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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 1  |  Page : 34-38

A clinical study of risk factors associated with amputation in diabetic foot disease patients attending a tertiary care hospital in a rural setting


1 Department of General Surgery, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, India
2 Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, Andhra Pradesh, India

Date of Submission02-Mar-2020
Date of Decision22-Mar-2020
Date of Acceptance27-Apr-2020
Date of Web Publication20-Jul-2020

Correspondence Address:
Lakshmi Venkata Simhachalam Kutikuppala
Final MBBS Part-1, Konaseema Institute of Medical Sciences and Research Foundation, Chaitanya Nagar, NH-216, Amalapuram - 533 201, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_13_20

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  Abstract 


Background: Diabetes mellitus is a disease of complications, which is rapidly increasing in prevalence worldwide. The total population affected by diabetes is projected to rise from 171 million in 2000 to 366 million by 2030. Approximately 20% of all diabetics who visit the hospital are admitted for foot problems. Diabetic foot ulcers and amputations continue to cause considerable morbidity among persons with diabetes throughout the world. Amputations are considered as a very debilitating complication of diabetes. Vast majority of diabetic foot complications resulting in amputation begin with formation of skin ulcers.
Objectives: The main objective of this study is to examine various risk factors to predict lower extremity amputation in diabetic patients and to understand various measures which will reduce the level of amputation.
Subjects and Methods: Fifty diabetic patients with foot lesion admitted in our hospital from September 2016 to August 2018 were studied by taking detailed history and thorough clinical examination. Grading of the foot lesions was done by Wagner's staging.
Results: The incidence of foot lesion was higher in 51–60 years' age group in males and females. Majority of the patients (38, 76%) had a history of trauma as a predisposing factor to diabetic foot. Out of 20 patients walking barefoot, 12 people (60%) had amputations.
Conclusions: It is concluded that rural origin of the patients was found to be another predisposing factor for the development of diabetic foot. This is due to the illiteracy of the patients regarding diabetes and its complications, unavailability of proper health-care facilities, and late presentation to the hospital.

Keywords: Amputation, diabetes mellitus, diabetic foot, ulcer


How to cite this article:
Nulukurthi TK, Kumar SR, Simhachalam Kutikuppala LV. A clinical study of risk factors associated with amputation in diabetic foot disease patients attending a tertiary care hospital in a rural setting. J Curr Res Sci Med 2020;6:34-8

How to cite this URL:
Nulukurthi TK, Kumar SR, Simhachalam Kutikuppala LV. A clinical study of risk factors associated with amputation in diabetic foot disease patients attending a tertiary care hospital in a rural setting. J Curr Res Sci Med [serial online] 2020 [cited 2020 Aug 3];6:34-8. Available from: http://www.jcrsmed.org/text.asp?2020/6/1/34/290241




  Introduction Top


Diabetes is a chronic disease, which is a major cause of blindness, kidney failure, heart attacks, stroke, and lower limb amputations. Its prevalence has been increasing more rapidly in middle- and low-income countries. The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014.[1] The changes in blood vessels and nerves in diabetic patients causes ulceration and subsequent limb amputation leading to diabetic foot disease. It is one of the most costly complications of diabetes, especially in communities with inadequate footwear.[2] Diabetic foot causes substantial morbidity, impairs quality of life, engenders high treatment costs, and is the most important risk factor for lower extremity amputation, which is one of the most disabling complications of diabetes.[3] Longer duration of diabetes mellitus, increasing age, poor control of diabetes, smoking, and occurrence of lesion in dominant foot are considered as significant risk factors for increased liability of lower extremity amputation in diabetic foot patients.[4] About 15% of diabetic patients develop foot ulcers in their lifetime, and amputation precedes in 85% of the cases. It is the most common cause of nontraumatic lower limb amputation.[5] In India, it is estimated that approximately 45,000 lower limbs are amputated every year and the vast majority of these are probably preventable. Many studies proved that severity of diabetic foot ulcer is the strongest significant risk factor of amputation for diabetes patients.[6] Diabetic foot disease is not only a serious health problem but also poses socioeconomic burden to the patient due to prolonged hospitalization and rehabilitation time. Early recognition and proper management of risk factors for amputation in diabetic foot disease patients may reduce major amputations and prevent adverse outcome.[7]


  Subjects and Methods Top


Fifty diabetic patients with foot lesion admitted in our hospital from September 2016 to August 2018 were studied prospectively. All cases presented to our hospital with diabetes mellitus and foot lesions (foot ulcers, vasculopathy, neuropathy, etc.), aged more than 18 years, residing in the study area were included in the study. Diabetics without foot lesions and already amputated limbs were excluded. A detailed history with proper case pro forma was taken from all the patients, and the patients are subjected to thorough clinical examination. Inquiry was made with regard to the incidence of diabetes in any other member of the family to know the hereditary tendency. The presenting symptoms were recorded in chronological order, and each symptom was elaborated in detail. Any history of injury and details of the mode of injury were enquired. History of local symptoms such as swelling, pain, wound, or discoloration and their duration were noted.

The detailed history about diabetic status was noted to know whether the patient was known as diabetic or not. If the patient was a known diabetic, then the duration and severity of diabetes, nature, and regularity of antidiabetic treatment were noted. The personal habits of smoking and alcoholism were also noted. General and physical examination of the patient was done to record the pulse, blood pressure, temperature, and respiratory rate. Anemia, if present, is particularly given importance as it is one of the major causes of poor wound healing. Detailed and meticulous clinical examination included peripheral pulses, trophic changes, features of neuropathy such as loss of ankle jerk, reduced vibration perception and sensory loss, and cutaneous pressure perception of foot by Semmes–Weinstein 10-mm monofilament.

In all fifty patients, urine sugar and ketone body estimation along with random blood sugar estimation was done. Fasting and postprandial blood sugar investigations were repeated twice a week for the first week and weekly thereafter to confirm the control of diabetic status.

The diagnosis of infection of wound was made by using clinical criteria, frank purulence, and with or without two or more of the local signs. These signs include warmth, erythema, lymphangitis, edema, pain, and loss of function. Pus was sent for culture and sensitivity before starting initial debridement. X-ray foot was done in all cases to see joint degeneration, soft-tissue infection, and vessel calcification. Fundoscopy was done in all cases to detect retinopathy. Grading of the foot lesions was done by Wagner's staging [Figure 1].
Figure 1: Wagner's Grade IV Diabetic foot. (a) Before debridement (b) after debridement

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  Results Top


In the present study, the youngest patient was a 28-year-old male and the eldest was an 80-year-old male. The maximum number of patients belongs to 51–60 years' age group. The number of males in the present study was 38 (76%) and that of females was 12 (24%) [Table 1]. Rural origin was predominant among the study population (60%). The incidence of foot lesion was higher in 51–60 years' age group in males and females. Majority of the patients (38, 76%) had a history of trauma as a predisposing factor to diabetic foot. Diabetic patients with foot lesions presented to the Out-Patient Department of General Surgery with symptoms of swelling in 28 (56%), pain in 23 (46%), wound in 40 (80%), discharge in 34 (68%), numbness in 13 (26), and discoloration in 10 (20%) cases [Table 2]. The diabetic status was uncontrolled in majority (29, 58%) of the cases. In the present study, 20 (40%) patients walked barefoot and 30 (60%) patients were using footwear. Out of 20 patients walking barefoot, 12 people (60%) had amputations. In the present study, 18 (36%) patients were known smokers and 12 (24%) were alcoholic. Ten smokers and nine alcoholics were found to have vascular complications. Six smokers and five alcoholics were having neuropathic complications. Different types of lesions including cellulitis, abscess, ulcer, and gangrene were seen in this series. Most of the patients presented with more than one lesion. Ulcer was the commonest lesion seen here which was present in 35 (70%) patients. Pulsations of the dorsalis pedis artery were absent in 24 (48%) patients, posterior tibial in 16 (32%), and popliteal in 3 (6%) patients. Eighteen (36%) patients had neuropathy, diagnosed by weakness of small muscles, foot deformity, loss of sensation, and loss of sweating. The maximum number of patients presented with Grade III diabetic foot, i.e., about 23 (46%) patients [Figure 2], Grade I in 6 (12%) patients, Grade II in 14 (28%) patients, Grade IV in 3 (6%) patients, and Grade V in 4 (8%) patients [Table 3]. Staphylococci (60%) were the most common organism to be isolated from the pus culture of these diabetic foot patients. Osteoporosis as a result of autonomic neuropathy was found in 13 (26%) patients. The development of neuropathic (Charcot's) joint was found in 5 (10%) patients. Debridement in 36 (72%), amputations in 24 (48%), skin grafting in 15 (30%), and incision and drainage in 6 (12%) patients were the surgical procedures employed in the management of study population [Table 4].
Table 1: Age and sex distribution

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Table 2: Symptoms in fifty patients of diabetic foot

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Figure 2: Wagner's Grade III Diabetic foot. (a) Before debridement (b) after debridement

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Table 3: Wagner's staging in fifty patients of diabetic foot

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Table 4: Surgical management in fifty patients of diabetic foot

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  Discussion Top


In our study, the prevalence of diabetes is more in patients over the age of 50 years. There is definite male preponderance with 38 (76%) male cases, which could be due to their increased exposure to outside environment making them more likely to be prone to injury leading to foot ulcer formation. Alcoholism and smoking habits prevalent in males can also add up to the male preponderance. Ulcer was the most common type of lesion during the patient presentation. Trauma was found to be a causative factor, commonly seen in patients from rural areas, walking barefoot and due to improper use of footwear. The maximum number of patients presented with Wagner's Grade III diabetic foot, and there were no patients with Grade “0.” The absence of the dorsalis pedis pulse is more prominent (48% = 24) among distal pulses felt among the study population. Dorsalis pedis pulse was found absent in different studies such as 31.4% in Edelson et al.[8] and 56% in Apelqvist et al.[9] The variability in results can be due vasculopathy, cellulitis with edema, and anatomical variation of the dorsalis pedis artery.

Eighteen (36%) patients had neuropathy, which was diagnosed by weakness of small muscles, foot deformity, loss of sensation, and loss of sweating. The incidence of neuropathy in different studies was 59.4% in Edelson et al.[8] and 67% in Apelqvist et al.[10] Smoking and alcohol contributed to vasculopathy, neuropathy, and other complications such as sepsis, ketoacidosis, and uremia. In most of the patients, more than one organism was isolated from pus culture of diabetic foot, in which Staphylococcus aureus (60%) is predominant. Control of infection was achieved by giving rest to the part, meticulous debridement, and antibiotic therapy. The most common surgical intervention was debridement, which was carried out in about 36 (72%) patients. Twenty-four (48%) patients had undergone amputations.[11] Amputations were considered on the clinical basis such as absent distal pulsations, life-threatening sepsis, gangrene, and osteomyelitis where conservative management has failed.[12] The incidence of amputations in the present study was 48% and in other similar studies is 18.3% in Ahuja et al.[13] and 22.04% in Apelqvist et al.[9] The reasons for the higher rates of amputation in the present study can be because the study population belonge to rural setting and walking barefoot is the norm, making them more prone to injury. Health education was given to the patients regarding foot care and diabetic control on discharge from the hospital.


  Conclusions Top


In this study of 50 patients, 38 (76%) patients were male compared to 12 (24%) females, with a maximum incidence between ages 51 and 60 years. The late presentation may be due to ignorance and lack of knowledge of the patients regarding diabetic control and lack of awareness about health and negligence to seek early medical help which is seen commonly in our population.[14] Majority of the patients gave a history of trauma as a predisposing factor which was found to be the most common precipitating factor and this may be because of walking barefoot, wearing improperly fitted footwear, and loss of sensation due to neuropathy.[15] Thirty (60%) patients were from a rural background, and 18 (75%) of these patients required amputations. Hence, it is concluded that rural origin of the patients was found to be another predisposing factor for the development of diabetic foot. This may be due to the ignorance of the patients regarding diabetes and its complications, unavailability of proper health-care facilities, and late presentation to the hospital.[16]

Diabetic foot lesions commonly result from a combination of neuropathy, vasculopathy, and infection in the lower extremity.[17] Patients presented in the late stage of disease may be because of lack of knowledge regarding the disease. Mortality is more because of advanced disease status, severe infection, and poor general condition at the time of presentation. Good diabetic control, improving nutritional status, meticulous debridement, and the use of broad-spectrum antibiotics and early control of infection are the main steps in reducing the major amputations.[18] Lack of attention to foot hygiene and the use of poorly fitting footwear are major preventable factors in the development of foot infections. Hence, raising awareness about the lethal complications of diabetic foot and educating the patient regarding the foot hygiene, use of well fitted closed footwear, early access to health-care system, and satisfactory rehabilitation might help in reducing the chance of amputations.

Limitations

This study was conducted on a sample size of 50, which may not represent the required population. The study population was only diabetic; hence, the results may not be applied to nondiabetic population.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by the Department of General Surgery, Konaseema Institute of Medical Sciences and Research Foundation, Amalapuram, India.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Available from: https://www.who.int/en/news-room/f act-sheets/detail/diabetes. [Last accessed on 2018 Apr 18].  Back to cited text no. 1
    
2.
Available from: https://www.who.int/diabetes/ac tion_online/basics/en/index 3.html. [Last accessed on 2018 Apr 18].  Back to cited text no. 2
    
3.
Cavanagh PR, Lipsky BA, Bradbury AW, Botek G. Treatment for diabetic foot ulcers. Lancet 2005;366:1725-35.  Back to cited text no. 3
    
4.
Surriah MH, Al-Imari AN, Bakkour AM, Al-Asadi RR. Predictive value of the risk factors for amputation of lower extremity in patients with diabetic foot in Al-Karama teaching hospital. Int Surg J 2019;6:1549-55.  Back to cited text no. 4
    
5.
Jain AK, Vishwanath S. Studying major amputations in a developing country using Amit Jain's typing and scoring system for diabetic foot complications – Time for standardization of diabetic foot practice. Int Surg J 2015;2:26-30.  Back to cited text no. 5
    
6.
Viswanathan V, Kumpatla S. Pattern and causes of amputation in diabetic patients – A multicentric study from India. J Assoc Physicians India 2011;59:11-5.  Back to cited text no. 6
    
7.
Kim SY, Kim TH, Choi JY, Kwon YJ, Choi DH, Kim KC, et al. Predictors for amputation in patients with diabetic foot wound. Vasc Specialist Int 2018;34:109-16.  Back to cited text no. 7
    
8.
Edelson GW, Armstrong DG, Lavery LA, Caicco G. The acutely infected diabetic foot is not adequately evaluates in impairment setting. Arch Intern Med 1996;156:2373-8.  Back to cited text no. 8
    
9.
Apelqvist J, Larsson J, Stenström A. Adhesive zinc oxide tape and hydrocolloidal dressing. Diabet Complications 1990;90:21-5.  Back to cited text no. 9
    
10.
Veves A, Murray HJ, Young MJ, Boulton AJ. Charcot's foot. Diabetologia 1992;35:660-3.  Back to cited text no. 10
    
11.
Yesil S, Akinci B, Yener S, Bayraktar F, Karabay O, Havitcioglu H, et al. Predictors of amputation in diabetics with foot ulcer: Single center experience in a large Turkish cohort. Hormones (Athens) 2009;8:286-95.  Back to cited text no. 11
    
12.
Lenselink E, Holloway S, Eefting D. Outcomes after foot surgery in people with a diabetic foot ulcer and a 12-month follow-up. J Wound Care 2017; 26:218-27.  Back to cited text no. 12
    
13.
Ahuja MMS. Epidemiological studies on diabetes mellitus in India. In: Ahuja MMS, editor. Epidemiology of diabetes in developing countries. New Delhi: Interprint; 1979. pp. 29-38.  Back to cited text no. 13
    
14.
Deribe B, Woldemichael K, Nemera G. Prevalence and factors influencing diabetic foot ulcer among diabetic patients attending Arbaminch Hospital, South Ethiopia. J Diabet Metab 2014;2:322.  Back to cited text no. 14
    
15.
Pscherer S, Dippel FW, Lauterbach S, Kostev K. Amputation rate and risk factors in type 2 patients with diabetic foot syndrome under real-life conditions in Germany. Prim Care Diabetes 2012;6:241-6.  Back to cited text no. 15
    
16.
Weck M, Slesaczeck T, Paetzold H, Muench D, Nanning T, von Gagern G, et al. Structured health care for subjects with diabetic foot ulcers results in a reduction of major amputation rates. Cardiovasc Diabetol 2013;12:45.  Back to cited text no. 16
    
17.
Quddus MA, Uddin MJ. Evaluation of foot ulcers in diabetic patients. Mymensingh Med J 2013;22:527-32.  Back to cited text no. 17
    
18.
Bakri FG, Allan AH, Khader YS, Younes NA, Ajlouni KM. Prevalence of diabetic foot ulcer and its associated risk factors among diabetic patients. Jordan Med J 2011;46:118-25.  Back to cited text no. 18
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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