Risk factors for major limb amputations in diabetic foot gangrene patients

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Abstract

We analyzed the clinical picture of diabetic foot lesion patients to investigate the risk factors for major limb amputations. The subjects were 210 diabetic foot lesion patients treated at our department over the past 9 years. The mean follow-up period was 604.5 [standard deviation (S.D.) 451.2] days with a median value of 492 days. There were 113 men and 97 women. By the final follow-up day, 18 underwent bypass surgeries (9%) and 13 skin grafts (6%), while 110 patients (52%) finally required limb amputation. The breakdown was 45 major amputations above or below the knee and 65 minor amputations of the toes or metatarsals. The outcomes of the major amputations were retrospectively analyzed by group. The blood glucose control was poor in all 45 major amputees, and their mean HbA1c (8.80%) was higher than that in the minor or non-amputation group (7.79%, P = 0.035). In the major amputation group, two patients had loss of vision due to retinopathy, and 30 patients received long-term hemodialysis due to nephropathy. The rate of arteriosclerosis obliterans (ASO) was higher in the major amputation group than in the minor or non-amputation group, and arteriography showed significantly high rates of multiple stenosis. Multivariate analysis of these results by the proportional hazard model showed that ASO with multiple stenosis (hazard ratio 3.23, 95% CI: 1.12–5.10), hemodialysis (2.14, 95% CI: 1.17–3.44), and HbA1c (1.20, 95% CI: 1.03–1.41) were independent risk factors for major amputation. The 3-year survival rate was 24.1% in the major amputation group and 93.0% in the minor or non-amputation group, and the life expectancy was significantly lower for the major amputees than the minor or non-amputees (P < 0.0001). Together with early detection and treatment of foot lesions, good blood glucose control and early management of systemic complications such as nephropathy and arteriosclerosis are considered important to avoid major amputations.

Introduction

According to a WHO study [1], the rates of gangrene and amputation due to diabetes mellitus are lower in Japan than in the other countries including the United States. However, in a study published by the Japanese Ministry of Health and Welfare in 2004 [2], the number of diabetic patients has already exceeded 7,400,000, and foot lesion complications are also increasing. The diabetic foot lesions are intractable, and aggravation often unavoidably leads to amputation. In the West, various reports are available on the risk factors for diabetic complications from early stage, aiming to avoid the severely reduced QOL of amputation [3], [4], [5]. In Japan, however, little data on the risk factors for amputation among the diabetic foot lesion patients are available, even in the field of dermatology. We retrospectively examined 210 patients who had been treated for diabetic foot gangrene to analyze the risk factors for major limb amputation.

Section snippets

Methods

The subjects were 210 patients who were examined at our department and diagnosed and treated for diabetic foot lesions between July 1997 and August 2003. During this period, major amputation above or below the knee was necessary in 45 of the patients. Based on their clinical picture, we examined the risk factors affecting the functional prognosis in diabetic foot lesions.

We first analyzed the sex, age at diagnosis, diabetic history, level of blood glucose control, diabetic complications, the

Results

The subjects of our analysis were 210 patients with a mean follow-up period of 604.5 [standard deviation (S.D.) 451.2] days and a median value of 492 days. The age of the 210 subjects ranged from 20 to 87 years, with a mean of 64.2 (S.D. 9.8) years and a median value of 65 years. There were 113 men and 97 women. The mean male age was 63.9 (S.D. 8.7) years with a median value of 65 years, and the mean female age was 64.2 (S.D. 9.8) years with a median value of 65 (NS, P = 0.110) years. The

Discussion

In the West, diabetic patients have a 10–15 times greater risk of lower extremity amputation than non-diabetic patients [7], [8]. Major amputation also greatly restricts the postoperative ADL of the patient. According to Larsson et al. [9], 50% of the major amputees can be fitted with a device after surgery, and 52% of the below-knee amputees can walk independently, while in the more proximal amputations the number of ambulatory patients is significantly less, and it is reportedly a restricting

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