Factors Related to Amputation Level and Wound Healing in Diabetic Patients

Baumfeld, Daniel; Baumfeld, Tiago; Macedo, Benjamim; Pinto, Roberto Zambelli de Almeida; Lopes, Fernando Araújo Silva; Nery, Caio

doi:10.1590/1413-785220182605173445

Cited by 24 publications

(16 citation statements)

References 13 publications

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“…Our finding of a 9.6% increase in subsequent minor LA is supported by Dillingham et al who report higher rates of reamputation after minor primary amputation in people with PAD [ 10 ]. The desire for limb preservation to enhance function as a possible precursor to revision amputation is well documented and may be the reason for the high rate of subsequent minor LA in our population [ 41 , 42 ].…”

Section: Discussionmentioning

confidence: 99%

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006–2019: a population-based study

Essien

Linassi

Farnan³

et al. 2021

BMC Surg

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Background Understanding trends in limb amputation (LA) can provide insight into the prevention and optimization of health care delivery. We examine the influence of primary (first report) and subsequent (multiple reports) limb amputation on the overall (all reports) rate of limb amputation in Saskatchewan considering amputation level. Methods Hospital discharged data associated with LA from 2006 to 2019 and population estimates in Saskatchewan were used. LA cases were grouped based on overall, primary, and subsequent LA and further divided by level into major (through/above the ankle/wrist) and minor (below the ankle/wrist). Incidence rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial were used to analyze the trends. In addition, the top three amputation predisposing factors (APF) were described by LA groups. Results The rate of overall LA and primary LA remained stable (AAPC − 0.9 [95% CI − 3.9 to 2.3]) and (AAPC −1.9 [95% CI −4.2 to 0.4]) respectively, while the rate of subsequent LA increased 3.2% (AAPC 3.2 [95% CI 3.1 to 9.9]) over the 14-year study period. The rate of overall major LA declined 4.6% (AAPC − 4.6 [95% CI −7.3 to −1.7]) and was largely driven by the 5.9% decline in the rate of primary major LA (AAPC − 5.9 [95% CI − 11.3 to –0.2]). Subsequent major LA remained stable over the study period (AAPC −0.4 [95% CI − 6.8 to 6.5]). In contrast, the overall rate of minor LA increased 2.0% (AAPC 2.0 [95% CI 1.0 to 2.9]) over the study period which was largely driven by a 9.6% increase in the rate of subsequent minor LA (AAPC 9.6 [95% CI 4.9 to 14.4]). Primary minor LA rates remained stable over the study period (AAPC 0.6 [95% CI − 0.2 to 1.5]). The study cohorts were 1.3-fold greater risk of minor LA than major LA. Diabetes mellitus (DM) was the leading APF representing 72.8% of the cohort followed by peripheral vascular disease (PVD) and trauma with 17.1 and 10.1% respectively. Most (86.7%) of subsequent LA were performed on people with DM. Conclusions Overall LA rates remained stable over the study period with declining rates of major LA countered by rising rates of minor LA. Minor LA exceeded major LA with the largest rate increase identified in subsequent minor LA. Diabetes was the greatest APF for all LA groups. This rising rate of more frequent and repeated minor LA may reflect changing intervention strategies implemented to maintain limb function. The importance of long-term surveillance to understand rates of major and minor LA considering primary and subsequent intervention is an important step to evaluate and initiate prevention and limb loss management programs.

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Section: Discussionmentioning

confidence: 99%

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006–2019: a population-based study

Essien

Linassi

Farnan³

et al. 2021

BMC Surg

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“…identified in the infected ulcers of DFU patients were associated with a much higher risk of major amputation . Baumfeld et al found that risk factors for major amputations were ischaemia and previous amputations history, and antibiotic therapy before operations appeared to be a protective factor . Khalfallah et al reported that age was the only independent predictor for major lower‐extremity amputation (LEA) in DFU patients with a threshold age value of no less than 65 years in their study .…”

Section: Introductionmentioning

confidence: 91%

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

Guo

Yue

Qian

et al. 2019

International Wound Journal

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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.

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“…45 Amputation levels in studies included in this review, while all classified as minor, varied from toe amputations 20 , 21 , 26 – 28 through to ray, 20 , 23 , 25 midfoot and TMAs. 20 , 21 , 23 , 24 , 26 – 29 While the initial amputation level is chosen to preserve as much of the foot as possible while still allowing healing, 46 more distal amputations have been associated with slower healing, 33 , 47 higher complication rates 48 and increased rates of revision amputations, 49 compared to more proximal amputations.…”

Section: Discussionmentioning

confidence: 99%

Do toe blood pressures predict healing after minor lower limb amputation in people with diabetes? A systematic review and meta-analysis

Linton

Searle

Hawke

et al. 2020

Diabetes and Vascular Disease Research

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Purpose of study: To investigate toe systolic blood pressure and/or toe-brachial pressure index in predicting healing post minor diabetic foot amputations. Key methods: A systematic search of EMBASE and PubMed (including Medline and The Cochrane Library) was conducted from database inception to 9 March 2020. Two authors independently reviewed and selected relevant studies. Quality was assessed with a modified Critical Appraisal Skill Programme checklist. Main results: Ten studies met the inclusion criteria. Nine studies investigating toe systolic blood pressure reported healing occurred at mean toe systolic blood pressure values ⩾30 mmHg, ranging between 30 and 83.6 mmHg. The meta-analysis (four studies) found toe systolic blood pressure <30 mmHg had 2.09 times the relative risk of non-healing post amputation, compared to toe systolic blood pressure ⩾30 mmHg (relative risk = 2.09, 95% confidence interval: 1.37–3.20, p = 0.001). Two studies investigating toe-brachial pressure index report successful healing where toe-brachial pressure index >0.2, with one study reporting a higher value of 0.8. Main conclusions: Successful post-amputation healing outcomes were reported at mean toe systolic blood pressure ⩾30 mmHg, and the results varied considerably between the studies. Further research should identify whether variables, including amputation level, method of wound closure and length of post-operative follow-up periods, affect the values of toe systolic blood pressure and toe-brachial pressure index observed in this review.

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Factors Related to Amputation Level and Wound Healing in Diabetic Patients

Cited by 24 publications

References 13 publications

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006–2019: a population-based study

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006–2019: a population-based study

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

Do toe blood pressures predict healing after minor lower limb amputation in people with diabetes? A systematic review and meta-analysis

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