Predicting Amputation in Patients With Diabetic Foot Ulcers: A Systematic Review

Abstract

Foot ulcers are a leading cause of morbidity in diabetics. One of the known complications of diabetic foot ulcers is lower limb amputation which makes it a major socioeconomic problem. Currently, there's a lack of knowledge on the predictors of amputations in diabetics with foot ulcers. We performed a systematic review of studies that identified risk factors of amputation in patients with diabetic foot ulcers. This systematic review aims to identify the predictors of amputation in order to optimize the management strategy and care plan. Medline database was searched and inclusion criteria were implemented for the selection of studies. The risk factors extracted were part of four categories: (i) history and physical examination, (ii) ulcer characteristics, (iii) lab results, and (iv) co-morbidities. The data extracted were in the form of odds ratios, 95% confidence intervals, and predictive values. The mean values with standard deviations of the included risk factors were recorded, and the incidence of risk factors among the amputation groups was identified or calculated when the data were sufficient. Seven articles were selected reporting on 3481 patients. This review identified peripheral arterial disease, neuropathy, high Wagner's grade, osteomyelitis, postprandial glucose level, white cell count, c-reactive protein, erythrocyte sedimentation rate, low hemoglobin, and albumin as the most significant predictors of amputation.

Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta‐analysis

“…Bigger, more homogeneous samples are mandatory for this examination and that would affect the significance and the level of confidence in some of the tested parameters, for example, body mass index and glycated haemoglobin. This was also emphasised in preceding studies that used a linked meta‐analysis technique and found equivalent values of the influence 58‐61 . Although the meta‐analysis was incapable to discover if differences in these characteristics are related to the outcomes being researched, properly‐led RCTs are vital to consider these aspects as well as the mixture of different ethnicities of subjects.…”

Risk factor analysis for diabetic foot ulcer‐related amputation including Controlling Nutritional Status score and neutrophil‐to‐lymphocyte ratio

“…Wagner grading was used to assess ulcer depth, osteomyelitis and necrosis/gangrene on a scale ranging from 0 to 5. Almost all DFU‐related amputation risk studies have highlighted the reliability of the Wagner classification in predicting amputation 16,17 . Because of the ulcer severity that increases with the Wagner classification grade, more extensive wounds often require amputation.…”

“…Our results supported this finding, with an amputation rate of 50.1% ( n = 195) for forefoot ulcer (OR = 0.130, 95% CI = 0.061–0.277) and a median amputation‐free survival time of 4 months. PAD, a marker of atherosclerosis, has been widely discussed as an independent risk factor for DFU‐related amputation 17 . One study of cardiovascular disease risk factors found that the relative risk of cardiovascular death in patients with PAD was 1.69 21 .…”

“…Almost all DFU-related amputation risk studies have highlighted the reliability of the Wagner classification in predicting amputation. 16,17 Because of the ulcer severity that increases with the Wagner classification grade, more extensive wounds often require amputation. In our study, the risk of amputation was significantly increased in moderate-to-severe cases (Wagner grade 3-5) (OR = 59.804, 95% CI = 20.299-176.190), and the median amputation-free survival time was 3 months.…”

“…PAD, a marker of atherosclerosis, has been widely discussed as an independent risk factor for DFU-related amputation. 17 One study of cardiovascular disease risk factors found that the relative risk of cardiovascular death in patients with PAD was 1.69. 21 PAD can lead to intermittent claudication, rest pain, refractory ulcer and gangrene.…”