Original Articles
Change in Major Amputation Rate in a Center Dedicated to Diabetic Foot Care During the 1980s: Prognostic Determinants for Major Amputation

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Abstract

From 1990 to 1993, 115 diabetic patients were consecutively hospitalized in our diabetologic unit for foot ulcer and 27 (23.5%) major amputations were carried out. The major amputation rate of this series of cases was compared with that occurring in diabetic subjects taken into our hospital for foot ulcer in two previous periods: 1979–1981 (17 major amputations in 42 inpatients or 40.5%) and 1986–1989 (26 major amputations in 78 inpatients or 33.3%). The comparison shows a progressive reduction in major amputation rate [Odds ratio 0.66, 95% confidence interval (CI) 0.46–0.96]. Univariate and multivariate analysis, carried out in the population of the 1990–1993 period, in order to detect the independent factors associated with major amputation show the following prognostic determinants of major amputation: Wagner grade (odds ratio 7.69, CI 1.58–37.53), prior stroke (odds ratio 35.05, CI 3.14– 390.53), prior major amputation (odds ratio 3.49, CI 1.26–9.38), transcutaneous oxygen level (odds ratio 1.06, CI 1.01–1.12), and ankle-brachial blood pressure index (odds ratio 4.35, CI 1.58–12.05), while an independent protective role was attributed to hyperbaric oxygen treatment (odds ratio 0.15, CI 0.03–0.64). In accordance with other studies, we, therefore, conclude that a comprehensive protocol as well as a multidisciplinary approach in a dedicated center can assure a decrease in major amputation rate. The parameters of limb perfusion were the modifiable prognostic determinants most strongly predictive for amputation.

Introduction

Aprimary target for diabetes care is to try and reduce the number of amputations.1, 2In some centers, use of a multidisciplinary approach,[3]extensive patient education,[4]and arterial reconstruction,[5]this objective has been reached in a series of cases including subjects without or with mild ulcers. In our diabetology center, we began dealing with foot lesions in diabetic patients in 1982. During the following years, a comprehensive clinical protocol for outpatient and inpatient diabetic subjects with foot lesions was created. Patients were admitted to the hospital if they had either full-thickness gangrene or abscess. Subjects with superficial ulcer were also admitted if the ulcer was large, infected, and showed a defective healing in 30 days of outpatient treatment. The aim of this study is to report the evolution that took place in our hospital between the end of the 1970s and the beginning of the 1990s, in the prevalence of major amputations in hospitalized diabetic patients with severe foot ulcer, and to assess in our cases the prognostic determinants involved in major amputations.

Section snippets

Methods

During the period 1990–1993, criteria for admission to hospital and therapeutic–diagnostic protocol were standardized according to the experience gained in the previous years. We compare the major amputation rate of this period with the amputation rate of two previous periods. In the population of the last period, the prognostic determinants involved in major amputation were investigated.

Major Amputations

From 1979 to 1981, 42 diabetic patients were admitted to the surgical department of our hospital for foot ulcer, and 17 major amputations were performed (40.5%).[17]From 1986 to 1989, 78 subjects were hospitalized in our diabetologic unit, and 26 (33.3%) major amputations were carried out. In the present series of cases of 115 patients, 27 (23.5%) major amputations have been carried out. Comparing these three periods, a trend in the decrease of the percentage of major amputations can be

Discussion

It is not easy to evaluate the results attained from conservative treatment when a severe foot ulceration has been established and “… in the amputation literature historical and remote geographic `controls' are commonly used.”18 The comparison we have carried out shows that the percentage of major amputations has progressively decreased in our hospital during the 1980s. We believe that this result has been attained because of the possibility of treating these patients in a “foot clinic” by a

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