Towards less amputations in diabetic patients: Incidence, causes, cost, treatment, and prevention—a review

Incidence of Lower-Limb Amputation in the Diabetic and Nondiabetic General Population

“…Approximately one-third of all amputations in both studies were toe amputations, which were not included in our study. A study that compared continuous registration of all amputations with the official patient register reported that only 36% of the diabetes-related amputations were noted in the official register and that the finding was in agreement with that in several other studies (8). Missing data are more likely to involve toe or ray-level amputations, as they are often performed in an emergency room or outpatient clinic and therefore are not registered in the surgical databases.…”

“…A literature review showed that in many previous studies the reported incidence rates were based on number of all "amputations" (7), which would imply that individuals were allowed to count more than once and continue to accrue person-time after the initial amputation. Without distinguishing the initial amputation from a reamputation and contralateral amputation, the incidence rates reported in such studies are likely to reflect multiple procedures performed on the same patient, which is more common at the foot level in diabetic patients (8).…”

“…However, the definitions of "major" and "minor" amputation used in various studies have been inconsistent, making comparisons difficult. For example, a major amputation has been defined in various studies as one extending from the tarsometatarsal joint (19), the "midfoot" (18), or the ankle (Symes) (8) and even beginning from the transtibial level (9). Furthermore, incidence rates based on amputations from the transmetatarsal level that exclude the most distal amputations are probably more accurate and have greater clinical significance with regard to the effects on functional mobility of the patients and the total cost of hospitalization (25).…”

“…These incidence rates were usually based on the total population rather than on age-groups of the diabetic or the nondiabetic general population in which severe peripheral vascular disease usually occurs (7). Furthermore, different definitions and incidence estimation methods have been used, and problems of incorrectly registered diagnoses and missing data have been described (3,8). Individuals with diabetes have accounted for less than half of all patients with LLA in studies from Finland and Sweden (5,9) but for as much as two-thirds of patients with LLA in a German general population study (6).…”

The inpatient care of patients with diabetes mellitus and foot ulcers. A validation study of the correspondence between medical records and the Swedish Inpatient Registry with the consequences for cost estimations

“…This agrees closely with a previous finding in which only 36% of the diabetes-related amputations were noted in the Inpatient Registry [12]. Therefore, calculating the cost of surgical procedures for this patient category using data from the Inpatient Registry, will likely underestimate costs regardless of how the primary or secondary diagnoses are selected.…”