Abstract
IntroductionFoot deformities and amputations are parameters that have been studied as risk factors for diabetic foot ulceration (DFU). However, inclusion of “foot deformities” and “amputations” in a single, broad variable and with reference to the severity of these deformities, may better characterize subjects who are prone to develop DFU.MethodsThe objective of the study was the examination of amputative and non-amputative foot deformities severity as risk factor for DFU in relation with the other established risk factors. A cross-sectional and case-control study was conducted from October 2005 to November 2016. One hundred and thirty-four subjects with type 1 and 2 diabetes, with and without active foot ulcers, participated. A structured quantitative interview guide was used. Univariate logistic regression analysis for the literature's established risk factors was performed, as well as for two versions of the “amputative and non-amputative foot deformities severity” variable. Subsequently, multivariate logistic regression analysis (MLRA) for three models and receiver operating characteristic (ROC) curve analysis were carried out.ResultsFrom the MLRA, only PAD (peripheral arterial disease) was significant (OR 3.56, 95% CI 1.17-10.82, P=0.025 and OR 3.33, 95% CI 1.02-10.08, P=0.033). Concerning the ROC curve analysis of the models, the one with the three categories amputative and non-amputative foot deformities severity variable, had the greatest area under the ROC curve (0.763, P<0.001).ConclusionA united variable for lower extremity amputations and other foot deformities with reference to their severity, could be more helpful to the clinicians in identifying patients with diabetes at risk for foot ulceration.
Highlights
The development of ulcers, of catalytic etiology either intrinsic (e.g resulting from high plantar pressures due to prominent metatarsal heads) or extrinsic [1], at feet of persons with diabetes, can bring about serious complications both individually and socially [2]
As for the clinical characteristics, 92.3% of the study subjects had type 2 diabetes, 57.9% peripheral neuropathy, 40.0% peripheral arterial disease (PAD), 43.4% non-amputative foot deformities, while 20.0% amputative foot deformities, 53.3% wore appropriate footwear and of the controls, 51.4% were at no risk for diabetic foot ulceration (DFU)
The univariate logistic regression analysis, in terms of the variables that were involved in the three models (1, 2 and 3) was significant (P≤0.05) for diabetic peripheral neuropathy, PAD, amputative foot deformities, history of previous foot ulceration and moderate/severe foot deformities from the two categories amputative and non-amputative foot deformities severity variable (Table 2, Table 3, Table 4)
Summary
The development of ulcers, of catalytic etiology either intrinsic (e.g resulting from high plantar pressures due to prominent metatarsal heads) or extrinsic (e.g. resulting from a pebble during walking shoeless) [1], at feet of persons with diabetes (diabetic foot ulceration, DFU), can bring about serious complications both individually (amputation-related disability and increased mortality) and socially (economic burden of the health systems) [2]. A non-amputative deformity could have a cause outside of diabetic neuropathy, which is an intrinsic factor (e.g. hammer toes can be a result of trauma or inappropriate shoes) [14]. Foot deformities and their severity are parameters that have been studied in the past as risk factors for ulceration development in patients with diabetes [6, 9]. Severity of foot deformities only recently has been studied, precisely and with breadth, as a united variable including both amputative and non-amputative ones [13]. No study yet has examined the amputative and non-amputative foot deformities severity as risk factor for DFU in association with the established risk factors (peripheral neuropathy, PAD, history of previous ulceration)
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