Incidence Of Major Amputation Research Articles

Major amputation rates and outcomes for Aboriginal and Torres Strait Islander and non-Indigenous people in North Queensland Australia between 2000 and 2015

BackgroundThis study estimated the incidence of major amputation for people in North Queensland, Australia, examined changes in amputation rates over time and investigated survival after major amputation.MethodsThis was a retrospective study of patients who underwent a major amputation above the ankle between 2000 and 2015. Major amputation rates and incidence rate ratios (IRR) were calculated using census data to define the at-risk population. Associations between risk factors and calendar year with major amputation were assessed using quasipoisson regression. Kaplan-Meier survival and Cox-proportional hazard analyses estimated the incidence of and risk factors for all-cause mortality.ResultsThe annual incidence of major amputation was estimated to be greater in Aboriginal and Torres Strait Islanders than non-Indigenous people (IRR 2.75, 95 % CI 1.92 to 3.84). After adjusting for population growth, the annual incidence of major amputations did not change significantly over time for either groups. Aboriginal and Torres Strait Islander people were at greater risk of all-cause mortality after major amputation compared to non-Indigenous people, although this association was not significant after adjusting for other risk factors (hazard ratio 1.24, 95 % CI 0.82 to 1.90).ConclusionsThe incidence of major amputation in North Queensland has not reduced over time, indicating the need for better preventative treatments, particularly in Aboriginal and Torres Strait Islander people.

Effect of recanalization of anterior tibial artery and peroneal artery on targeted angiosomes of posterior tibial artery in the foot through different aspects

Objective The purpose of this study is to evaluate the outcome of percutaneous transluminal angioplasty of ipsilateral peroneal artery and the anterior tibial artery for revascularization of targeted angiosomes in the vascular territory of posterior tibial artery (PTA) in the foot, through interconnecting branches, and the resulting effect on existing wound healing and limb salvage, in comparison with the effect of percutaneous transluminal angioplasty on PTA alone on revascularization and wound healing in these angiosomes. Patients and methods We included 80 patients for 80 angioplasty procedure (80 limbs) who were divided into two equal groups. Group A included patients with peroneal and anterior tibial patent vessel runoff, who were fit for percutaneous transluminal angioplasty for both vessels, whereas group B were candidates for PTA angioplasty. We studied the arterial supply in 80 limbs with TASC C-D lesions with follow-up along 1 year, all with PTA occlusion. Patients with single-vessel or three-vessel runoff were excluded from the study. Outcome measures included wound healing of targeted angiosomes of PTA with complete epithelialization of the affected lesion with or without secondary interventions such as debridement or skin grafting and limb salvage with absence of major amputation. Conclusions We found that recanalization of peroneal artery together with anterior tibial artery can supply angiosomes of PTA and accelerate wound healing through communicating branches in the foot with comparable outcome on wound healing and decreased incidence of major amputation to single recanalization of PTA as primary and secondary outcome, obviating the need for lengthy and more risky interventional procedure.

Survival and Factors Predicting Mortality in Patients Undergoing Major Lower Limb Amputations

This study estimated the incidence of major amputations for people in North Queensland, Australia, examined changes in rate over time and investigated survival after major amputation.

Service user and community clinician design of a partially virtual diabetic service improves access to care and education and reduces amputation incidence

IntroductionDesign of an integrated diabetes service based on needs of service users (persons living with diabetes) and community clinicians in a semirural low-income health district of the UK.Research design and...

Accuracy of SVS-WIfI Classification in Predicting Major Amputation in Critical Limb Ischemic Patients

In 2014, The Society for Vascular Surgery revealed a new classification system for Critical Limb Ischemia (CLI) referred as the Society for Vascular Surgery Lower Extremity Threatened Limb Classification System based on Wound, Ischemia, and foot Infection (SVS WIfI). This scoring system was created to stratify major amputations risk within 1 year and benefit of revascularization for the patient. This study aimed to assess the accuracy of SVS WIFi in predicting major amputations in patients with lower limb ischemia underwent revascularization at Department of Surgery, Faculty of Medicine, Universitas Padjadjaran-Dr. Hasan Sadikin General Hospital in 2016 - 2019. This was a retrospective observational analytic study with cohort design. Patients who fulfilled the inclusion criteria were assessed with SVS WIfI and results after 1 year of revascularization were identified. Data were analyzed statistically using the Chi-square test. 0f 56 subjects, 39 had limb salvage and 17 underwent major amputations within 1 year. In high revascularization benefit group, 31 had limb salvage and 7 underwent amputation. Meanwhile, in moderate-low revascularization benefits group, 8 had limb salvage and 10 underwent amputation. The accuracy of the SVS WIfI recommendation was 73.2%. Therefore, WIfI SVS classification accurately predicts the incidence of major amputations in patients with lower limb ischemia who underwent revascularization.

Heterogeneity of Age and Its Associated Features in Patients with Critical Limb Ischemia.

Aim: Critical limb ischemia (CLI) has a wide age distribution. We aimed here to reveal age-associated clinical features in CLI patients.Materials and Methods: We analyzed 531 Japanese CLI patients referred to vascular centers. The three-year mortality risk by age was compared to that for the Japanese nationals, derived from Japan’s national life table data. Clinical characteristics associated with age in CLI patients were also explored.Results: Mean age was 73±10 years. Whereas 27.9% were aged ≥80 years, 19.2% were aged <65 years. Mortality risk was increased with age, but its risk ratio relative to the same-aged nationals was higher in younger patients. Incidence of major amputation was higher in a younger population. Receiving welfare, smoking, increased body mass index, diabetes with hemoglobin A1c ≥7.0%, non-high density lipoprotein cholesterol ≥190 mg/dL, renal failure, and the Wound, Ischemia, and foot Infection classification stage 4 were associated with younger age, whereas non-ambulation and institutionalization were associated with older age.Conclusion: Patients aged <65 years, belonging to the working-age population, reached almost one fifth of the CLI population. Younger patients had a lower mortality risk in the population, but had a higher risk ratio relative to the same-aged nationals. Socioeconomic disadvantage, poor cardiovascular risk control, and wound severity were associated with younger age.

The Impact of a Limb Preservation Service on the Incidence of Major Amputations for All Indications at a Level I Trauma Center

Multidisciplinary limb preservation services (LPS) have improved the care of patients with limb-threatening vascular disease. However, the impact of an LPS on major amputations for nonvascular etiologies is unknown. We sought to characterize the trends in major amputations performed at a level I trauma center following the institution of an LPS. A retrospective review of all patients undergoing amputation at a level I trauma center from January 2009 to December 2018 was performed. Patients were divided into 2 cohorts: those undergoing amputation pre-LPS (2009-2013) and post-LPS (2014-2018). Major amputations were defined as any amputation at or proximal to the below-knee level. Indications for amputation included chronic limb-threatening ischemia (CLTI), acute limb ischemia (ALI), trauma, infection, and revision amputations. During the study period, 609 major amputations were performed, 490 pre-LPS and 119 post-LPS, representing a 76% reduction. Reductions were seen for every indication, including trauma (95%), ALI (90%), chronic infection (83%), revision (79%), CLTI (68%), and acute infection (62%). Although previous work has validated the role of an LPS in advanced vascular disease, its value extends beyond vascular disease alone. The drastic reductions seen in the number of amputations performed for a variety of indications, including trauma and diabetic foot infections, further validate the use of a multidisciplinary LPS.

Present-day analysis of early failure after forefoot amputation

BackgroundForefoot transmetatarsal amputation is performed commonly to achieve limb salvage, but transmetatarsal amputations have a high rate of failure, requiring more proximal amputations. Few contemporary studies have examined the incidence of major amputation (transtibial or transfemoral) after transmetatarsal amputation. The goal of this study is to determine risk factors and outcomes for a more proximal amputation after forefoot amputation. MethodsWe queried the 2012 to 2016 database of the American College of Surgeons National Quality Improvement Program for patients undergoing a complete transmetatarsal amputation with wound closure by Current Procedural Terminology code. Patients requiring early (within 30 days) more proximal amputation after transmetatarsal amputation were compared with those who did not need further amputation. Characteristics of patients requiring more proximal amputation were examined, and a multivariable logistic regression model was created to identity risk factors for early more proximal amputation. ResultsIn the study, 1,582 transmetatarsal amputation were identified. Most patients were male (70%), white (59%), and diabetic (74%), with a median age of 63 years. More proximal amputation occurred in 4.2% of patients within the first 30 days postoperatively. This early failure was associated with greater hospital stays postoperatively (10 days vs 7 days), more wound complications (29% vs 11%), pneumonia (8% vs 2%), stroke (3% vs 0.1%), and overall complications (50% vs 28%; P ≤ .025 each). Although there was no difference in 30-day mortality (P = .27), there was a marked increase in unplanned readmission (59% vs 14%; P < .0001) for those undergoing reamputation. On multivariable analysis, preoperative systemic inflammatory response, sepsis, or septic shock (odds ratio 2.1; 95% confidence interval, 1.2–3.6) were independent predictors of more proximal amputation. ConclusionEarly below-knee or above-knee amputation early after transmetatarsal amputation leads to increased morbidity. Because patients with preoperative sepsis may be at increased risk of failure after transmetatarsal amputation, the level of amputation should be considered carefully in these patients.

Systemic inflammatory response syndrome as a predictor of poorer outcomes in diabetic foot infection: a prospective analytical study

Background: This study was done to diagnose the severity of infection in a group of hospitalized diabetic foot infection (DFI) patients based on the presence or absence of systemic inflammatory response syndrome (SIRS) and compare the outcomes.Methods: This was a single-center cohort study, in which 50 consecutive DFI patients having SIRS and 50 consecutive patients not having SIRS were included. Patients were followed for the duration of the hospital stay; parameters for glycaemic control, minor and major amputation, microbial culture, duration of hospital and ICU stay and mortality was recorded.Results: The relative risk of major amputation among the patients of DFI who presented with SIRS was 2.66 times higher compared to who was not having SIRS at presentation (95% CI, 1.56-4.55). The presence of polymicrobial infection also had a statistically significant association with the incidence of major amputation. The duration of hospital stay was ~9.5 days longer in the DFI patients who presented with SIRS compared to who was not having SIRS at the time of presentation [8.00 (4.00-20.50) days versus 17.50 (10.75-38.25) days]. DFI patients with SIRS required a significantly prolonged ICU.Conclusions: SIRS can be used as objective criteria to predict poorer outcomes in the diabetic foot infection patient and also to classify it.

Outcomes of rotational atherectomy in complex lesions of the superficial femoral artery

BackgroundThe effectiveness of rotational atherectomy in the treatment of complex superficial femoral artery (SFA) lesions remains poorly defined. Outcomes of SFA lesions treated with rotational atherectomy were analyzed. MethodsThis retrospective review assessed all patients who underwent rotational atherectomy of the SFA at a single institution between 2015 and 2018. The data of all patients were deidentified, and the study was approved by the Institutional Review Board. Informed consent was not obtained for this retrospective analysis. Main outcomes were Kaplan-Meier primary patency rate, freedom from major amputation, and 2-year survival rate. The effect of drug-coated balloon angioplasty (DCBA) on patency and time to death was investigated with univariate regression. The safety profile for atherectomy and DCBA was assessed by the 30-day incidence of major amputation and all-cause mortality. ResultsFifty-three patients (mean age, 70.2 ± 9.8 years; 73% male; 65% critical limb-threatening ischemia; 47 [90%] current or former smokers; seven [13%] with prior failed ipsilateral endovascular intervention) underwent rotational atherectomy (Jetstream; Boston Scientific, Marlborough, Mass) with mean follow-up of 543 days. Forty-six (87%) patients underwent DCBA (Lutonix; BD Bard, Covington, Ga) after atherectomy. Mean lesion length was 13.2 ± 9.0 cm. Thirty-one (58%) lesions were TransAtlantic Inter-Society Consensus C or D class. At 1-month follow-up, 39 of 45 (87%) patients experienced improvement in symptoms and Rutherford class. An improvement in ankle-brachial index was also noted in 13% of patients without improvement of symptoms, with no patients progressing to surgical bypass or major amputation. Mean ankle-brachial index increased from 0.54 ± 0.035 to 0.90 ± 0.031 at 1 month after intervention (P < .001) and remained constant out to 18 months. Mean toe pressure increased from 36 ± 3.8 mm Hg to 67 ± 4.5 mm Hg at 1 month after intervention (P < .001) and remained constant out to 18 months. Kaplan-Meier primary patency rate was 75% (95% confidence interval, 61%-85%) at 12 months and 65% (51%-77%) at 24 months. There was a trend toward improved primary patency after adjunctive DCBA compared with plain balloon angioplasty at 1 year (75% vs 43%; P = .1082). There was no significant difference in mortality between adjunctive DCBA and plain balloon angioplasty at 2 years (11% vs 0%). The 2-year incidence of major amputation in critical limb-threatening ischemia patients was 3.9% (1.2%-6.5%). One patient died and none underwent amputation within 30 days. ConclusionsRotational atherectomy with adjunctive DCBA of long SFA lesions has excellent long-term patency. Two-year major amputation and mortality rates are low, and the technique has an exceptional safety profile.

Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: A systematic review.

Clinical outcomes of patients with diabetes, foot ulceration, and peripheral artery disease (PAD) are difficult to predict. The prediction of important clinical outcomes, such as wound healing and major amputation, would be a valuable tool to help guide management and target interventions for limb salvage. Despite the existence of a number of classification tools, no consensus exists as to the most useful bedside tests with which to predict outcome. We here present an updated systematic review from the International Working Group of the Diabetic Foot, comprising 15 studies published between 1980 and 2018 describing almost 6800 patients with diabetes and foot ulceration. Clinical examination findings as well as six non-invasive bedside tests were evaluated for their ability to predict wound healing and amputation. The most useful tests to inform on the probability of healing were skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg, or TcPO2 ≥ 25 mmHg. With these thresholds, all of these tests increased the probability of healing by greater than 25% in at least one study. To predict major amputation, the most useful tests were ankle pressure < 50 mmHg, ABI < 0.5, toe pressure < 30 mmHg, and TcPO2 < 25 mmHg, which increased the probability of major amputation by greater than 25%. These indicative values may be used as a guide when deciding which patients are at highest risk for poor outcomes and should therefore be evaluated for revascularization at an early stage. However, this should always be considered within the wider context of important co-existing factors such as infection, wound characteristics, and other comorbidities.

Impacts of A Limb Preservation Service On The Incidence Of Major Amputations For All Indications At A Level I Trauma Center

Impacts of A Limb Preservation Service On The Incidence Of Major Amputations For All Indications At A Level I Trauma Center

International Variations in Amputation Practice – A Vascunet Report

Introduction - To study international differences in incidence and practice patterns as well as time-trends in lower limb amputations related to peripheral arterial disease and/or diabetes mellitus. Methods - Data on lower limb amputations during 2010-2014 were collected from population-based administrative data from countries in Europe and Australasia participating the VASCUNET collaboration. Amputation rates, time-trends, in-hospital or 30-days mortality and reimbursement systems were analysed. Results - Data from 12 countries covering 259 million inhabitants in 2014 were included. Individuals aged ≥65 years ranged from 4.2% (Slovakia) to 20.7% (Germany) and diabetes prevalence among amputees from 25.7% (Finland) to 74.3% (Slovakia). Mean incidence of major amputation varied between 7.2/100 000 (New Zealand) to 41.4/100 000 (Hungary) with an overall declining time-trend with the exception of Slovakia, while minor amputations increased over time. The older age group (≥65 years) was up to 4.9 times more likely to be amputated compared to those younger than 65 years. Reported mortality rates were lowest in Finland (6.3%) and highest in Hungary (20.3%). Countries with a fee for service reimbursement system had lower incidence of major amputation compared to countries with a population based reimbursement system (14.3/100 000 versus 18.4/100 000, respectively, p<0.001). Conclusion - This international audit showed large geographical differences in major amputation rates, almost by a factor six, and an overall declining time-trend during the four-year observation of this study. Diabetes prevalence, age distribution and mortality rates were also found to vary between countriesty. Despite limitations attributable to registry data, these findings are important, and warrant further research on how to improve limb salvage in different demographic settings.

Diabetic foot and disaster; risk factors for amputation during the Syrian crisis

BackgroundDiabetic foot patients in Syria faced many challenges and difficulties during the recent long term crisis that has prevailed since 2011. This study establishes the risk factors of diabetic foot amputation, either minor or major amputation. It also suggests facilities to improve diabetic foot care in the disaster. MethodsThis is a retrospective study that reviewed diabetic foot outpatients' charts between Jan 2012 and Dec 2017 in Diabetic Foot Clinic in Damascus Teaching Hospital, Syria. We classified the lesions according to the final outcome into: non-amputation, minor and major amputation. We predicted the independent risk factors of lower extremity amputation (LEA). ResultsA total of 2317 diabetic patients visited our clinic regularly with 2722 diabetic foot symptoms. We studied 2006 lesions belong to 1630 diabetic foot patients. They were divided into: group A (outcome without amputation, n = 1372), group B (outcome with minor amputation, n = 528) and group C (final outcome with major amputation, n = 106). Males were slightly predominant (56.73%; n = 1138), but with clearly higher risk of major amputation (6.77%; n = 77). 15.10% of patients was older than 70 years, with no significant relationship between age and amputation risk. According to Meggitt-Wagner classification system, the major amputation rate was (5.28%) in the lesions grade 1 through 5, it went up to (87.30) in isolated grade 5 lesions.The study recorded a degree of infection in (42.07%; n = 844) of the cases. The amputation rate went up in this group of patients to 38.5% and 8.44% for minor and major amputation, respectively. The presence of peripheral occlusive artery disease (PAD) doubled the minor amputation incidence one time (44.02%), and major amputation incidence five times (15.16%). The heel ulcer showed a great tendency toward the major amputation (18.80%), while the incidence rate in the DFUs spared heel was (3.36%). The war injuries of the diabetic foot was followed up in three cases that were treated conservatively and didn’t considered an independent risk factor for amputation as long as the standard care was applied. ConclusionThis article is the first one that discussed the reality of the diabetic foot care in disasters. It figures out that diabetic foot patients are obviously at higher risk of neglect during the crisis. In the absence of early detecting of wounds, deformities and PAD, DFUs likely come to the podiatrists in advanced stages. The unhealthy environment drives DFUs toward injuries, cellulites and infection. Non-Governmental Organizations (NGOs) and local institutions that work in crisis areas should pay attention for special care requirements of diabetic foot patients, for the standard care of the diabetic foot and the regular follow-up till the healing eventually.

Major Amputation Rates in Patients with Peripheral Arterial Disease Aged 50 Years and Over in Denmark during the period 1997–2014 and their Relationship with Demographics, Risk Factors, and Vascular Services

The aim of this nationwide study was to provide insight into the incidence and geographical distribution of vascular services and major amputations in patients with peripheral arterial disease (PAD) in Denmark. The incidence of major amputation caused by PAD was investigated by linking data from population based healthcare and administrative databases. The study period was divided into three parts, i.e. 1997-2002, 2003-2008, and 2009-2014. Amputation rates and revascularisation rates per 100000 inhabitants ≥ 50 years of age were calculated and the association was displayed using scatter plots. The association between amputation rates and revascularisation rates was explored using a mixed effect model. Multivariable logistic regression was used to identify risk factors for having amputation without prior revascularisation relative to having amputation with prior revascularisation. During 1997-2014, 13075 first time major amputations were performed. The proportions of patients with diabetes as well as atherosclerotic comorbidity increased through the decades. The incidence rate decreased from 41.67 per 100000 citizens ≥ 50 years of age in 1997-2002, to 32.53 in 2009-2014 (r=-0.88, p<.001), but with municipal differences. In parallel, revascularisations increased from 166.63 per 100000 citizens ≥ 50 years of age in 1997-2002, to 239.05 in 2009-2014 (r=0.83, p<.001). The percentage of patients evaluated by a vascular surgeon within a year prior to amputation increased from 23.7% to 31.3% (p<.001), while no increase in the proportion having revascularisation within a year prior to amputation was seen. Multivariable logistic regression analysis showed that diabetes mellitus (OR 1.28; CI 1.17-1.40), stroke (OR 1.66; CI 1.52-1.81), coronary heart disease (OR 1.25; CI 1.14-1.37), and renal disease (OR 1.31; CI 1.15-1.48) were associated with a higher risk of undergoing amputation without prior revascularisation. The incidence of major amputations decreased, while general cardiovascular prevention and revascularisation rates increased. Despite that, few patients had revascularisation prior to amputation, leaving room for improvements.

Lower limb arterial intervention or autologous platelet-rich gel treatment of diabetic lower extremity arterial disease patients with foot ulcers.

To investigate whether lower limb vascular intervention or autologous platelet-rich gel (APG) treatment would benefit diabetic lower extremity arterial disease (LEAD) patients with foot ulcers. A total of 82 diabetic LEAD patients with foot ulcers were recruited and divided into three groups: group A (30 patients received basal treatment), group B (21 patients received basal and APG treatment), and group C (31 patients received basal and lower limb vascular intervention treatment). All patients underwent routine follow-up visits for 6 months. The baseline characteristics and parameters were examined. After treatment, changes in all parameters from baseline were recorded. The differences between groups and the relationship among each parameter were determined. There were no differences in the ankle brachial index (ABI) or major amputation between groups A and B (P>0.05). Compared with groups A and B, the ABI and major amputation rate of group C were improved (P<0.05). There were no significant differences in transcutaneous oxygen partial pressure (TcPO2), the heal rate or minor amputation between groups A and C (P>0.05). Compared with groups A and C, TcPO2, the heal rate and minor amputation of group B were improved (P<0.05). The logistic regression analysis indicated that major amputation was mainly associated with the ABI, and minor amputation was mainly associated with TcPO2. Lower limb vascular intervention improves the ABI and reduces major amputation, and APG improves TcPO2 and reduces minor amputation. In diabetic LEAD patients with foot ulcers, major amputation was mainly associated with the ABI, while minor amputation was mainly associated with TcPO2. Interventional surgery (angioplasty) mainly improves the ABI, reduces the incidence of major amputation and improves the macrovasculature, and APG mainly improves local TcPO2, reduces the incidence of minor amputation and improves the microcirculation.

International Variations in Amputation Practice: A VASCUNET Report

To study international differences in incidence and practice patterns as well as time trends in lower limb amputations related to peripheral arterial disease and/or diabetes mellitus. Data on lower limb amputations during 2010–2014 were collected from population based administrative data from countries in Europe and Australasia participating in the VASCUNET collaboration. Amputation rates, time trends, in hospital or 30 day mortality and reimbursement systems were analysed. Data from 12 countries covering 259 million inhabitants in 2014 were included. Individuals aged ≥ 65 years ranged from 12.9% (Slovakia) to 20.7% (Germany) and diabetes prevalence among amputees from 25.7% (Finland) to 74.3% (Slovakia). The mean incidence of major amputation varied between 7.2/100,000 (New Zealand) and 41.4/100,000 (Hungary), with an overall declining time trend with the exception of Slovakia, while minor amputations increased over time. The older age group (≥65 years) was up to 4.9 times more likely to be amputated compared with those younger than 65 years. Reported mortality rates were lowest in Finland (6.3%) and highest in Hungary (20.3%). Countries with a fee for service reimbursement system had a lower incidence of major amputation compared with countries with a population based reimbursement system (14.3/100,000 versus 18.4/100,000, respectively, p < .001). This international audit showed large geographical differences in major amputation rates, by a factor of almost six, and an overall declining time trend during the 4 year observation of this study. Diabetes prevalence, age distribution, and mortality rates were also found to vary between countries. Despite limitations attributable to registry data, these findings are important, and warrant further research on how to improve limb salvage in different demographic settings.

A renaissance in diabetic foot care: new evidence-based treatments

Unhealed diabetic foot ulcers can result in up to 84% of lower extremity amputations. 1 Pecoraro R Reiber G Burgess E Pathways to diabetic limb amputation: basis for prevention. Diabetes Care. 1990; 13: 513-521 Crossref PubMed Scopus (1230) Google Scholar , 2 Larsson J Apelqvist J Agardh CD Stenström A Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach?. Diabet Med. 1995; 12: 770-776 Crossref PubMed Scopus (315) Google Scholar It is thus important that ulcers are healed quickly. However, there has been a scarcity of evidence-based topical therapy to accelerate the healing of diabetic foot ulcers and this drought has led to a call for well-designed clinical trials. 3 Jeffcoate WJ Bus SA Game FL Hinchliffe RJ Price PE Schaper NC International Working Group on the Diabetic Foot and the European Wound Management AssociationReporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: required details and markers of good quality. Lancet Diabetes Endocrinol. 2016; 4: 781-788 Summary Full Text Full Text PDF PubMed Scopus (124) Google Scholar Over the past year, there has been a renaissance in diabetic foot care and three relatively robust trials on foot ulcers have been published. The first (the Explorer study 4 Edmonds M Lazaro-Martinez JL Alfayate-Garcia JM et al. Sucrose octasulfatedressing versus control dressing in patients with neuroischaemic diabetic foot ulcers (Explorer): an international, multicentre, double-blind, randomised, controlled trial. Lancet Diabetes Endocrinol. 2018; 6: 186-196 Summary Full Text Full Text PDF PubMed Scopus (117) Google Scholar ) reported the benefit of sucrose octasulphate dressing and the second (the ProNOx1 study 5 Edmonds ME Bodansky HJ Boulton AJ et al. Multicenter, randomized controlled, observer-blinded study of a nitric oxide generating treatment in foot ulcers of patients with diabetes – ProNOx1 study. Wound Repair Regen. 2018; (published online April 4.)DOI:10.1111/wrr.12630 Crossref Scopus (25) Google Scholar ) reported the positive outcome of a nitric oxide generating device. The third study (LeucoPatch 6 Game F Jeffcoate W Tarnow L et al. LeucoPatch system for the management of hard-to-heal diabetic foot ulcers in the UK, Denmark, and Sweden: an observer-blinded, randomised controlled trial. Lancet Diabetes Endocrinol. 2018; (published online September 7.)http://dx.doi.org/10.1016/S2213-8587(18)30240-7 Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar ) reported the benefit of a multi-layered patch comprising autologous leucocytes, platelets, and fibrin, which releases cytokines and growth factors involved in tissue repair, 7 Game FL Apelqvist J Attinger C et al. Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review. Diabetes Metab Res Rev. 2016; 32: 154-168 Crossref PubMed Scopus (121) Google Scholar in a multinational, observer-blinded, randomised, controlled trial now published in The Lancet Diabetes & Endocrinology by Frances Game and colleagues. 6 Game F Jeffcoate W Tarnow L et al. LeucoPatch system for the management of hard-to-heal diabetic foot ulcers in the UK, Denmark, and Sweden: an observer-blinded, randomised controlled trial. Lancet Diabetes Endocrinol. 2018; (published online September 7.)http://dx.doi.org/10.1016/S2213-8587(18)30240-7 Summary Full Text Full Text PDF PubMed Scopus (66) Google Scholar The trial recruited people with hard-to-heal ulcers, which were defined as ulcers that had less than a 50% reduction of area in response to standard care during a 4-week run-in period. 34% of these ulcers healed within 20 weeks in the intervention group (together with standard care) compared with 22% in patients undergoing standard care alone (odds ratio 1·58, 96% CI 1·04–2·40; p=0·0235). LeucoPatch system for the management of hard-to-heal diabetic foot ulcers in the UK, Denmark, and Sweden: an observer-masked, randomised controlled trialThe use of LeucoPatch is associated with significant enhancement of healing of hard-to-heal foot ulcers in people with diabetes. Full-Text PDF

International Variations in Amputation Practice: A VASCUNET Report

To study international differences in incidence and practice patterns as well as time trends in lower limb amputations related to peripheral arterial disease and/or diabetes mellitus. Data on lower limb amputations during 2010-2014 were collected from population based administrative data from countries in Europe and Australasia participating in the VASCUNET collaboration. Amputation rates, time trends, in hospital or 30 day mortality and reimbursement systems were analysed. Data from 12 countries covering 259 million inhabitants in 2014 were included. Individuals aged ≥ 65 years ranged from 12.9% (Slovakia) to 20.7% (Germany) and diabetes prevalence among amputees from 25.7% (Finland) to 74.3% (Slovakia). The mean incidence of major amputation varied between 7.2/100,000 (New Zealand) and 41.4/100,000 (Hungary), with an overall declining time trend with the exception of Slovakia, while minor amputations increased over time. The older age group (≥65 years) was up to 4.9 times more likely to be amputated compared with those younger than 65 years. Reported mortality rates were lowest in Finland (6.3%) and highest in Hungary (20.3%). Countries with a fee for service reimbursement system had a lower incidence of major amputation compared with countries with a population based reimbursement system (14.3/100,000 versus 18.4/100,000, respectively, p<.001). This international audit showed large geographical differences in major amputation rates, by a factor of almost six, and an overall declining time trend during the 4 year observation of this study. Diabetes prevalence, age distribution, and mortality rates were also found to vary between countries. Despite limitations attributable to registry data, these findings are important, and warrant further research on how to improve limb salvage in different demographic settings.

Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England.

AimsTo investigate the relationship between high diabetes‐related lower limb amputation incidence and foot care services in the South‐West region of England.MethodsThe introduction of 10 key elements of foot care service provision in one area of the South‐West resulted in stabilization of foot ulcer incidence and sustained reduction in amputation incidence from 2007. Services introduced included administrative support, standardized general practice foot screening, improved community podiatry staffing, hospital multidisciplinary foot clinics, effective care pathways, availability of an orthotist and audit. Peer reviews of the region's diabetes foot care services were undertaken to assess delivery of these service provisions and compare this with major amputation incidence in other regions with data provided by Yorkshire and Humber Public Health Observatory Hospital Episode Statistics. Recommendations were made to improve service provision. In 2015 changes in service provision and amputation incidence were reviewed.ResultsInitial reviews in 2013 showed that the 3‐year diabetes‐related major amputation incidence correlated inversely with adequate delivery of diabetes foot care services (P=0.0024, adjusted R 2 =0.51). Repeat reviews in 2015 found that two or more foot care service improvements were reported by six diabetes foot care providers, with improvement in outcomes. The negative relationship between major amputation incidence and service provision remained strong both in the period 2012–2015 and in the year 2015 only (P ≤0.0012, adjusted R 2 =0.56, and P= 0.0005, R 2=0.62, respectively).ConclusionsMajor diabetes‐related lower limb amputation incidence is significantly inversely correlated with foot care services provision. Introduction of more effective service provision resulted in significant reductions in major amputation incidence within 2 years. Failure to improve unsatisfactory service provision resulted in continued high amputation incidence.