Spectrum of disease and outcome of primary amputation for diabetic foot sepsis in rural KwaZulu-Natal

Abstract

Background: Primary amputation (stump closure) for diabetic foot sepsis is perceived to have a higher re-amputation rate due to stump sepsis. A guillotine amputation with elective stump closure is widely practised due to the lower risk of stump sepsis and re-amputation. Aims: To provide an epidemiological analysis of the spectrum of disease and outcomes of primary amputation for diabetic foot sepsis in a regional rural hospital. Methods: A prospective cohort study of 100 patients who underwent surgery for diabetic foot sepsis over a 5-year period was undertaken at Madadeni Provincial Hospital, in northern KwaZulu-Natal. Demographic data, co-morbid profile, radiographic features, anatomical level of vascular occlusion and type of surgery performed were recorded. The Wagner classification (Wag) was used to classify disease severity. Outcome measures included length of hospital stay, in-hospital mortality and re-amputation rates. Results: Of the 100 patients, females (n = 50) accounted for 50% of admissions. The median age was 61 years (range: 29 to 80 years). Most patients presented with advanced disease: Wag 5, n = 71 (71%); Wag 4, n = 20 (20%); Wag 3, n = 7 (7%); Wag 2, n = 2 (2%). The anatomic levels of vascular occlusion comprised: aortoiliac disease n = 2 (2%), femoropopliteal n=21(21%) and tibioperoneal disease n = 77 (77%). The following surgical procedures were undertaken: above knee amputation (AKA), n = 35 (35%); below knee amputation (BKA), n = 46 (46%); transmetatarsal amputation (TMA), n = 8 (8%); toe ectomy, n = 8 (8%) and debridement, n = 3 (3%). The re-amputation rate to above knee amputation was n = 2/46 (4.3%). All AKA stumps healed completely. The overall in-hospital mortality was n = 7 (7%) and median length of hospital stay was 7.8 ± 3.83 days. Conclusion: Most patients present with advanced disease requiring a major amputation. A definitive one stage primary amputation is a safe and effective procedure for diabetic foot sepsis with distinct advantages of a short hospital stay, low reamputation rates and mortality. A guillotine amputation should be reserved for physiologically unstable patients.

RETRACTED: Risk factors for amputation in diabetic foot ulcers: A retrospective analysis

“…Although it has high diagnostic value, some patients have unclear local infection symptoms and cannot quantitatively analyse the risk of infection, and its application is limited 12 . Related studies have pointed out that various inflammatory indicators are related to the occurrence and development of infections in the body, and can be used to early evaluate the risk of infection 13 . This study retrospectively studied the clinical data of DFU and explored the risk factors related to DFU amputation, aiming to provide theoretical basis for the prevention and treatment of DFU 14 .…”

“…12 Related studies have pointed out that various inflammatory indicators are related to the occurrence and development of infections in the body, and can be used to early evaluate the risk of infection. 13 This study retrospectively studied the clinical data of DFU and explored the risk factors related to DFU amputation, aiming to provide theoretical basis for the prevention and treatment of DFU. 14 Binary logistic regression analysis showed that the independent risk factors for DFU amputation include elevated CRP, elevated WBC count, elevated NLR and elevated Wagner grading.…”

Evolving Indications for Lower Limb Amputations in South Africa Offer Opportunities for Health System Improvement

“…A study from the rural town of Newcastle in the northern part of the province identified 100 patients requiring LLA for diabetes over a 4-year period. [19]. These figures are very much in keeping with our own.…”

Diabetes and lower extremity amputation -rehabilitation pathways and outcomes at a regional hospital

“…25,26 There is variability in the prevalence of amputation levels in the lower extremity among different studies. BKAs predominated in this series, an observation made by other local 21 and international studies. 17,18,24 Other studies, however, have shown a predominance of AKAs.…”

“…7,8,[17][18][19] The majority of diabetic-related amputations are preceded by foot ulcers which act as a portal for infection leading to sepsis or gangrene that may require amputation. 21,22 This is further compounded in diabetics by peripheral vasculopathy and neuropathy which also contribute to the risk of amputation. 23 There is geographical variation in amputation rates worldwide.…”