A STUDY ON ANALYSING PREDICTIVE FACTORS FOR MAJOR LOWER EXTREMITY AMPUTATION IN DIABETIC FOOT PATIENTS

Abstract

Diabetic foot is defined by World Health Organisation as “The foot of a Diabetes mellitus patient that has the potential risk
of pathologic consequences, including infection, ulceration, and/or destruction of deep tissues associated with neurologic abnormalities, various degrees of peripheral vascular diseases and/or metabolic complications of diabetes in lower limb”. The objective of our study is to analyse various clinical and pathological factors which contribute to major amputations of the lower extremities in diabetic foot patients and to determine the influence of each factor in the final therapeutic outcome. This study was conducted on 100 cases of diabetic foot ulcer patients admitted to Thanjavur Medical College Hospital during a period of 10 months from February 2018 to November 2018. The cases were all proven diabetics suffering from ulcers of the foot. Of the total 100 patients who were studied, 57% were managed conservatively. The overall amputation rate was 43% with 27 patients undergoing major amputations (22 below knee amputations and 5 above knee amputations) and 16 patients having to undergo minor amputations (13 digital ray-amputations and 3 tarsometatarsal amputations). This study has demonstrated that old age, male gender, the presence of gangrene, absence of pulsations of the affected limb, osteomyelitis, longer duration of diabetes, increased total leucocyte count (TLC), higher Wagner's grading of ulcer (grade 3 or more), low hemoglobin and soft tissue infection are adverse predictive factors for major lower extremity amputation in diabetic foot patients.

Full text

A STUDY ON ANALYSING PREDICTIVE FACTORS FOR MAJOR LOWER
EXTREMITY AMPUTATION IN DIABETIC FOOT PATIENTS
Premalatha
Sharon Rose
Associate Professor, Department of General Surgery, Thanjavur Medical College
Hospital Thanjavur- 613004
Original Research Paper
General Surgery
INTRODUCTION AND AIM:
Diabetic foot encompasses a constellation of syndromes, in which the
cumulative effects of neuropathy, ischaemia and infection lead to
tissue breakdown. Global prevalence of diabetes in 2003 was
estimated to be 194 million. By 2030, this figure is expected to rise to
an astronomical 366 million due to longer life expectancy and
changing dietary habits. India, with its oncoming diabetic epidemic
and increasing geriatric population, has shown an upsurge in the in the
incidence of peripheral vascular disease. Gangrene and ulcers
preceding amputations are largely preventable through awareness
generated by health education and organized foot care programmes.
Diabetes-related peripheral vascular disease and foot ulcers constitute
a significant percentage of hospital admissions and this is of great
socio-economic importance as majority of them are in the prime
earning age group and are poor. The management of treating foot
ulcers is rig orous and entails fre quent surgical consult atio ns,
expensive drugs, repeated investigations, dressings and procedures
and this proves to be beyond the reach of most of the Indian population
which struggles to have daily ends met. Various research papers
published world over have demonstrated that the reaching out
approach has dramatically reduced amputation rates and this is more
impactful than tertiary care. Early detection and attention to warning
signs can surely avert amputations and its attending repercussions,
both socio-economic and personal. Lower limb ischaemia in diabetes
due to ma croa ngio pathy causes non-healing ulce rs, infection,
ampu tation and even mor tality. Foot ulce ration is absol utely
preventable and by simple interventions one can reduce amputations
rates in up to 80% of patients. Regular evaluation and early treatment
are the most effective mechanisms to prevent the devastating diabetic
foot complications.
This study was conducted to analyse the predictive factors (clinical and
pathological) for major lower extremity amputation in diabetic foot
patients.
MATERIALS AND METHODS:-
Study was conducted on 100 cases of diabetic foot ulcer patients
admitted to Thanjavur Medical College Hospital during a period of 10
months from February 2018 to November 2018. The cases were all
proven diabetics suffering from lower limb ulcers secondary to
Diabetes Mellitus and were evaluated for various clinical and
pathological factors which were thought likely to favourably or
adversely influence the prognosis of diabetic foot ulcers. All values
were analysed using percentages and tabulated for comparison.
INCLUSION CRITERIA:
Ÿ All patients aged 12 years or more with diabetic foot ulcers.
EXCLUSION CRITERIA:
Ÿ Paediatric age group less than 12 years.
Ÿ Immunocompromised states like HIV, TB, and malignancy.
Ÿ Those who expired at the time of admission.
RESULTS AND OBSERVATIONS
AGE DISTRIBUTION:
The youngest patient was 32 years old, and eldest was 80 years old.
Highest number of cases were found in the age group of 51-70 years.
SEX DISTRIBUTION:
Out of 100 patients, 58 were male and 42 were females. Males are more
commonly affected by diabetic foot disease and amputation rates are
also higher compared to females.
Diabetic foot is defined by World Health Organisation as “The foot of a Diabetes mellitus patient that has the potential risk
of pathologic consequences, including infection, ulceration, and/or destruction of deep tissues associated with neurologic
abnormalities, various degrees of peripheral vascular diseases and/or metabolic complications of diabetes in lower limb”. The objective of our
study is to analyse various clinical and pathological factors which contribute to major amputations of the lower extremities in diabetic foot
patients and to determine the influence of each factor in the final therapeutic outcome. This study was conducted on 100 cases of diabetic foot
ulcer patients admitted to Thanjavur Medical College Hospital during a period of 10 months from February 2018 to November 2018. The cases
were all proven diabetics suffering from ulcers of the foot. Of the total 100 patients who were studied, 57% were managed conservatively. The
overall amputation rate was 43% with 27 patients undergoing major amputations (22 below knee amputations and 5 above knee amputations) and
16 patients having to undergo minor amputations (13 digital ray-amputations and 3 tarsometatarsal amputations). This study has demonstrated
that old age, male gender, the presence of gangrene, absence of pulsations of the affected limb, osteomyelitis, longer duration of diabetes,
increased total leucocyte count (TLC), higher Wagner's grading of ulcer (grade 3 or more), low hemoglobin and soft tissue infection are adverse
predictive factors for major lower extremity amputation in diabetic foot patients.
ABSTRACT
Volume - 10 | Issue - 11 | November - 2020 | . PRINT ISSN No 2249 - 555X | DOI : 10.36106/ijar
KEYWORDS : Gangrene, Wagner, Osteomyelitis
Thivagar
Thirugnanam
Assistant Professor, Department of General Surgery, Thanjavur Medical College
Hospital Thanjavur- 613004
Navin Sundar*
Junior Resident, Department of General Surgery, Thanjavur Medical College Hospital
Thanjavur- 613004.*Corresponding Author
INDIAN JOURNAL OF APPLIED RESEARCH
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Volume - 10 | Issue - 11 | November - 2020 | . PRINT ISSN No 2249 - 555X | DOI : 10.36106/ijar
DURATION OF DIABETES MELLITUS:
Over 70% of major amputations involved patients with longer duration
of diabetes mellitus.
PRESENCE OF GANGRENE:
100% of patients with complete gangrene ended up in major or minor
amputations with 58.33% patients needing major amputations.
PULSE STATUS OF THE AFFECTED PART:
100 % of patients with absent pulse went for major amputations.
Osteomyelitis:
All 7 patients with osteomyelitis had to undergo amputation.
INFECTIONS:
Out of 27 amputations, 24 (89%) were infected with microorganisms.
Gangrene
Number
of
patients
Major
Amputat
ions
Minor
Amputat
ions
Major
amputati
on%
Minor
amputat
ion%
Conservative
Management
%
Present
26
15
11
57.69%
42.31%
0%
Absent
74
12
5
16.21%
6.75%
77.04%
Pulsations
Number
of
patients
Major
Amput
ation
Minor
Amput
ation
Major
amputat
ion%
Minor
amputation
%
Conservative
Management
%
Absent
22
22
0
100%
0%
0%
Present
78
5
16
6.40%
20.53%
73.07%
Osteomyel
itis
Numb
er of
Patien
ts
Major
Amputati
on
Minor
Amputati
on
Major
Amputati
on%
Minor
Amputati
on%
Conservat
ive
Managem
ent %
Present
7
3
4
42.85%
57.15%
0%
Bacterial
Culture
No of
Patients
Major
Amputations
Minor
Amputations
Major
Amputations%
Minor
Amputations%
Conservative Management%
Positive
24
14
6
58.33%
25%
16.67%
Negative
76
13
10
17.10%
13.15%
69.75%
Grade
Number of
Patients
Major
Amputations
Minor
Amputations
Major
Amputations%
Minor
Amputations%
Conservative%
1
04
0
0
0%
0%
100%
2
53
0
0
0%
0%
100%
3
14
12
2
85.72%
14.28%
0%
4
24
10
14
41.67%
58.33%
0%
5
5
5
0
100%
0%
0%
Common organisms were St aph ylococcus aur eus, Klebs iel la,
Pseudomonas, E. coli and Proteus.
GRADING OF ULCER:
Patients were arbitrarily divided into two groups according to
Wagne r's Gr adi ng sys tem (low grade 0-2; H igh grade 3-5).
Amputation rates were higher in Grade 3 and above.
Total Leucocyte Count (TLC):
HAEMOGLOBIN:
An analysis of 100 cases of diabetic foot was done. These cases were
treated in different surgical units in the department of general surgery,
Thanjavur Medical College Hospital. Of the total 100 patients who
were studied, 57 were managed conservatively with 27 patients
undergoing major amputations (22 below knee amputations and 5
above knee amputations) and 16 patients having to undergo minor
amputations (13 digital ray-amputations and 3 tarsometatarsal
amputations).
DISCUSSION:
Of the total of 100 patients who were studied, 57 were managed
conservatively with 27 patients undergoing major amputations (22
below knee amputations and 5 above knee amputations) and 16
patients having to undergo minor amputations (13 digital ray-
amputations and 3 tarsometatarsal amputations). Most of the patients
in this study presented when infection or gangrene had already set in.
In this study, the major amputation rate in diabetic patients was as high
as 27%. Male patients had a slightly higher rate of major amputations
(16%) relative to female patients (5%). The major amputations were
common in patients in their 5th-7th decades of age (16%). Positive
bacterial cultures lead to significantly higher rates of major amputation
with 58% of those showing organisms on culture needing major
amputations. Presence of gangrene warranted major amputation in
58% patients and absence of peripheral pulses led to all patients having
major amputations. Wagner's grading III- V was associated with higher
rates of major amputations (86%, 42% and 100% for grades III, IV and
V respectively). In this study, major amputation rates increased in
patients having diabetes for more than 3 years (70%), possibly owing
to worsening of arteriopathy. All seven patients with foot ulcers having
oste omye litis ended up having major (43 %) o r mi nor (57%)
amputations. We have observed that higher levels of total leucocyte
count (TLC) due to infection increases the rate of major amputation by
eight times (24% in patients with TLC >12,000 against 3% in patients
with TLC< 12,000). And amputation tendency increases with fall in
haemoglobin level with 45% of patients with Hb< 10gm needing major
amputations possibly attributed to diminished oxygen supply in an
already ischemic limb.
CONCLUSION:
This study shows that old age, male gender, absence of pulsations,
presence of infection, longer duration of disease, osteomyelitis,
presence of gangrene, higher grade of Wagner's severity classification,
leukocytosis, low hemoglobin were independent adverse predictors of
major lower extremity amputation rates in diabetic foot patients. The
care of the diabetic foot thus takes place at 3 levels; the patient must
take routine measures to take care of his/her foot with early lesions
getting quick attention from a podiatrist and advanced lesions
requiring early specialised care.
Hemogl
obin
gm%
Number
of
patients
Major
Amputa
tions
Minor
Amput
ations
Major
Amputati
ons%
Minor
Amputa
tions%
Conservati
ve
Manageme
nt%
<10gm
%
36
16
9
44.45%
25%
30.55%
>10gm
%
64
11
7
17.18%
10.93%
71.89%
36
INDIAN JOURNAL OF APPLIED RESEARCH

ACKNOWLEDGEMENTS: None
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