SALİH BEYAZ, ÜMİT ÖZGÜR GÜLER, Gülay ŞİMŞEK BAĞIR

Factors affecting lifespan following below-knee amputation in diabetic patients

Introduction: Untreatable foot problems in diabetics may require lower extremity amputation, which has a high level of patient mortality. This high mortality rate is worse than most malignancies. The present study aimed to identify parameters that can be used to estimate survival in DM patients undergoing below-knee amputations for diabetic foot problems. Materials and methods: A total of 470 patients (299 males, 171 females) with a mean age of 64.32 years who underwent below-knee amputation for diabetic foot problems between 2004 and 2014 were enrolled in the study. The length of time from the operation to time of death was recorded in days. Patient details were obtained, including age during surgery, BMI, oral antidiabetic and insulin usage, dialysis therapy history, lower extremity endovascular intervention, previous amputation at the same extremity, the need for stump revision surgery during follow-up, and above-knee amputation at the same site. Biochemical test results of pre-operative HbA1c, ESR, and levels of CRP, BUN, and creatinine were also obtained. Results: A total of 333 patients (70.9%) died and 137 (29.1%) survived post-surgery. Survival rates were 90% in the first 7 days, 84% in the first 30 days, and 64% after the first year. Patient median life expectancy post-surgery was 930 ± 106 days. Hemodialysis treatment (p = 0.001), endovascular intervention (p = 0.04), sex (p = 0.004), age (p = 0.001), BUN level (p = 0.001), and duration of insulin use (p = 0.003) were shown to be effective predictors of mortality. Conclusions: Life expectancy is low ( < 3 years) in DM patients requiring below-knee amputations for untreatable foot problems. Survival could be predicted by duration of insulin use, age, sex, and renal insufficiency.

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1. Rathur HM, Boulton AJ. The diabetic foot. Clin Dermatol. 2007;25(1):109e120.

2. Shojaiefard A, Khorgami Z, Larijani B. Independent risk factors for amputation in diabetic foot. Int J Diabetes Dev Ctries. 2008;28(2):32e37.

3. Yesil S, Akinci B, Yener S, et al. Predictors of amputation in diabetics with foot ulcer: single center experience in a large Turkish cohort. Horm (Athens). 2009;8(4):286e295.

4. Frykberg RG, Zgonis T, Armstrong DG, et al. Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg. 2006;45(suppl 5):S1eS66.

5. Fortington LV, Geertzen JH, van Netten JJ, Postema K, Rommers GM, Dijkstra PU. Short and long term mortality rates after a lower limb amputation. Eur J Vasc Endovasc Surg. 2013;46(1):124e131.

6. Won SH, Chung CY, Park MS, et al. Risk factors associated with amputation-free survival in patient with diabetic foot ulcers. Yonsei Med J. 2014;55(5): 1373e1378.

7. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217e228.

8. Eskelinen E, Lepantalo M, Hietala EM, et al. Lower limb amputations in Southern Finland in 2000 and trends up to 2001. Eur J Vasc Endovasc Surg. 2004;27(2):193e200.

9. Kristensen MT, Holm G, Kirketerp-Moller K, Krasheninnikoff M, Gebuhr P. Very low survival rates after non-traumatic lower limb amputation in a consecutive series: what to do? Interact Cardiovasc Thorac Surg. 2012;14(5):543e547.

10. Remes L, Isoaho R, Vahlberg T, et al. Major lower extremity amputation in elderly patients with peripheral arterial disease: incidence and survival rates. Aging Clin Exp Res. 2008;20(5):385e393.

11. Davenport DL, Ritchie JD, Xenos ES. Incidence and risk factors for 30-day postdischarge mortality in patients with vascular disease undergoing major lower extremity amputation. Ann Vasc Surg. 2012;26(2):219e224.

12. Subramaniam B, Pomposelli F, Talmor D, Park KW. Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics. Anesth analgesia. 2005;100(5):1241e1247 [table of contents].

13. Atkins RC, Zimmet P. Diabetic kidney disease: act now or pay later. Saudi J Kidney Dis Transpl. 2010;21(2):217e221.

14. Morbach S, Quante C, Ochs HR, Gaschler F, Pallast JM, Knevels U. Increased risk of lower-extremity amputation among Caucasian diabetic patients on dialysis. Diabetes Care. 2001;24(9):1689e1690.

15. Kim TG, Moon SY, Park MS, et al. Factors affecting length of hospital stay and mortality in infected diabetic foot ulcers undergoing surgical drainage without major amputation. J Korean Med Sci. 2016;31(1):120e124.

16. Selvin E, Wattanakit K, Steffes MW, Coresh J, Sharrett AR. HbA1c and peripheral arterial disease in diabetes: the Atherosclerosis Risk in Communities study. Diabetes Care. 2006;29(4):877e882.

17. Bagdade JD, Root RK, Bulger RJ. Impaired leukocyte function in patients with poorly controlled diabetes. Diabetes. 1974;23(1):9e15.

18. Adler AI, Stevens RJ, Neil A, Stratton IM, Boulton AJ, Holman RR. UKPDS 59: hyperglycemia and other potentially modifiable risk factors for peripheral vascular disease in type 2 diabetes. Diabetes care. 2002;25(5):894e899.

19. Papanas N, Maltezos E. Glycated hemoglobin as a risk factor for lower extremity amputations in diabetes: “success is counted sweetest”. Int J Low Extrem Wounds. 2015;14(2):106e107.

20. Pscherer S, Dippel FW, Lauterbach S, Kostev K. Amputation rate and risk factors in type 2 patients with diabetic foot syndrome under real-life conditions in Germany. Prim Care Diabetes. 2012;6(3):241e246.

21. Winkley K, Stahl D, Chalder T, Edmonds ME, Ismail K. Risk factors associated with adverse outcomes in a population-based prospective cohort study of people with their first diabetic foot ulcer. J Diabetes Complicat. 2007;21(6): 341e349.

22. Amin L, Shah BR, Bierman AS, et al. Gender differences in the impact of poverty on health: disparities in risk of diabetes-related amputation. Diabet Med. 2014;31(11):1410e1417.

23. Namgoong S, Jung S, Han SK, Jeong SH, Dhong ES, Kim WK. Risk factors for major amputation in hospitalised diabetic foot patients. Int Wound J. 2015.

24. Pemayun TG, Naibaho RM, Novitasari D, Amin N, Minuljo TT. Risk factors for lower extremity amputation in patients with diabetic foot ulcers: a hospitalbased case-control study. Diabet Foot Ankle. 2015;6, 29629.

25. Ries Z, Rungprai C, Harpole B, et al. Incidence, risk factors, and causes for thirtyday unplanned readmissions following primary lower-extremity amputation in patients with diabetes. J Bone Jt Surg Am. 2015;97(21):1774e1780.

26. Yusof NM, Rahman JA, Zulkifly AH, et al. Predictors of major lower limb amputation among type II diabetic patients admitted for diabetic foot problems. Singap Med J. 2015;56(11):626e631.

27. Ilavska S, Horvathova M, Szabova M, et al. Association between the human immune response and body mass index. Hum Immunol. 2012;73(5):480e485.

28. Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ. Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort. Diabetes Care. 2003;26(5):1435e1438.

29. Tang ZQ, Chen HL, Zhao FF. Gender differences of lower extremity amputation risk in patients with diabetic foot: a meta-analysis. Int J Low Extrem Wounds. 2014;13(3):197e204.

30. Moura Neto A, Zantut-Wittmann DE, Fernandes TD, Nery M, Parisi MC. Risk factors for ulceration and amputation in diabetic foot: study in a cohort of 496 patients. Endocrine. 2013;44(1):119e124.

31. Brownrigg JR, Schaper NC, Hinchliffe RJ. Diagnosis and assessment of peripheral arterial disease in the diabetic foot. Diabet Med. 2015;32(6):738e747.

32. Courtois MC, Sapoval M, Del Giudice C, Ducloux R, Mirault T, Messas E. Distal revascularization in diabetic patients with chronic limb ischemia. J Mal Vasc. 2015;40(1):24e36.

33. Pernes JM, Auguste M, Borie H, et al. Infrapopliteal arterial recanalization: a true advance for limb salvage in diabetics. Diagn Interv Imaging. 2015;96(5): 423e434.