Lower extremity amputations - a review of global variability in incidence

Diabetic patients have an increased risk of lower extremity amputations (LEAs). In the present study we analyzed the incidence of LEA in patients with type 2 diabetes mellitus (T2DM) in Taiwan from 2001 to 2010, and determined risk factors for LEA. Data from the Taiwan National Health Insurance Research Database collected between 1 January 2001 and 31 December 2010 were analyzed. First, the incidence of LEA in the diabetic population was calculated. Subsequently, patients with new-onset T2DM during the study period were selected, and Cox's proportional hazards model was used to identify factors associated with LEA. The characteristics of patients who underwent major and multiple amputations were also analyzed. From 2001 to 2010, 1588 non-traumatic LEAs were performed among the study subjects; 776 (48.9%) were minor and 812 (51.1%) were major LEAs. Over the period in question, the incidence of LEAs decreased from 3.08 to 1.65 per 1000 person-years. Factors associated with LEA included peripheral arterial occlusive disease (hazard ratio [HR] 4.134; 95% confidence interval [CI] 2.72-6.29), diabetic neuropathy (HR 2.34; 95% CI 1.62-3.38), diabetic retinopathy (HR 2.07; 95% CI 1.12-3.82), heart failure (HR 2.13; 95% CI 1.45-3.15), male gender (HR 1.64; 95% CI 1.24-2.18), and adult onset diabetes (HR 1.02; 95% CI 1.01-1.04). Patients with a history of stroke were more likely to undergo major and multiple amputations (P < 0.001 and P < 0.01, respectively). The incidence of LEA in the Taiwan diabetic population decreased over the study period. The results indicate that efforts to improve diabetic care should be supported and sustainable, especially for those at high risk.

1369-P: The Natural Trends in Incidence of Lower Extremity Amputations in South Korea, 2003–2021

We analyzed the incidence of lower extremity amputations (LEAs) in the 3rd Health Care Area of Madrid before and after the March 2008 introduction of a multidisciplinary team for managing diabetic foot disease. We compared the amputation rates in people with and without diabetes during 2 periods: before (2001-2007) and after (2008-2011) the introduction of a Multidisciplinary Diabetic Foot Unit (MDFU). We also analyzed the trend of the amputation rates by joinpoint regression analysis and measured the annual percentage change (APC). During the study period, 514 nontraumatic LEAs were performed, 374 (73%) in people with diabetes and 140 (27%) in people without the disease. The incidence of LEAs showed a significant reduction in major amputations in people with diabetes, from 6.1 per 100 000 per year (95% confidence interval [CI] = 4.9 to 7.2), in the 2001 to 2007 period, to 4.0 per 100 000 per year (95% CI = 2.6 to 5.5) in the 2008 to 2011 period (P = .020). There were no changes in incidence of minor or total amputations in the diabetic population or in amputations in the nondiabetic population during the study period. Joinpoint regression analysis showed a significant reduction in the incidence of major LEAs in diabetic population with an APC of -6.6% (95% CI = -10.2 to -2.8; P = .003), but there were no other significant changes. This study demonstrates that the introduction of a multidisciplinary team, coordinated by an endocrinologist and a podiatrist, for managing diabetic foot disease is associated with a reduction in the incidence of major amputations in patients with diabetes.

67-OR: Longitudinal Trends in Diabetic Foot Ulcers and Lower Extremity Amputations before and after the COVID-19 Pandemic

Background: The study is to determine the relation between the high HbA1c and ESR as prognostic factors with the severity of the diabetic foot ulcer disease, particularly, in predicting the final outcome in the form of higher incidence of lower extremity amputation (LEA) and/or prolonged hospital stay. The study explored the importance of increased level of serum HbA1c and erythrocyte sedimentation rate (ESR) in determining the final outcome of the disease. It revealed that the severity of diabetic foot ulcer disease is more in patients who had concomitant high levels of baseline HbA1c and ESR on admission.Methods: This observational study was done in 89 patients who were admitted in the surgical wards of the two teaching hospitals in India. The cohort consisted of patients from the age of 26 to 83 years of age who presented with clinically infected foot ulcers. Routine blood tests were done which include HbA1C on the day of admission and fasting ESR (1st hour) on the next day morning. The standard X-ray plates were routinely taken on the first day for determination of the involvement of underlying bones and soft tissues. The outcome of the diabetic foot ulcer was assessed from the severity of the disease according to Meggit-Wagner classification, the incidence of lower extremity amputation and the duration of hospital stay.Results: The high levels of baseline HbA1C (more than 7.0%) in blood on the first day of admission was found in all of the 89 patients who were included in this study but the criteria for consideration of high risk was more than 9% which was found in 41 patients. The criteria for consideration of high ESR in this study was set to be 50 mm/h. High ESR of more than 50 mm was found in 63 patients. We had subdivided 31 patients into a High Risk Group whose baseline levels of HbA1C &gt; 9% and ESR &gt; 50 mm/h. The incidence of amputation was 79.31% and 44.44% with HbA1c of more than 9.0% and ESR of more than 50 mm respectively and was considerably increased (83.87%) when both HbA1c and ESR were more than the critical value as set in the study. Similarly, the incidence of prolonged hospital stay of more than 14 days was 58.54% in patients with HbA1C level of greater than 9 %, 51.85% in patients with baseline ESR &gt; 50 mm/h and 93.55% in presence of high levels of both HbA1C (&gt;9%) and ESR (&gt;50 mm/h)..Conclusions: The study observed that the patients who presented with baseline high levels of HbA1C, ESR or both on admission had unfavourable prognosis with increased incidence of lower extremity amputation and prolonged hospital stay than the other patients in the cohort.

Aim To assess trends in lower extremity amputation (LEA) incidence in European Union (EU15+) countries for the years 1990-2017. Method This was an observational study using data obtained from the 2017 Global Burden of Disease (GBD) Study. Age standardised incidence rates (ASIRs) for LEA (stratified into toe amputation, and LEA proximal to toes) were extracted from the GBD Results Tool (http://ghdx.healthdata.org/gbd-results-tool) for EU15+ countries for each of the years 1990-2017. Trends were analysed using Joinpoint regression analysis. Results Between 1990 and 2017, variable trends in the incidence of LEA were observed in EU15+ countries. For LEAs proximal to toes, increasing trends were observed in six of 19 countries and decreasing trends in nine of 19 countries, with four countries showing varying trends between sexes. For toe amputation, increasing trends were observed in eight of 19 countries and decreasing trends in eight of 19 countries for both sexes, with three countries showing varying trends between sexes. Australia had the highest ASIRs for both sexes in all LEAs at all time points, with steadily increasing trends. The USA observed the greatest reduction in all LEAs in both sexes over the time period analysed (LEAs proximal to toes: female patients 22.93%, male patients 29.76%; toe amputation: female patients 29.93%, male patients 32.67%). The greatest overall increase in incidence was observed in Australia. Conclusions Variable trends in LEA incidence were observed across EU15+ countries. These trends do not reflect previously observed reductions in incidence of PAOD over the same time period.

1497-P: Secular Trends in Incidence and One-Year Mortality Rates of Lower Extremity Amputation in People with Diabetes in Hong Kong between 2001 and 2016

To examine the association of retinal vascular changes with the incidence of lower extremity amputations (LEAs) in a cohort with diabetes mellitus. Baseline examinations were performed in a cohort of 996 persons with diabetes diagnosed before the age of 30 years and using insulin. History of LEA was obtained at baseline and at 4, 10, 14, and 20 years. The cumulative 20-year incidence of first LEA was calculated by the product-limit method in 906 persons with follow-up information. Retinal arterioles and venules were measured on digitized fundus photographs obtained at baseline by a standard protocol. Generalized arteriolar narrowing was defined as the lowest 25% of the arteriole-venule ratio. Measurements were obtained in at least one eye for 820 persons. Focal arteriolar narrowing and arteriovenous nicking were also determined from fundus photographs by a standard protocol. The 20-year cumulative incidence of LEAs was 9.9%. The unadjusted risk of undergoing a LEA was higher in persons with generalized arteriolar narrowing than in those without it (15.7% vs 5.7%; odds ratio [OR], 3.08; 95% confidence interval [CI], 1.60-4.68), and in persons with focal narrowing (33.1% vs 6.8%; OR, 5.59; 95% CI, 3.27-9.54). The results for arteriovenous nicking were not significant. With control for age, sex, levels of glycosylated hemoglobin, diastolic blood pressure, and history of ulcers of the feet, the relationships were attenuated but still statistically significant for both generalized narrowing (OR, 1.89; 95% CI, 1.06-3.35) and focal narrowing (OR, 3.56; 95% CI, 1.87-6.78). In persons with diabetes, generalized as well as focal retinal arteriolar narrowing may reflect damage to the microvasculature, which manifests itself elsewhere in the body as a need for LEAs.

One of the most devastating complications of diabetes is diabetes-related foot disease (DFD), which is a priority for public health systems. The 2016-2020 Catalonia Health Plan aimed to reduce the incidence of total and major lower-extremity amputations (LEAs) due to DFD by 10% in the population aged 45-74 years. The aim of the present study was to compare the incidence of LEA-DFD 5 years before and after the creation of the Diabetic Foot Multidisciplinary Unit at our Hospital. We prospectively collected all cases of LEA-DFD performed at Vall d'Hebron University Hospital from 1 January 2016 to 31 December 2020. Cases of LEA-DFD performed from 1 January 2011 to 31 December 2015 were retrospectively reviewed. The incidence of LEA-DFD between these periods was compared. A total of 457 LEAs due to DFD were performed in 316 patients. We observed a reduction of 27.9% [CI: 23.7-32.1%] in the incidence of total LEA in the 2016-2020 period in comparison with the period 2011-2016 (0.8 ± 0.1 vs. 1.1 ± 0.3 per 10.000 inhabitants/year, p < 0.001), as well as a reduction of 49.3% [CI: 44.6-53.9%] in the incidence of major LEA-DFD (0.15 ± 0.1 vs. 0.30 ± 0.1 per 10.000 inhabitants/year, p < 0.001). The implementation of a Diabetic Foot Multidisciplinary Unit resulted in a significant reduction in the rate of amputations due to DFD in the population with diabetes in North Barcelona.

Retinal vascular changes and 20-year incidence of lower extremity amputations in a cohort with diabetes

Background: There is minimal focus on traumatic lower-extremity amputations due to their relatively low incidence, but they often come with a higher morbidity and mortality than their upper extremity counterparts. The purpose of this study was to evaluate the incidence and trends of lower extremity amputations in the United States over 10 yr. Methods: The National Electronic Injury Surveillance System (NEISS) was queried from 2008 to 2017 for lower-extremity amputations presenting to United States emergency departments. Date of presentation, age at presentation, amputated appendage, disposition, and cause of the amputation were reported and used for statistical analysis. Results: From 2008 to 2017, 393 patients were reported to have sustained lower-extremity amputations within the NEISS database with an estimated total of 11,475 patients sustaining a lower-extremity amputation over the past 10 yr and an incidence of 2.2 per 100,000 person-years. The incidence of lower-extremity amputations is highest in those under 5 years old. Lawnmowers were the most common mechanism of injury in all age groups. Discussion: Due to the high morbidity and mortality associated with these injuries, it is prudent to follow the trends in lower-extremity amputations. This is particularly important in promoting awareness and prevention of the more common mechanisms such as lawnmower incidents. Level of Evidence: Level IV.

Category:TraumaIntroduction/Purpose:Currently there is minimal focus on traumatic lower extremity amputations due to their relatively low incidence, but they often come with a higher morbidity and mortality than its upper extremity counterparts. The purpose of this study was to evaluate the incidence and trends of lower extremity amputations in the United States over a ten-year period.Methods:The National Electronic Injury Surveillance System (NEISS), was used for evaluation of lower extremity amputations that presented to the United States emergency departments. The overall incidence rate of lower extremity amputations within the United States was calculated as per 100,000 persons. After grouping mechanisms of injury, the data were stratified by both age groups and gender. Chi-square tests were used for direct comparisons of proportions. The five most common mechanisms were ranked for each age group and the most common overall age group for lower extremity amputations were determined using descriptive statistics. Trends for injury incidence and hospital admissions were evaluated using linear regression and Pearson correlation with Bonferroni correction.Results:From 2008 to 2017, 393 patients were reported to have sustained lower extremity amputations via the NIESS database with an estimated 11,475 patients sustaining a lower extremity amputation over the past ten years and an incidence of 2.2/100,000 person-years. The incidence of lower extremity amputations is highest in those less than five years old. Lawnmower incidents are the most common mechanism of injury in all age groups.Conclusion:Due to the high morbidity and mortality associated with these injuries, it is prudent to follow the trends in lower extremity amputations.

This study analysed the incidence of lower extremity amputation and its associated risk factors in patients with diabetic foot ulcers. This study systematically searched both Chinese and English databases, including CNKI, Wanfang, VIP, PubMed, EMBASE and Web of Science, to identify cohort studies related to lower extremity amputation and associated risk factors in patients with diabetic foot ulcers up to October 2023. The patients were stratified based on whether they underwent lower extremity amputation, and relevant data, including basic information, patient characteristics, complications, comorbidities and pertinent laboratory test data, were extracted from the included studies. The literature quality assessment in this study utilized the Newcastle‐Ottawa Scale to screen for high‐quality literature, resulting in the inclusion of 16 cohort studies, all of which were of at least moderate quality. Meta‐analysis of outcome indicators was conducted using the Stata 14.0 software. The results indicate that the overall amputation rate of lower extremities in patients with diabetic foot ulcers is 31% (0.25, 0.38). Among the 16 variables evaluated, gender (male), smoking history, body mass index (BMI), hypertension, cardiovascular disease, kidney disease, white blood cell count, haemoglobin and albumin levels were found to be correlated with the occurrence of lower extremity amputation in patients with diabetic foot ulcers. However, no significant correlation was observed between age, diabetes type, duration of diabetes, stroke, glycosylated haemoglobin, creatinine and total cholesterol levels and lower extremity amputation in patients with diabetic foot ulcers. This meta‐analysis indicates that the overall amputation rate in patients with diabetic foot ulcers is 31%. Factors such as gender (male), smoking history, high BMI, hypertension, cardiovascular disease, kidney disease, white blood cell count, haemoglobin and albumin levels are identified as significant risk factors for lower extremity amputation in diabetic foot ulcer patients. These findings suggest that attention should be focused on these risk factors in patients with diabetic foot ulcers to reduce the risk of lower extremity amputation. Therefore, preventive and intervention measures targeting these risk factors are of significant importance in clinical practice. (Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier [CRD42024497538]).

Diabetes-related lower extremity amputations (LEA) are high cost and high prevalence. Individuals with complications such as neuropathy, foot deformity, history of diabetic foot ulcer or LEA increased morbidity and mortality.1 Current national recommend a foot exam for individuals with diabetes annually or more often depending on risk for LEA.2, The purpose of this pilot study was to examine the relationship between annual foot exams and incident lower extremity amputation in a large Veteran cohort. We conducted a secondary analysis of a national VA Diabetes administrative dataset registry for Veterans with diabetes aged 65 and older during the period of fiscal year 2002-2014 (n=1,544,654; mean age 77.6 years; 97.9 % male). Using logistic regression, we examined the association between annual foot exams and incident LEA. Our analysis was adjusted for demographics, comorbidities, and LEA foot risk. The study included 18,759 (1.21%) Veterans with incident LEA and foot exams, 2,234 (0.14%) Veterans with incident LEA without foot exams. Median age range was 65-75 years old. Gangrene, osteomyelitis, foot ulcers, and neuropathy were the covariates with the highest risk of incident LEA with foot exam. Foot exams did not reduce the risk of LEA when examining Veterans with incident LEA (unadjusted OR of 1.62 (CI 1.56 - 1.69), p<.0001 and adjusted OR was 1.77 (CI 1.69 -1.86), p<.0001. Annual foot exams were not protective for LEA in Veterans with foot exams and incident LEA. Additional research is warranted to examine this relationship considering the effect of early intervention on LEA risk.

Temporal trends in major, minor and recurrent lower extremity amputations in people with and without diabetes in Belgium from 2009 to 2018