Indicators for Comparing the Incidence of Diabetic Amputations: A Nationwide Population-based Register Study

Can Early Post-Operative Scoring of Non-Traumatic Amputees Decrease Rates of Revision Surgery?

Background and Objectives: Medical registries evolved from a basic epidemiological data set to further applications allowing deriving decision making. Revision rates after non-traumatic amputation are high and dramatically impact the following rehabilitation of the amputee. Risk scores for revision surgery after non-traumatic lower limb amputation are still missing. The main objective was to create an amputation registry allowing us to determine risk factors for revision surgery after non-traumatic lower-limb amputation and to develop a score for an early detection and decision-making tool for the therapeutic course of patients at risk for non-traumatic lower limb amputation and/or revision surgery. Materials and Methods: Retrospective data analysis was of patients with major amputations lower limbs in a four-year interval at a University Hospital of maximum care. Medical records of 164 patients analysed demographics, comorbidities, and amputation-related factors. Descriptive statistics analysed demographics, prevalence of amputation level and comorbidities of non-traumatic lower limb amputees with and without revision surgery. Correlation analysis identified parameters determining revision surgery. Results: In 4 years, 199 major amputations were performed; 88% were amputated for non-traumatic reasons. A total of 27% of the non-traumatic cohort needed revision surgery. Peripheral vascular disease (PVD) (72%), atherosclerosis (69%), diabetes (42%), arterial hypertension (38%), overweight (BMI > 25), initial gangrene (47%), sepsis (19%), age > 68.2 years and nicotine abuse (17%) were set as relevant within this study and given a non-traumatic amputation score. Correlation analysis revealed delayed wound healing (confidence interval: 64.1% (47.18%; 78.8%)), a hospital length of stay before amputation of longer than 32 days (confidence interval: 32.3 (23.2; 41.3)), and a BKA amputation level (confidence interval: 74.4% (58%; 87%)) as risk factors for revision surgery after non-traumatic amputation. A combined score including all parameters was drafted to identify non-traumatic amputees at risk for revision surgery. Conclusions: Our results describe novel scoring systems for risk assessment for non-traumatic amputations and for revision surgery at non-traumatic amputations. It may be used after further prospective evaluation as an early-warning system for amputated limbs at risk of revision.

Impact of Diabetic Foot Multidisciplinary Unit on Incidence of Lower-Extremity Amputations by Diabetic Foot

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Global trends in the incidence of hospital admissions for diabetes-related foot disease and amputations: a review of national rates in the 21st century

AIMS/HYPOTHESIS

Diabetic foot disease (DFD) is a leading cause of hospital admissions and amputations. Global trends in diabetes-related amputations have been previously reviewed, but trends in hospital admissions for multiple other DFD conditions have not. This review analysed the published incidence of hospital admissions for DFD conditions (ulceration, infection, peripheral artery disease [PAD], neuropathy) and diabetes-related amputations (minor and major) in nationally representative populations.

METHODS

PubMed and Embase were searched for peer-reviewed publications between 1 January 2001 and 5 May 2022 using the terms 'diabetes', 'DFD', 'amputation', 'incidence' and 'nation'. Search results were screened and publications reporting the incidence of hospital admissions for a DFD condition or a diabetes-related amputation among a population representative of a country were included. Key data were extracted from included publications and initial rates, end rates and relative trends over time summarised using medians (ranges).

RESULTS

Of 2527 publications identified, 71 met the eligibility criteria, reporting admission rates for 27 countries (93% high-income countries). Of the included publications, 14 reported on DFD and 66 reported on amputation (nine reported both). The median (range) incidence of admissions per 1000 person-years with diabetes was 16.3 (8.4-36.6) for DFD conditions (5.1 [1.3-7.6] for ulceration; 5.6 [3.8-9.0] for infection; 2.5 [0.9-3.1] for PAD) and 3.1 (1.4-10.3) for amputations (1.2 [0.2-4.2] for major; 1.6 [0.3-4.3] for minor). The proportions of the reported populations with decreasing, stable and increasing admission trends were 80%, 20% and 0% for DFD conditions (50%, 0% and 50% for ulceration; 50%, 17% and 33% for infection; 67%, 0% and 33% for PAD) and 80%, 7% and 13% for amputations (80%, 17% and 3% for major; 52%, 15% and 33% for minor), respectively.

CONCLUSIONS/INTERPRETATION

These findings suggest that hospital admission rates for all DFD conditions are considerably higher than those for amputations alone and, thus, the more common practice of reporting admission rates only for amputations may substantially underestimate the burden of DFD. While major amputation rates appear to be largely decreasing, this is not the case for hospital admissions for DFD conditions or minor amputation in many populations. However, true global conclusions are limited because of a lack of consistent definitions used to identify admission rates for DFD conditions and amputations, alongside a lack of data from low- and middle-income countries. We recommend that these areas are addressed in future studies.

REGISTRATION

This review was registered in the Open Science Framework database ( https://doi.org/10.17605/OSF.IO/4TZFJ ).

Editor's Choice - Incidence of Lower Limb Amputations in Sweden from 2008 to 2017

OBJECTIVE

This study examined the recent national and regional incidence of lower limb amputations (LLAs) in Sweden and their annual changes.

METHODS

This was an observational study using Swedish national register data. All initial amputations were identified in Sweden from 2008 to 2017 in individuals 18 years or older using the national inpatient register. The amputations were categorised into three levels: high proximal (through or above the knee joint), low proximal (through the tibia to through the ankle joint), and partial foot amputations. To examine the national and regional incidence and annual changes, the age, sex, and region specific population count each year was used as the denominator and Poisson regression or negative binomial regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) adjusted for age and sex.

RESULTS

The national annual incidence of LLAs was 22.1 per 100 000 inhabitants, with a higher incidence in men (24.2) than in women (20.0). The incidence of LLAs (all levels combined) declined during the study period, with an IRR of 0.984 per year (95% CI 0.973 - 0.994). This was mainly due to a decrease in high proximal amputations (0.985, 95% CI 0.974 - 0.995) and low proximal amputations (0.973, 95% CI 0.962 - 0.984). No change in the incidence of partial foot amputations was observed (0.994, 95% CI 0.974 - 1.014). Such declines in LLA incidence (all levels combined) were observed in nine of the 21 regions. Compared with the national average and with adjustment for age, sex, diabetes, and artery disease, the regional IRR varied from 0.85 to 1.36 for all LLAs, from 0.67 to 1.61 for high proximal amputations, from 0.50 to 1.51 for low proximal amputations, and from 0.13 to 3.68 for partial foot amputations.

CONCLUSION

The incidence of LLAs has decreased in Sweden. However, regional variations in incidence, time trends, and amputation levels warrant further research.

Major Lower Limb Amputations and Amputees in an Aging Population in Southwest Finland 2007-2017

Purpose

The aim of the present study was to describe and analyze changes in the incidences of lower extremity amputations (LEAs), patient characteristics, vascular history of amputees and survival in Southwest Finland.

Patients and Methods

This is a retrospective patient study in the Hospital District of Southwest Finland. All consecutive patients with atherosclerosis and diabetes-caused LEA, between 1st January 2007 and 31st December 2017, were included. The annual incidences of major LEA patients were statistically standardized. Patients' diagnoses, functional status, previous revascularizations and minor amputations were recorded, and survival was analyzed.

Results

During the 11-year-period major LEAs were performed on 891 patients, 118 (13.2%) were urgent operations. The overall incidence of major LEA was 17.2/100 000 and was age-dependent (3.1 for ≤64 years, 34.3 for 65-74 years, 81.5 for 75-84 years, 216 for ≥85 years). A decrease in incidence was detected in the <65 year-age-group (incidence 4.98 in 2007 and 1.88 in 2017; p = 0.0018). Among older age groups, there was no significant change. Half (50.6%) of all amputees were diabetics. Altogether, 472 patients (53.0%) had a history of revascularization before LEA. 80.1% of index amputations were transfemoral and 19.9% transtibial. Re-surgery was performed on 94 (10.5%) patients. The 1-, 3- and 5-year overall survival were 56%, 30%, and 18%, respectively.

Conclusion

Our results suggest that in an aging population, despite good availability of vascular services, a significant number of patients are not fit for active revascularization, and LEA is the only feasible treatment for critical limb ischemia.

Spatial analysis of factors impacting lower limb major amputation rates in Hungary

Summary: Background: Lower limb major amputations represent a substantial public health burden in Hungary, where previous research revealed markedly high rates with significant spatial variations. Therefore, we aimed to assess to what extent healthcare and socio-economic factors in the local environment explain the regional disparity. Patients and methods: In a retrospective cohort analysis, based on the healthcare administrative data of the Hungarian population, lower limb major amputations were identified from 1st of January 2017 to 31st of December 2019. The permanent residence of the amputees on the local administrative level (197 geographic units) was used to identify potential healthcare (outpatient care, revascularisation activity) and socio-economic (educational attainment, local infrastructure and services, income and employment) determinants of amputations. Spatial effects were modelled using the spatial Durbin error regression model. Results: 10,209 patients underwent 11,649 lower limb major amputations in the observational period. In our spatial analysis, outpatient care was not associated with local amputation rates. However, revascularisation activity in a geographic unit entailed an increased rate of amputations, while revascularisations in the neighbouring areas were associated with a lower rate of amputations, resulting in an overall neutral effect (β=−0.002, 95% CI: −0.05 – 0.04, p=0.96). The local socio-economic environment had a significant direct inverse association with amputations (β=−7.45, 95% CI: −10.50 – −4.42, p<0.0001) . Our spatial model showed better performance than the traditional statistical modelling (ordinary least squares regression), explaining 37% of the variation in amputations rates. Conclusions: Regional environmental factors explain a substantial portion of spatial disparities in amputation practice. While the socio-economic environment shows a significant inverse relationship with the regional amputation rates, the impact of the local healthcare-related factors (outpatient care, revascularisation activity) is not straightforward. Unravelling the impact of the location on amputation practice requires complex spatial modelling, which may guide efficient healthcare policy decisions.

The incidence and trend of geriatric amputations in Taiwan from 1996 to 2013

BACKGROUND

There has been a reported reduction in the incidence of amputation, but it is unclear whether the number of amputations has decreased in the elderly, a cohort that typically has the largest proportion of amputees.

OBJECTIVES

To investigate the incidence proportion and time trends of amputation in patients aged ≥ 65 years in Taiwan.

STUDY DESIGN

A retrospective cohort study from a large national database.

METHODS

The records of patients who underwent an amputation were collected from a nationally representative sample of 1,000,000 enrollees of Taiwan's National Health Insurance program during 1996-2013. The patients were divided into four age groups: ≤64, 65-74, 75-84, and ≥85 years. Joinpoint regression was performed with adjustment for age and sex to identify changes in incidence proportion by year.

RESULTS

During the 18 years, the incidence of upper and lower limb amputation decreased significantly in the total population, with the average annual percentage change (AAPC) of -6.1 and -1.8, respectively. However, in the elderly population over 65 years, the incidence did not decrease significantly for upper minor amputation, lower minor amputation, and major amputation with the AAPC of -1.1, -0.1, and -0.4, respectively. Although not significant, the incidence of major and minor lower limb amputation in the population over 85 years old showed an increasing trend, with the AAPC of 1.2 and 3.2, respectively.

CONCLUSION

During the study period, although the incidence of amputation of the overall population decreased in Taiwan, this trend was not simultaneously observed in the elderly and hence, it should not be ignored.

Lower Limb Amputation Rates in Germany

Background and Objectives: The current epidemiology of lower limb amputations is unknown. Therefore, the purpose of this study was to determine (1) lower extremity amputation rates as a function of age, gender, and amputation level between 2015 and 2019, (2) main diagnoses indicating amputation, (3) revision rates after lower extremity amputation. Materials and Methods: Lower extremity amputation rates were quantified based on annual Operation and Procedure Classification System (OPS) and International Classifications of Disease (ICD)-10 codes from all German medical institutions between 2015 through 2019, provided by the Federal Statistical Office of Germany (Destatis). Results: In 2019, 62,016 performed amputations were registered in Germany. Out of these 16,452 procedures (26.5%) were major amputations and 45,564 patients (73.5%) underwent minor amputations. Compared to 2015, the incidence of major amputations decreased by 7.3% to 24.2/100,000 inhabitants, whereas the incidence of minor amputation increased by 11.8% to 67.1/100,000 inhabitants. Highest incidence was found for male patients aged 80-89 years. Patients were mainly diagnosed with peripheral arterial disease (50.7% for major and 35.7% for minor amputations) and diabetes mellitus (18.5% for major and 44.2% for minor amputations). Conclusions: Lower limb amputations remain a serious problem. Further efforts in terms of multidisciplinary team approaches and patient optimization strategies are required to reduce lower limb amputation rates.

The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study

OBJECTIVE

To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018.

METHODS

Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%).

RESULTS

A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period.

CONCLUSION

The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.

Regional variation of lower limb major amputations on different geographic scales - a Hungarian nationwide study over 13 years

Background: The incidence of lower limb major amputations is an important healthcare quality indicator, as it reflects all efforts aimed to prevent limb loss. Analysis of within-country regional variations in incidence may reveal the sources of disparities in care. Materials and methods: Based on the data of the Hungarian healthcare beneficiary population from 2004 to 2016, the incidence of lower limb major amputations and its spatial variations was determined regionally on four levels of geographic resolution. Variability and autocorrelation were quantified on different resolutions. Results: A total of 56,468 lower limb major amputation procedures were identified in 49,528 patients over the observation period. Marked regional variations were detected at all geographic scale levels. In the case of county-level and local administrative level, the systematic component of variation was 0.03 and 0.09, respectively. Only half of the variation at local administrative level was explained by county. Conclusions: Lower limb major amputations show marked regional variations on the different geographic levels of resolution. The more granular the assessment, the higher the regional variation was. Assumingly, this observation is partially a mathematical necessity but may also be related to the different characteristics of care at a given level of spatial aggregation. The decomposition of the variance of amputation rates indicates that the potential explanatory factors contributing to spatial variability are multiple and may be interpreted on different levels of geographic resolution. Addressing the unwarranted variations and resolving the issues that contribute to high lower limb major amputation rates needs further explorative analysis.

An in-depth assessment of diabetes-related lower extremity amputation rates 2000-2013 delivered by twenty-one countries for the data collection 2015 of the Organization for Economic Cooperation and Development (OECD)

BACKGROUND

International comparisons of diabetes-related lower extremity amputation rates are still hampered by different criteria used for data collection and analysis. We aimed to evaluate trends and variation of major/minor amputations, using agreed definitions adopted by the Organization for Economic Cooperation and Development in 2015.

METHODS

Direct age-sex standardized rates were calculated per 100,000 subjects per year between 2000 and 2013, using major/minor amputations with diabetes diagnosis as numerators and the total population or number of people with diabetes as denominators. Longitudinal trends were investigated using generalized estimating equations.

RESULTS

Twenty-one countries reported major amputations referred to the general population, showing a mean reduction from 10.8 to 7.5 per 100,000 (- 30.6%). Eleven countries also reported major amputations among people with diabetes, showing a mean reduction from 182.9 to 128.3 per 100,000 (- 29.8%). Minor amputations remained stable over the study period. Longitudinal trends showed a significant average annual decrease of - 0.19 per 100,000 in the general population (95% CI - 0.36 to - 0.02; p = .03) and - 4.52 per 100,000 among subjects with diabetes (95% CI - 6.09 to - 2.94; p < .001). The coefficient of variation of major amputation rates between countries was fairly high (64%-in the total population, 67% among people with diabetes).

CONCLUSIONS

The study highlighted a clinically significant reduction of major amputations, in both the general population and among people with diabetes. The use of standardized definitions, while increasing the comparability of multinational data, highlighted remarkable differences between countries. These results can help identifying and sharing best practices effectively on a global scale.

Potentials, challenges, and limitations of the analysis of administrative data on vascular limb amputations in health care

Although more and more data on lower limb amputations are becoming available by leveraging the widening access to health care administrative databases, the applicability of these data for public health decisions is still limited. Problems can be traced back to methodological issues, how data are generated and to conceptual issues, namely, how data are interpreted in a multidimensional environment. The present review summarised all of the steps from converting the claims data of administrative databases into the analytical data and reviewed the wide array of sources of potential biases in the analysis of such data. The origins of uncertainty of administrative data analysis include uncontrolled confounding due to a lack of clinical data, the left- and right-censored nature of data collection, the non-standardized diagnosis/procedure-based data extraction methods (i.e., numerator/denominator problems) and additional methodological problems associated with temporal and spatial analyses. The existence of these methodological challenges in the administrative data-based analysis should not deter the analysts from using these data as a powerful tool in the armamentarium of clinical research. However, it must be done with caution and a thorough understanding and respect of the methodological limitations. In addition to this requirement, there is a profound need for pursuing further research on methodology and widening the search for other indicators (structural, process or outcome) that allow a deeper insight how the quality of vascular care may be assessed. Effective research using administrative data is based on strong collaboration in three domains, namely expertise in claims data handling and processing, the clinical field, and statistical analysis. The final interpretations of results and the countermeasures on the level of vascular care ought to be grounded on the integrity of research, open discussions and institutionalized mechanisms of science arbitration and honest brokering.

Regional differences in the incidence of diabetic cardiovascular events reflect the quality of care

OBJECTIVES

Diabetic patients have two-fold excess risk of cardiovascular complications (CVCs). To compare the treatment quality of diabetic patients we compared the incidence of CVCs between the five university hospital districts (UHDs) in Finland.

DESIGN

The study population comprised all persons with diabetes in Finland since 1964. They were followed up for the incidence of first acute coronary syndrome (ACS) and first ischemic stroke (IS) using the National Hospital Discharge Register and the National Causes of Death Register data between the years 2000 and 2011. Incidence differences among diabetic patients were also compared with corresponding results in the total population. The main analysis tool was Poisson regression adjusted for age, sex and study year. The UHD of Helsinki was used as the reference category.

RESULTS

In the diabetic population the risk for ACS exceeded the reference significantly in three UHDs ranging from 1.03 (95% CI 0.89-1.19) to 1.70 (1.46-1.97). The incidence of IS exceeded the reference in two UHDs ranging from 1.01 (0.89-1.15) to 1.36 (1.18-1.56). These differences were similar to the corresponding figures in the total population. Differences between the UHDs remained stable over time.

CONCLUSIONS

We found major and stable differences in the incidence of ACS and IS between the UHDs among patients with diabetes. The differences result from several factors influencing the risk of these complications, including the treatment. These differences tended to be larger than the corresponding differences in the total population, which suggests that there is potential to prevent CVCs by improving diabetes care.

Lower Limb Amputation in Germany

BACKGROUND

Declining amputation rates have been reported in multiple countries in recent years. It is not yet known whether amputation rates have declined in Germany as well.

METHODS

On the basis of DRG (diagnosis-related group) data, we received a list from the German Federal Statistical Office of all major and minor amputations documented in German hospitals from 2005 to 2014. Changes over this period were studied with linear regression.

RESULTS

The absolute number of amputations per year in Germany rose slightly from 55 689 in 2005 to 57 637 (+3.5%) in 2014. After the exclusion of cases in which the main diagnosis was trauma, intoxication, musculoskeletal disease, diseases of the skin and subcutaneous tissue, or neoplasia, the corresponding numbers were 48 043 in 2005 and 48 561 in 2014 (+1.1%). The age-adjusted rate of major amputations per 100 000 persons per year fell from 23.3 to 16.1 (-30.9%), while the rate of minor amputations rose from 35.0 to 43.9 (+25.4%). The percentage of major amputations that took place in patients with diabetes mellitus as the main diagnosis or a side diagnosis declined from 70.2% to 63.7%. For all of these changes, p <0.0001.

CONCLUSION

From 2005 to 2014, the major amputation rate fell by 30.9% while the minor amputation rate rose by 25.4%. The goal of lowering amputation rates still further will be best served not only by applying the recognized preventive measures in patients with foot lesions, but also by further research into the causes of the recent changes in amputation numbers. Prospective registries will be needed.

Trends in the epidemiology of diabetic foot and lower limb amputations in Russian Federation according to the Federal Diabetes Register (2013–2016)

BACKGROUND: The epidemiological study of diabetic foot (DF) is very important because of high risk lower limbs amputations in patients with diabetes mellitus (DM). AIMS: The aim of the study was to evaluate the DF prevalence in adult patients with type 1 (T1) and 2 (T2) diabetes in Russian Federation for period 201316years. METHODS: We have used the database of the Russian Federal Diabetes register, 81st regions included in the online register. Indicators were estimated per 10,000 adult DM patients (18years). RESULTS: In 2016, the prevalence of DF in RF was T1 4,7%, T2 1,9%, with marked interregional differences: 0,1519,9%, 0,0710,3%, respectively. The DF prevalence in RF decreased: T1 506,3473,6, T2 214,60194,8. The incidence of new DF cases/per year was stable in adults with T1: 20,820,4/; increased in T2 13.214.2. The mean age of DF diagnosis increased by 2years for both DM types. The average DM duration of DF determine increased T1 15.419.0years, T2 7.410.1years. Proportion of DF forms: neuropathic with trophic ulcer 41.6%, neuropathic form (Charcot's foot) 17.9%, the neuroischemic 28.3%, ischemic 12.2%, in T2: 41.6%, 7,4%, 32,4%, 18,5%, respectively. The amount of new cases of amputations/per year in dynamics: T1 10,512,4, T2 9,610,9, with marked interregional differences 0.132.9% in T1, 0.04-6.0% in T2. The mean DM duration before amputation increased in T1 18.421.3years, in T2 9.19.9. The average amputation age: T1 51.7years, T2 66.2years. There was marked decrease in proportion of major amputations: T1 43,637,0%, T2 52.245.5 by redistribution in one toe amputations T14,010.0%, in T22,89.1%. CONCLUSIONS: The dynamic of new DF cases in adult patients in Russian Federation is stable at T1, in T2 tends to increase. The interregional differences in frequency of DF and amputations may be due to differences in the quality of specialized care, the lack or shortage of diabetic foot cabinets, treatment of patients with DF in general surgical practice in a number of regions, which is recognized as a less effective strategy. A positive fact that proportion of high amputations declines, DF develops in later age and longer diabetes duration, that may reflect the increasing effectiveness of preventive lower limbs in diabetes.

Improved limb salvage for patients with vascular disease and tissue loss associated with new model of provision targeted at the diabetic foot

AIMS

The establishment of a vascular surgeon-led emergency diabetic foot service in 2006 has evolved to provide lower limb wound care for patients with and without diabetes. We aimed to determine whether the service was associated with sustained, improved limb salvage rates for the whole population, analyse key aspects of service provision and compare outcomes against published studies.

METHODS

The vascular unit serves a largely rural population of approximately 240,000. Data was collected prospectively on lower limb amputations, arterial and minor surgical interventions from 2006 to 2015, and retrospectively retrieved for 2004-2005, prior to service commencement. Data was also collected on referral patterns, volume of patient admissions and attendances, and delays. Lower limb amputation rates were compared against published data and analysis of admission trends and delays employed non-parametric tests.

RESULTS

Age/gender adjusted major lower limb amputations for the populations with and without diabetes were 412/100,000 in 2004 and 15/100,000 in 2005 respectively. Following service introduction, major amputations reduced and since 2012 have been sustained at between 15-44/100,000 and 1-3/100,000 for patients with and without diabetes respectively, comparing favourably with published data. Vascular interventions have remained static, but referrals of patients directly to the service and numbers of minor procedures have increased.

CONCLUSIONS

The sustained decreases in all major lower limb amputations that have coincided with the development of a core team approach to providing rapid access and comprehensive care for patients with emergency diabetic foot problems may indicate that this service design benefits patients with and without diabetes.

Increased amputation risk with canagliflozin treatment: behind the large cardiovascular benefit?

A growing body of evidence suggests that sodium-glucose cotransporter 2 (SGLT2) inhibitors appear to be a powerful option to improve the cardiovascular (CV) prognosis in high CV-risk patients with type 2 diabetes. Despite a significant reduction in major adverse CV events with SGLT2 inhibitor treatment, however, an unexpected increased risk of amputation was observed in the CANVAS program and the subsequent pharmacovigilance analysis. Although the underlying mechanisms are currently unknown, because amputation has a large negative impact on patient clinical course, clinicians want to know the exact reason for the increased amputation in the canagliflozin treatment. We herein discuss a need to elucidate the actual reasons with more appropriate statistical consideration, taking into account individual clinical course potentially involved in the diabetes-related amputation. Decreases in the hardendpoints by canagliflozin might result in an alternate increase in the other diabetes-related complications, including amputation. In addition, if amputation occurred after stopping canagliflozin, the incidence might be caused by worsened glycemic control and a decrease in hematocrit, accompanied by a subsequent worsening of diabetic foot disease. More detailed approach considering individual clinical course potentially involved in the amputation, would help to further unravel the cause for suspected risk of amputation with canagliflozin.

Outcomes of dysvascular partial foot amputation and how these compare to transtibial amputation: a systematic review for the development of shared decision-making resources

BACKGROUND

Dysvascular partial foot amputation (PFA) is a common sequel to advanced peripheral vascular disease. Helping inform difficult discussions between patients and practitioners about the level of PFA, or the decision to have a transtibial amputation (TTA) as an alternative, requires an understanding of the current research evidence on a wide range of topics including wound healing, reamputation, quality of life, mobility, functional ability, participation, pain and psychosocial outcomes, and mortality. The aim of this review was to describe a comprehensive range of outcomes of dysvascular PFA and compare these between levels of PFA and TTA.

METHODS

The review protocol was registered in PROSPERO (CRD42015029186). A systematic search of the literature was conducted using MEDLINE, EMBASE, psychINFO, AMED, CINAHL, ProQuest Nursing and Allied Health, and Web of Science. These databases were searched using MeSH terms and keywords relating to different amputation levels and outcomes of interest. Peer reviewed studies of original research-irrespective of the study design-were included if published in English between 1 January 2000, and 31 December 2015, and included discrete cohort(s) with dysvascular PFA or PFA and TTA. Outcomes of interest were rate of wound healing and complications, rate of ipsilateral reamputation, quality of life, functional ability, mobility, pain (i.e., residual limb or phantom pain), psychosocial outcomes (i.e., depression, anxiety, body image and self-esteem), participation, and mortality rate. Included studies were independently appraised by two reviewers. The McMaster Critical Review Forms were used to assess methodological quality and identify sources of bias. Data were extracted based on the Cochrane Consumers and Communication Review Group's data extraction template by a primary reviewer and checked for accuracy and clarity by a second reviewer. Findings are reported as narrative summaries given the heterogeneity of the literature, except for mortality and ipsilateral reamputation where data allowed for proportional meta-analyses.

RESULTS

Twenty-nine unique articles were included in the review, acknowledging that some studies reported multiple outcomes. Eighteen studies reported all-cause proportionate mortality. A smaller number of studies reported outcomes related to functional ability (two), mobility (four), quality of life (three), ipsilateral reamputation (six) as well as wound healing and complications (four). No studies related to pain, participation or psychosocial outcomes met the inclusion criteria. Subjects were typically older and male and had diabetes among other comorbidities. More detailed information about the cohorts such as race or sociodemographic factors were reported in an ad hoc manner. Common sources of bias included contamination, co-intervention, or lack of operational definition for some outcomes (e.g., wound healing) as illustrative examples.

CONCLUSIONS

Aside from mortality, there was limited evidence regarding outcomes of dysvascular PFA, particularly how outcomes differ between levels of PFA and TTA. Acknowledging that there is considerable uncertainty given the small body of literature on many topics where the risk of bias is high, the available evidence suggests that a large proportion of people with PFA experience delayed wound healing and ipsilateral reamputation. People with TTA have increased risk of mortality compared to those with PFA, which may reflect that those considered suitable candidates for TTA have more advanced systemic disease that also increases the risk of dying. Mobility and quality of life may be similar in people with PFA and TTA.

SYSTEMATIC REVIEW REGISTRATION

CRD42015029186.

Lower extremity amputation rates in people with diabetes as an indicator of health systems performance. A critical appraisal of the data collection 2000-2011 by the Organization for Economic Cooperation and Development (OECD)

AIMS

Critical appraisal of secondary data made available by the OECD for the time frame 2000-2011.

METHODS

Comparison of trends and variation of amputations in people with diabetes across OECD countries. Generalized estimating equations to test the statistical significance of the annual change adjusting for major potential confounders.

RESULTS

A total of 26 OECD countries contributed to the OECD data collection for at least 1 year in the reference time frame, showing a decline in rates of over 40 %, from a mean of 13.2 (median 9.4, range 5.1-28.1) to 7.8 amputations per 100,000 in the general population (9.9, 1.0-18.4). The multivariate model showed an average decrease equal to -0.27 per 100,000 per year (p = 0.015), adjusted by structural characteristics of health systems, showing lower amputation rates for health systems financed by public taxation (-4.55 per 100,000 compared to insurance based, p = 0.002) and non-ICD coding mechanisms (-7.04 per 100,000 compared to ICD-derived, p = 0.001). Twelve-year decrease was stronger among insurance-based financing systems (tax based: -0.16 per 100,000, p = 0.064; insurance based: -0.36 per 100,000; p = 0.046).

CONCLUSIONS

In OECD countries, amputation rates in diabetes continuously decreased over 12 years. Still, in 2011, one amputation every 7 min could be directly attributed to diabetes. Although interesting, these results should be taken with extreme caution, until common definitions are improved and data quality issues, e.g., a different ability in capturing diabetes diagnoses, are fully resolved.

[Hallux amputation]

OBJECTIVE

Debridement of infected tissue with the main aim being the re-establishment of mobilization with preservation of standing and walking ability. Prevention of secondary pressure points or amputations due to inadequate resection or deficient soft tissue cover.

INDICATIONS

In the case of increasing necrosis of the big toe, surgical abrasion and/or amputation is considered unavoidable. Other indications where surgery could be considered include diabetes and its associated angiopathies together with peripheral arterial angiopathy.

CONTRAINDICATIONS

In the case of insufficient blood supply an expansion of the resection margins should be taken into account. If there are possible alternatives to amputation. Surgery for patients with renal failure requiring dialysis associated with increased complication rate.

SURGICAL TECHNIQUE

A dorsal cuneiform resection is performed to facilitate implantation of a plantar skin transplant and wound healing. Important is the resection of bone in a slide oblique technique. Amputation scars should be outside pressure zones. Partial amputations in the area of the first ray as exarticulation or via the individual amputated segments possible (as opposed to toes 2-5).

POSTOPERATIVE MANAGEMENT

Direct postoperative weight-bearing with rigid insole and dispensing aid for 6-8 weeks. Following complete wound healing, foot support with orthopedic arch and transverse strain relief should be advocated, together with a joint roll in ready-made individual shoes.

RESULTS

Both trauma and nontrauma cases were included in our present cohort. A total of 7 cases were surgically revised in 2014 due to superficial skin necrosis that was likely the result of skin tension from the wound stitches.

The changing face of diabetes complications

The global increase in type 2 diabetes prevalence is well documented, but international trends in complications of type 2 diabetes are less clear. The available data suggest large reductions in classic complications of type 2 diabetes in high-income countries over the past 20 years, predominantly reductions in myocardial infarction, stroke, amputations, and mortality. These trends might be accompanied by less obvious, but still important, changes in the character of morbidity in people with diabetes. In the USA, for example, substantial reductions in macrovascular complications in adults aged 65 years or older mean that a large proportion of total complications now occur among adults aged 45-64 years instead, rates of renal disease could persist more than other complications, and obesity-related type 2 diabetes could have increasing effect in youth and adults under 45 years of age. Additionally, the combination of decreasing mortality and increasing diabetes prevalence has increased the overall mean years lived with diabetes and could lead to a diversification of diabetes morbidity, including continued high rates of renal disease, ageing-related disability, and cancers. Unfortunately, data on trends in diabetes-related complications are limited to only about a dozen countries, most of which are high income, leaving the changing character for countries of low and middle income ambiguous.

Quality of life in persons with partial foot or transtibial amputation: A systematic review

STUDY DESIGN

Systematic review.

BACKGROUND

Common beliefs about quality of life in people with partial foot and transtibial amputation are often described as passing comments in the literature with seeming little research evidence. A clear understanding of the research evidence is important to inform decisions about amputation level from a quality of life perspective.

OBJECTIVE

To systematically gather and appraise research evidence comparing quality of life between persons with partial foot and transtibial amputation.

METHODS

A comprehensive suite of databases (e.g. Cochrane Library, MEDLINE and Web of Science) were searched using terms relating to amputation level and quality of life. Reference lists of articles that met the inclusion criteria were hand searched. Included studies reported quantitative data for persons with partial foot and transtibial amputation secondary to peripheral vascular disease and diabetes. Studies were appraised using the McMaster University Critical Review form.

RESULTS

There is insufficient evidence comparing quality of life in people with partial foot and transtibial amputation. The available evidence suggests that quality of life may be very similar in people with partial foot and transtibial amputation and the small differences are not likely to be clinically meaningful.

CONCLUSION

Without adequate evidence comparing quality of life in people with partial foot and transtibial amputation, it is difficult to inform decisions about amputation level from a quality of life perspective.

CLINICAL RELEVANCE

There is insufficient evidence about differences in QoL between persons with PFA or TTA. Contrary to common belief, the available evidence suggests that QoL may be similar in persons with PFA and TTA. Further research is needed to inform decisions about amputation level from a QoL perspective.

National trends in incidence and outcomes in lower extremity amputations in people with and without diabetes in Spain, 2001-2012

AIMS

To describe trends in the incidence and outcomes of lower-extremity amputations (LEAs) in patients with T1DM and T2DM in Spain, 2001-2012.

METHODS

We used national hospital discharge data. Incidence of discharges attributed to LEA procedures were calculated stratified by diabetes status and type of LEA. Joinpoint log-linear regression for incidence trends and logistic regression for factors associated with in-hospital mortality were used.

RESULTS

From 2001 to 2012, 73,302 minor LEAs and 64,710 major LEAs were performed. We found that incidence of minor LEA procedures in T1DM patients decreased by 9.84% per year from 2001 to 2008 and then remained stable through 2012. In T2DM patients, LEA increased by 1.89% per year over the entire study period. Among patients with T1DM, major LEA incidence rate decreased by 10.5% from 2001 to 2012. In patients with T2DM, it increased by 4.29% from 2001 to 2004, and then decreased by 1.85% through 2012. In-hospital mortality after major or minor LEAs was associated with older age in all groups and with being female in T2DM and in people without diabetes.

CONCLUSIONS

Our national data show a decrease in the incidence of minor LEAs in patients with diabetes and in major LEAS in patients with T1DM over the period of study. In patients with T2DM, we found a decrease between 2004 and 2012. An additional improvement in preventive care, such as the introduction of diabetes foot units in hospitals, is necessary.

Temporal trends in initial and recurrent lower extremity amputations in people with and without diabetes in Western Australia from 2000 to 2010

AIMS

To examine temporal trends in lower extremity amputations in people with type 1 diabetes, type 2 diabetes and cardiovascular disease (CVD) without diabetes in Western Australia (WA) from 2000 to 2010.

METHODS

We used linked health data to identify all non-traumatic lower extremity amputations in adults aged ≥20 years with diabetes and/or CVD from 2000 to 2010 in WA. Annual age- and sex-standardised rates of total, initial and recurrent amputations, stratified by major and minor status, were calculated for type 1 and type 2 diabetes, and CVD without diabetes, from the at-risk population for each group. Age- and sex-adjusted trends were estimated from Poisson regression models.

RESULTS

5891 lower extremity amputations were identified. Peripheral vascular disease (71%), hypertension (70%) and chronic kidney disease (60%) were highly prevalent. Average annual rates of total amputations were 724, 564 and 66 per 100,000 person-years in type 1, type 2 diabetes and CVD without diabetes respectively. Rates of initial amputations fell significantly by 2.4%/year (95% CI -3.5, -1.4) in type 2 diabetes, with similar declines for type 1 diabetes and CVD without diabetes (interaction p=0.96), driven by large falls in major amputations. There was limited improvement in recurrence rates overall, with recurrent minor amputations increasing significantly in type 2 diabetes (+3.5%/year, 95% CI +1.3%, +5.7%).

CONCLUSION

Lower extremity amputation rates have declined at a population level in people with diabetes and CVD without diabetes, suggesting improvements in prevention and management for this high-risk patient group, however limited declines in recurrent amputations requires further investigation.