Temple University School of Podiatric Medicine Journal Review Club
Editor's note: This post is part of the Temple University School of Podiatric Medicine (TUSPM) journal review club blog series. In each blog post, a TUSPM student will review a journal article relevant to wound management and related topics and provide their evaluation of the clinical research therein.

Article Title: Predictors of Lower Extremity Amputation and Reamputation Associated With the Diabetic Foot
Authors: Erdinc Acar MD, Burkay Kutluhan Kacıram, MS
Journal name and issue: The Journal of Foot & Ankle Surgery 56 (2017) 1218–1222
Reviewed by: Anthony Samaan, Class of 2018, Temple University School of Podiatric Medicine

Introduction

A major concern in managing patients with diabetes is their susceptibility to acquiring ulcers in their feet. If these patients are not careful, these ulcers may become infected and eventually lead to additional sequelae, ending in lower extremity amputation. The focus of this study was to determine the major factors of lower extremity amputation in the diabetic foot, in hopes that clinicians may be able to reduce the rate of amputations more effectively.

Methods

The authors performed a retrospective review of the records of 132 consecutive patients who had already received a lower extremity amputation or reamputation as a result of diabetic wounds. All patients had been diagnosed with diabetes mellitus type 2, and demographic and clinical data were collected on all of them. These data included age, sex, cigarette smoking history, duration of diabetes, diabetic comorbidities (nephropathy, neuropathy), general comorbidities (peripheral artery disease, hypertension, hyperlipidemia, malignancy), leukocytosis, wound infection status, and culture microorganism and antibiogram results. The side and level of amputation or reamputation were also recorded. Only those patients with wounds of a Wagner-Meggitt classification of 3 to 6 were included.

Results

Of the 132 patients reviewed by the authors, 110 had undergone an initial amputation, whereas 22 had undergone a reamputation. The authors found the average age to be 64.3 years, and the more common gender was male. In comparing the amputation group with the reamputation group, the authors found that the group undergoing reamputation had a significantly longer mean diabetes duration and a significantly greater frequency of male patients, cigarette smoking, diabetic nephropathy, diabetic neuropathy, peripheral artery disease, hypertension, and wound infection. In both groups, the most common Wagner-Meggitt classification was a 4. The level of amputation was most common in the digits, whereas reamputation was most common at the transtibial level.

Discussion

The authors found that the predictors of both amputation and reamputation were similar. They found that the strongest predictors for either group were male gender, longer diabetes duration, wound infection, diabetic neuropathy, and positive smoking history. The predictor outcomes make sense because they are risk factors for advanced diabetes mellitus and/or vascular disease, both of which are known to delay wound healing and contribute to increased infection rates. Additionally, the authors found that the most common reamputation involved the conversion of a ray amputation to a transtibial reamputation. This could be attributed to the absence of sufficient and strong soft tissue for healing, as may occur after ray amputation. The data also showed that reamputation most commonly occurred within 7 months of the initial amputation.

Conclusion

Although the Wagner-Meggitt classification is a strong predictor of the need for amputation, it does not take into account whether the patient is neuropathic and is not specific to diabetic ulcers. Future studies should consider at least four additional wound classifications that are available and can be used in this setting, one of which is the University of Texas diabetic wound classification. In this study, the authors found that decisions on the level of amputation were determined primarily by the surgeon’s clinical impression and judgment. A more objective approach should be taken to determine the proper level of amputation. Early identification of male gender, longer-term diabetes, wound infection, diabetic neuropathy, and a positive smoking history should be used as strong predictors of the need for both amputation and reamputation.

About the Authors:
Anthony Samaan is a third year podiatric medical student at Temple University School of Podiatric Medicine (TUSPM) in Philadelphia, Pennsylvania. He graduated from California State University, Fullerton in 2014 with a Bachelor of Science in Biological Sciences. In college, Anthony was involved in student government, representing the College of Natural Sciences and Mathematics on the Board of Representatives. He was a Resident Advisor for 2 years in which he cared for over 60 student residents in the Housing department. Additionally, he was a Clinical Care Extender at Queen of the Valley Hospital in West Covina, CA in which he rotated through numerous departments as an intern.

Dr. James McGuire is the director of the Leonard S. Abrams Center for Advanced Wound Healing and an associate professor of the Department of Podiatric Medicine and Orthopedics at the Temple University School of Podiatric Medicine in Philadelphia.