Skip to main content
SpringerLink
Log in

The major predictors of amputation and length of stay in diabetic patients with acute foot ulceration

Die wesentlichsten Prädiktoren einer Amputation und der Dauer des Spitalsaufenthaltes bei Diabetikern mit akutem Ulkus im Fußbereich

  • original article
  • Published:
Wiener klinische Wochenschrift Aims and scope Submit manuscript

Summary

Background

Diabetic foot infections are associated with substantial morbidity and mortality. Prediction of diabetic foot ulcer outcome may be helpful for optimizing management strategy. This study aimed to determine the major predictors of amputation and length of stay in diabetic patients with acute foot ulceration.

Methods

A total of 55 type 2 diabetic patients with diabetic foot infection were enrolled. The patients were evaluated according to the Infectious Diseases Society of America and International Working Group on the Diabetic Foot criteria and also the Wagner’s classification. Blood samples were taken at the start of hospitalization for the measurement of glucose, hemoglobin A1C (HbA1C), white blood cells (WBC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Length of stay in hospital was recorded.

Results

WBC and CRP were significantly higher in lower-extremity amputation (LEA) group (p = 0.001 and p = 0.008, respectively); also, ESR was higher in this group, but there was no statistical significance. Wagner grade and infection severity were significantly higher in the LEA group as compared with the non-LEA group (both p values < 0.001). Glycemic control parameters (i.e., HbA1C, plasma glucose) were not different in LEA and non-LEA groups. In correlation analyses, amputation rate was negatively correlated (r = − 0.512, p < 0.001) with length of stay. WBC, ESR, CRP, Wagner grade, and severity of infection showed positive correlation with length of stay (r = 0.493, p < 0.001; r = 0.271, p = 0.045; r = 0.299, p = 0.027; r = 0.434, p = 0.001; and r = 0.464, p < 0.001, respectively).

Conclusions

Baseline levels of acute-phase reactants, especially CRP, WBC, ESR, and increased Wagner grade, appeared to be helpful in predicting amputation and length of stay in diabetic patients with acute foot ulceration. However, duration of diabetes and glucose control seems to have no effect.

Zusammenfassung

Grundlagen

Infektionen von Fußulzera Ulcera sind bei Diabetikern mit einer beträchtlichen Morbidität und Mortalität verbunden. Eine Vorhersage des Verlaufs des Ulkus kann zur Optimierung der Managementstrategies hilfreich sein. Die vorliegende Studie hatte zum Ziel, die wesentlichsten Prädiktoren für eine Amputation und für die Dauer des Aufenthaltes im Spital zu erheben.

Methodik

Es wurden insgesamt 55 Patienten mit einem Typ 2 Diabetes mellitus mit einer Infektion im Bereich von Fußulzera in die Studie aufgenommen. Die Patienten wurden entsprechend der diabetischen Fußkriterien der Infectious Diseases Society of America und der International Working Group on the Diabetic Foot criteria, sowie der Klassifikation nach Wagner evaluiert. Am Beginn des Spitalsaufenthaltes wurde Blut zur Messung der Glukose, des HbA1c, der Leukozyten, des C reaktiven Proteins (CRP) und der Blutsenkung (Skg) abgenommen. Die Dauer des Spitalsaufenthaltes wurde registriert.

Ergebnisse

Die Leukozyten und das CRP waren in der LEA Gruppe (LEA = lower-extremity amputation) signifikant höher (p = 0,001 beziehungsweise p = 0,008). Die Skg war in dieser Gruppe zwar auch schneller – allerdings war dieser Unterschied statistisch nicht signifikant.

Der Schweregrad der Infektion und die Graduierung nach Wagner waren in der LEA Gruppe signifikant höher als in der Nicht-LEA Gruppe (beide p < 0,001). Die Parameter der glykämischen Kontrolle (Blutzucker, HbA1c) waren in der LEA und Nicht-LEA Gruppe nicht unterschiedlich. In der Korrelationsanalyse zeigte sich die Rate der Amputationen negativ mit der Dauer des Spitalsaufenthaltes korreliert (r = − 0,512, p < 0,001). Leukozyten, Skg, CRP, Wagner Grad und Schweregrad der Infektion waren positiv mit der Dauer des Spitalsaufenthaltes korreliert (r = 0,493, p < 0,001; r = 0,271, p = 0,045; r = 0,299, p = 0,027; r = 0,434, p = 0,001 and r = 0,464, p < 0,001 respektive).

Schlussfolgerungen

Die Ausgangswerte von Akutphasenparametern, insbesondere des CRP, der Leukozyten, der Skg und höhere Grade nach Wagner, scheinen in der Vorhersage einer Amputation bzw. der Dauer des Spitalsaufenthaltes hilfreich zu sein. Die Dauer des Diabetes mellitus, beziehungsweise die glykämische Kontrolle scheinen allerdings keine Bedeutung zu haben.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Pittet D, Wyssa B, Herter-Clavel C, Kursteiner K, Vaucher J, Lew PD. Outcome of diabetic foot infections treated conservatively: a retrospective cohort study with long-term follow-up. Arch Intern Med. 1999;159(8):851–6.

    Article  CAS  PubMed  Google Scholar 

  2. Ince P, Kendrick D, Game F, Jeffcoate W. The association between baseline characteristics and the outcome of foot lesions in a UK population with diabetes. Diabet Med. 2007;24(9):977–81.

    Article  CAS  PubMed  Google Scholar 

  3. Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Reiber GE, Wagner EH. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22(3):382–7.

    Article  CAS  PubMed  Google Scholar 

  4. Prompers L, Huijberts M, Schaper N, Apelqvist J, Bakker K, Edmonds M, Holstein P, Jude E, Jirkovska A, Mauricio D, Piaggesi A, Reike H, Spraul M, Van Acker K, Van Baal S, Van Merode F, Uccioli L, Urbancic V, Ragnarson Tennvall G. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia. 2008;51(10):1826–34.

    Article  CAS  PubMed  Google Scholar 

  5. Pinto A, Tuttolomondo A, Di Raimondo D, Fernandez P, La Placa S, Di Gati M, Licata G. Cardiovascular risk profile and morbidity in subjects affected by type 2 diabetes mellitus with and without diabetic foot. Metabolism. 2008;57(5):676–82.

    Article  CAS  PubMed  Google Scholar 

  6. Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006;29(6):1288–93.

    Article  PubMed  Google Scholar 

  7. Levin ME. Foot lesions in patients with diabetes mellitus. Endocrinol Metab Clin North Am. 1996;25(2):447–62.

    Article  CAS  PubMed  Google Scholar 

  8. Muller IS, de Grauw WJ, van Gerwen WH, Bartelink ML, van Den Hoogen HJ, Rutten GE. Foot ulceration and lower limb amputation in type 2 diabetic patients in dutch primary health care. Diabetes Care. 2002;25(3):570–4.

    Article  PubMed  Google Scholar 

  9. Walters DP, Gatling W, Mullee MA, Hill RD. The distribution and severity of diabetic foot disease: a community study with comparison to a non-diabetic group. Diabet Med. 1992;9(4):354–8.

    Article  CAS  PubMed  Google Scholar 

  10. Abbott CA, Carrington AL, Ashe H, Bath S, Every LC, Griffiths J, Hann AW, Hussein A, Jackson N, Johnson KE, Ryder CH, Torkington R, Van Ross ER, Whalley AM, Widdows P, Williamson S, Boulton AJ, North-West Diabetes Foot Care Study. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med. 2002;19(5):377–84.

    Article  CAS  PubMed  Google Scholar 

  11. Al-Mahroos F, Al-Roomi K. Diabetic neuropathy, foot ulceration, peripheral vascular disease and potential risk factors among patients with diabetes in Bahrain: a nationwide primary care diabetes clinic-based study. Ann Saudi Med. 2007;27(1):25–31.

    Article  PubMed  Google Scholar 

  12. Sims DS, Jr., Cavanagh PR, Ulbrecht JS. Risk factors in the diabetic foot. Recognition and management. Phys Ther. 1988;68(12):1887–902.

    PubMed  Google Scholar 

  13. Boyko EJ, Ahroni JH, Cohen V, Nelson KM, Heagerty PJ. Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study. Diabetes Care. 2006;29(6):1202–7.

    Article  PubMed  Google Scholar 

  14. Peters EJ, Lavery LA, Armstrong DG. Diabetic lower extremity infection: influence of physical, psychological, and social factors. J Diabetes Complications. 2005;19(2):107–12.

    Article  PubMed  Google Scholar 

  15. de Sonnaville JJ, Colly LP, Wijkel D, Heine RJ. The prevalence and determinants of foot ulceration in type II diabetic patients in a primary health care setting. Diabetes Res Clin Pract. 1997;35(2–3):149–56.

    Article  CAS  PubMed  Google Scholar 

  16. Stockl K, Vanderplas A, Tafesse E, Chang E. Costs of lower-extremity ulcers among patients with diabetes. Diabetes Care. 2004;27(9):2129–34.

    Article  PubMed  Google Scholar 

  17. Ribu L, Hanestad BR, Moum T, Birkeland K, Rustoen T. A comparison of the health-related quality of life in patients with diabetic foot ulcers, with a diabetes group and a nondiabetes group from the general population. Qual Life Res. 2007;16(2):179–89.

    Article  PubMed  Google Scholar 

  18. Malgrange D, Richard JL, Leymarie F, French Working Group On The Diabetic Foot. Screening diabetic patients at risk for foot ulceration. A multi-centre hospital-based study in France. Diabetes Metab. 2003;29(3):261–8.

    Article  CAS  PubMed  Google Scholar 

  19. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366(9498):1719–24.

    Article  PubMed  Google Scholar 

  20. Ismail K, Winkley K, Stahl D, Chalder T, Edmonds M. A cohort study of people with diabetes and their first foot ulcer: the role of depression on mortality. Diabetes Care. 2007;30(6):1473–9.

    Article  PubMed  Google Scholar 

  21. Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Armstrong DG, Harkless LB, Boulton AJ. The effects of ulcer size and site, patient’s age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers. Diabet Med. 2001;18(2):133–8.

    Article  CAS  PubMed  Google Scholar 

  22. Eneroth M, Apelqvist J, Stenström A. Clinical characteristics and outcome in 223 diabetic patients with deep foot infections. Foot Ankle Int. 1997;18(11):716–22.

    Article  CAS  PubMed  Google Scholar 

  23. Lawrence SM, Wraight PR, Campbell DA, Colman PG. Assessment and management of inpatients with acute diabetes-related foot complications: room for improvement. Intern Med J. 2004;34(5):229–33.

    Article  CAS  PubMed  Google Scholar 

  24. Pendsey S. Epidemiological aspects of diabetic foot. Int J Diab Dev Countries. 1994;14:37–8.

    Google Scholar 

  25. Nather A, Bee CS, Huak CY, Chew JL, Lin CB, Neo S, Sim EY. Epidemiology of diabetic foot problems and predictive factors for limb loss. J Diabetes Complications. 2008;22(2):77–82.

    Article  PubMed  Google Scholar 

  26. Rezende KF, Nunes MA, Melo NH, Malerbi D, Chacra AR, Ferraz MB. [In hospital care for diabetic foot: a comparison between the estimated cost and the SUS reimbursement]. Arq Bras Endocrinol Metabol. 2008;52(3):523–30.

    Article  PubMed  Google Scholar 

  27. Siitonen OI, Niskanen LK, Laakso M, Siitonen JT, Pyörälä K. Lower-extremity amputations in diabetic and nondiabetic patients. A population-based study in eastern Finland. Diabetes Care. 1993;16(1):16–20.

    Article  CAS  PubMed  Google Scholar 

  28. Tentolouris N, Al-Sabbagh S, Walker MG, Boulton AJ, Jude EB. Mortality in diabetic and nondiabetic patients after amputations performed from 1990 to 1995: a 5-year follow-up study. Diabetes Care. 2004;27(7):1598–604.

    Article  PubMed  Google Scholar 

  29. Papazafiropoulou A, Tentolouris N, Soldatos RP, Liapis CD, Dounis E, Kostakis AG, Bastounis E, Katsilambros N. Mortality in diabetic and nondiabetic patients after amputations performed from 1996 to 2005 in a tertiary hospital population: a 3-year follow-up study. J Diabetes Complications. 2009;23(1):7–11.

    Article  PubMed  Google Scholar 

  30. Izumi Y, Satterfield K, Lee S, Harkless LB, Lavery LA. Mortality of first-time amputees in diabetics: a 10-year observation. Diabetes Res Clin Pract. 2009;83(1):126–31.

    Article  PubMed  Google Scholar 

  31. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837–53.

    Article  Google Scholar 

  32. Holman RR, Paul SK, Bethel MA, Matthews DR, Neil HA. 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med. 2008;359:1–13.

    Article  Google Scholar 

  33. Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003;26(2):491–4.

    Article  PubMed  Google Scholar 

  34. Yesil S, Akıncı B, Yener S, et al. Predictors of amputation in diabetics with foot ulcer: single center experience in a large Turkish cohort. Hormones. 2009;8(4):286–95.

    Article  PubMed  Google Scholar 

  35. Adler AI, Erqou S, Lima TA, Robinson AH. Association between glycated haemoglobin and the risk of lower extremity amputation in patients with diabetes mellitus-review and meta-analysis. Diabetologia. 2010;53(5):840–9.

    Article  CAS  PubMed  Google Scholar 

  36. Genuth S, Nathan DM, Engel S, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353:2643–53.

    Article  CAS  PubMed  Google Scholar 

  37. Dormandy JA, Charbonnel B, Eckland DJ, et al. Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Lancet. 2005;366:1279–89.

    Article  CAS  PubMed  Google Scholar 

  38. Shichiri M, Kishikawa H, Ohkubo Y, Wake N. Long-term results of the Kumamoto Study on optimal diabetes control in type 2 diabetic patients. Diabetes Care. 2000;23(Suppl. 2):B21–9.

    PubMed  Google Scholar 

  39. Patel A, MacMahon S, Chalmers J, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med. 2008;358:2560–72.

    Article  CAS  PubMed  Google Scholar 

  40. Miyajima S, Shirai A, Yamamoto S, Okada N, Matsushita T. Risk factors for major limb amputations in diabetic foot gangrene patients. Diabetes Res Clin Pract. 2006;71(3):272–9.

    Article  PubMed  Google Scholar 

  41. Adler AI, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care. 1999;22(7):1029–35.

    Article  CAS  PubMed  Google Scholar 

  42. Resnick HE, Carter EA, Sosenko JM, Henly SJ, Fabsitz RR, Ness FK, Welty TK, Lee ET, Howard BV, Strong Heart Study. Incidence of lower-extremity amputation in American Indians: the Strong Heart Study. Diabetes Care. 2004;27(8):1885–91.

    Article  PubMed  Google Scholar 

  43. Moss SE, Klein R, Klein BE. The prevalence and incidence of lower extremity amputation in a diabetic population. Arch Intern Med. 1992;152(3):610–6.

    Article  CAS  PubMed  Google Scholar 

  44. Lehto S, Rönnemaa T, Pyörälä K, Laakso M. Risk factors predicting lower extremity amputations in patients with NIDDM. Diabetes Care. 1996;19(6):607–12.

    Article  CAS  PubMed  Google Scholar 

  45. Humphrey AR, Dowse GK, Thoma K, Zimmet PZ. Diabetes and nontraumatic lower extremity amputations. Incidence, risk factors, and prevention—a 12-year follow-up study in Nauru. Diabetes Care. 1996;19(7):710–4.

    Article  CAS  PubMed  Google Scholar 

  46. Lipsky BA, Sheehan P, Armstrong DG, Tice AD, Polis AB, Abramson MA. Clinical predictors of treatment failure for diabetic foot infections: data from a prospective trial. Int Wound J. 2007;4(1):30–8.

    Article  PubMed  Google Scholar 

  47. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL, Lew DP, Mader JT, Norden C, Tan JS, Infectious Diseases Society of America. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004;39(7):885–910.

    Article  PubMed  Google Scholar 

  48. Wagner FW. The dysvascular foot: a system of diagnosis and treatment. Foot Ankle. 1981;2:64–122.

    Article  PubMed  Google Scholar 

  49. Abbas ZG, Lutale JK, Game FL, Jeffcoate WJ. Comparison of four systems of classification of diabetic foot ulcers in Tanzania. Diabet Med. 2008;25(2):134–7.

    Article  CAS  PubMed  Google Scholar 

  50. Imran S, Ali R, Mahboob G. Frequency of lower extremity amputation in diabetics with reference to glycemic control and Wagner’s grades. J Coll Physicians Surg Pak. 2006;16(2):124–7.

    PubMed  Google Scholar 

  51. Lee JS, Lu M, Lee VS, Russell D, Bahr C, Lee ET. Lower-extremity amputation. Incidence, risk factors, and mortality in the Oklahoma Indian Diabetes Study. Diabetes. 1993;42(6):876–82.

    Article  CAS  PubMed  Google Scholar 

  52. Payne CB. Diabetes-related lower-limb amputations in Australia. Med J Aust. 2000;173(7):352–4.

    CAS  PubMed  Google Scholar 

  53. Smith D, Cullen MJ, Nolan JJ. The cost of managing diabetic foot ulceration in an Irish hospital. Ir J Med Sci. 2004;173(2):89–92.

    Article  CAS  PubMed  Google Scholar 

  54. Benotmane A, Mohammedi F, Ayad F, Kadi K, Medjbeur S, Azzouz A. Management of diabetic foot lesions in hospital: costs and benefits. Diabetes Metab. 2001;27(6):688–94.

    CAS  PubMed  Google Scholar 

  55. Zafar A. Management of diabetic foot–two years experience. J Ayub Med Coll Abbottabad. 2001;13(1):14–6.

    CAS  PubMed  Google Scholar 

  56. Currie CJ, Morgan CL, Peters JR. The epidemiology and cost of inpatient care for peripheral vascular disease, infection, neuropathy, and ulceration in diabetes. Diabetes Care. 1998;21(1):42–8.

    Article  CAS  PubMed  Google Scholar 

  57. Vaccaro O, Lodato S, Mariniello P, De Feo E. Diabetes-related lower extremity amputations in the community: a study based on hospital discharge diagnoses. Nutr Metab Cardiovasc Dis. 2002;12(6):331–6.

    CAS  PubMed  Google Scholar 

  58. Apelqvist J, Ragnarson-Tennvall G, Persson U, Larsson J. Diabetic foot ulcers in a multidisciplinary setting. An economic analysis of primary healing and healing with amputation. J Intern Med. 1994;235(5):463–71.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Endocrinology, Gaziantep University Faculty of Medicine, Gaziantep, Turkey

    Suzan Tabur

  2. Department of Endocrinology, Balıklıgol State Hospital, Sanliurfa, Turkey

    Mehmet Ali Eren

  3. Department of Internal Medicine, Nehır Medical Center, Sanliurfa, Turkey

    Yakup Çelik

  4. Department of Internal Medicine, Guney Derman Medical Center, Sanliurfa, Turkey

    Omer Faruk Dağ

  5. Department of Endocrinology, Faculty of Medicine, University of Harran, Sanliurfa, Turkey

    Tevfik Sabuncu

  6. Department of Internal Medicine, Gaziantep University Faculty of Medicine, Gaziantep, Turkey

    Zeynel Abidin Sayiner

  7. Division of Social Medicine, Department of Internal Medicine, Gaziantep University Faculty of Medicine, Gaziantep, Turkey

    Esen Savas

Authors
  1. Suzan Tabur
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mehmet Ali Eren
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Yakup Çelik
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Omer Faruk Dağ
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tevfik Sabuncu
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Zeynel Abidin Sayiner
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Esen Savas
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Suzan Tabur.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tabur, S., Eren, M., Çelik, Y. et al. The major predictors of amputation and length of stay in diabetic patients with acute foot ulceration. Wien Klin Wochenschr 127, 45–50 (2015). https://doi.org/10.1007/s00508-014-0630-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00508-014-0630-5

Keywords

Schlüsselwörter

Search

Navigation