducted using a 1 : 10 ratio of amputee cases to randomly selected nonamputee controls matched on follow-up days. The association of co-morbid conditions, demographic factors, and severity (5+ outpatient claims for DFU) on amputation was estimated by adjusted odds ratios (AOR) with 95% confidence intervals (CIs). The 5911 eligible patients yielded an incidence density rate of 2.30 amputations per 100 person years (95% CI = 1.91, 2.77). The 116 cases and 1153 controls averaged 307.3 and 308.5 observation days, respectively. Amputation was significantly increased by male gender (AOR 1.98), Charlson co-morbidity scores of 4-5 and 6+ (AOR = 2.89 and 5.36, respectively), renal disease (AOR = 2.11), peripheral vascular disease (AOR = 2.67), and 5+ outpatient DFU services (AOR = 2.17). Practitioners may consider more aggressive care and earlier referral to specialists for DFU patients who fit risk profiles for amputation, which include peripheral vascular disease, multiple co-morbid conditions, and repeated outpatient DFU services.     

Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01–1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001–1.01) infection (OR 2.08, 95% CI 1.06–4.07) and presence of diabetes (OR 3.77, 95% CI 1.12–12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.     

Risk factors for amputation in patients with diabetic foot infection: a prospective study

There is a variety of diagnostic and therapeutic algorithms for diabetic foot infections (DFIs). Some of them are too difficult to be applied in routine clinical approach. In the routine clinical approach, it is necessary to find new risk factors and end up with a quick and easy assessment of DFIs. In this study, we aimed to evaluate the independent risk factors for osteomyelitis, amputation and major amputation in patients with DFI using standard scoring procedures. We prospectively studied 379 patients with DFI. The variables were analysed using logistic analysis. A total of 126 cases (33·2%) underwent amputation. The odds ratios in the amputation model were 3·09 for osteomyelitis (P < 0·001), 4·90 for arterial stenosis (AS) (P < 0·001), 3·67 for the history of DFI (P = 0·001), 2·47 for ulcer duration >60 days (P = 0·001), 3·10 for ulcer depth > 15 mm (P < 0·001) and 10·28 for fungal DFI (P = 0·015). In this study, the unusual result of well‐known literature was fungal DFI as an independent risk factor for amputation in patients with DFI.     

Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease

BackgroundLower extremity complications are a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD) and diabetes mellitus. Patient education programs may decrease the risk of diabetic foot complications.MethodsA preventive program was instituted, consisting of regular assessments by a foot care nurse with expertise in foot care and wound management and patient education about foot care practices and footwear selection. Medical records were reviewed and patients were examined. A comparison was made with data about patients from a previous study done from this institution prior to development of the foot care program.ResultsDiabetic subjects more frequently had weakness of the left tibialis anterior, left tibialis posterior, and left peroneal muscles than non-diabetic subjects. A smaller percentage of diabetic subjects had sensory neuropathy compared with the previous study from 5 years earlier, but a greater percentage of diabetic subjects had absent pedal pulses in the current study. The frequency of inadequate or poor quality footwear was less in the current study compared with the previous study.ConclusionsThe current data suggest that a foot care program consisting of nursing assessments and patient education may be associated with a decrease in frequency of neuropathy and improved footwear adequacy in diabetic patients with ESRD.     

Effects of corrective insole on leg muscle activation and lower extremity alignment in rice farmers with pronated foot: a preliminary report

BackgroundExecution of strenuous activities in conjunction with slippery and viscous muddy working terrain in rice cultivation leads to a high prevalence of farmer musculoskeletal disorders and malalignments. Recommended intervention strategies originally designed for congenitally disabled individuals may also be applicable to farmers, including simple corrective wedges to reduce foot eversion. The objective of the present study was to conduct a preliminary investigation of the effects of corrective wedges on lower extremity muscle activity and alignment when subjects stood on flat rigid ground or muddy terrain, simulating typical work conditions encountered by the unique but populous Thai rice farming workforce.MethodsNine healthy farmers with pronated feet were recruited to participate and wedges were custom fabricated for each farmer based on physical therapy assessment and use of rapid prototyping techniques. Participants were asked to stand barefoot or with wedges on the two surface types.ResultsResults revealed foot pronation and knee valgus to improve (ranging, on average between 5.5 and 16.1 degrees) when participants were equipped with corrective wedges. The muscle activity of the peroneus longus and the tibialis anterior increased for muddy terrain, as compared with the rigid surface. In general, the wedges induced less tibialis anterior activity and greater peroneus longus activity, compared to when participants were standing barefoot. An elevation in evertor muscle activity may reflect stretching of the shortened muscle as a result of the reduced degree of foot pronation.ConclusionsFindings demonstrate potential benefits of corrective insole usage for farmers with pronated feet, including improved lower extremity alignment and invertor muscle activity reduction for both rigid and muddy terrains.     

Distal revascularization and microvascular free tissue transfer: an alternative to amputation in ischemic lesions of the lower extremity

Most lower extremity amputations result from complications of diabetes and arterio-sclerotic occlusive diseases below the inguinal ligament. Improved limb salvage has been achieved by an aggressive approach to distal revascularization in the severely ischemic lower extremity. There remains, however, a high incidence of amputation resulting from progression of the ulceration or gangrene into deeper and less well-vascularized tissues, such as tendon and bone. Even in the nonischemic extremity, such wounds rarely heal without flap coverage. Microvascular free tissue transfers promote healing by providing coverage with healthy, nondiseased, well-vascularized tissue for these difficult defects. Successful free flap transfer requires a high-pressure recipient inflow vessel. In contrast to individuals with nonarteriosclerotic lesions, many individuals with nonhealing ischemic lesions have no acceptable artery demonstrated on high-resolution angiography to serve as a recipient vessel. Limb salvage has been achieved in four candidates for amputation utilizing distal revascularization followed by free tissue transfer coverage of the ischemic lower leg defects.     

Recurring wounds in a diabetic with multiple medical problems: lower extremity wound care

Acute trauma leading to open wounds in the lower extremity of a patient with diabetes mellitus can be life threatening. Diabetes mellitus complicates and compromises wound care and tissue repair for several reasons. This case report describes the successful wound care treatment modalities used in the care of a 53-year-old male who presented with diabetes and a full-thickness lower leg wound.     

How ESKD complicates the management of diabetic foot ulcers: The vital role of the dialysis team in prevention,early detection,and support of multidisciplinary treatment to reduce lower extremity amputations

Diabetic foot ulcers do not heal as well in ESKD as in the absence of kidney failure, and rates of recurrent foot ulcers, as well as lower extremity amputation, are higher. This review of the literature highlights the vital role of the dialysis team in prevention, early detection, and support of treatment of diabetic foot ulcers. Our review has five goals—(a) increase nephrologists’ understanding of the high morbidity and mortality associated with chronic foot ulcers and (lower extrimity) LE amputations in ESKD; (b) promote nephrologists’ understanding of grading systems for diabetic foot ulcer severity, in order to expedite communication with local diabetic foot experts; (c) promote collaboration between nephrologists and infectious disease specialists regarding the dose, route, and delivery logistics of intravenous antibiotics for infected chronic foot ulcers, in particular in the presence of osteomyelitis and other deep-seated infections; (d) increase the awareness of dialysis nurses, technicians, dietitians, social workers and administrators regarding evidence-based and multidisciplinary approaches to patients’ diabetic foot ulcers; (e) encourage the application of published works integrating patient-centered diabetic foot education into the dialysis setting to reduce lower extremity amputations.     

Analysis of risk factors for amputation in patients with diabetic foot ulcers: a cohort study from a tertiary center

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, one-way 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 High-density 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.Level of Evidence: Level IV, Prognostic Study