ORIGINAL ARTICLE

Foot Ulcer a Devastating Complication of Diabetes Mellitus: A Single-Center Experience of 400 Patients
Diyabetes Mellitusun Yıkıcı Bir Komplikasyonu Olan Ayak Ülseri: 400 Hastadan Oluşan Tek Merkez Deneyimi
Received Date : 23 Jan 2021
Accepted Date : 22 Mar 2021
Available Online : 07 Apr 2021
Doi: 10.25179/tjem.2021-81583 - Makale Dili: EN
Turk J Endocrinol Metab. 2021;25:133-141
Bu makale, CC BY-NC-SA altında lisanslanmış açık erişim bir makaledir.
ABSTRACT
Objective: To identify the clinical predictors of amputation outcomes in patients with diabetic foot ulcers (DFUs) and the management of such patients. Material and Methods: Four hundred (273 men; 127 women) patients with DFUs, who were followed at our clinic between 2008-2014, were included. Patients' demographic characteristics, glycemic parameters, and diabetic complications were evaluated. The amputations were classified as minor (distal to metatarsus) and major (Chopart, and below or upper knee) amputations. Results: The mean age of the patients was 62.4±10.5 years. Three hundred and ninety-five patients had type 2 diabetes mellitus. The mean diabetes duration was 17±8 years. The rate of chronic diabetic complications consisting of neuropathy, nephropathy, and retinopathy were 97.5%, 81.3%, and 94.8%, respectively. Osteomyelitis and peripheral arterial disease rates were 327 (81.8%) and 265 (66%), respectively. The majority of the foot ulcers were of Wagner grade 3 (53.2%) and 4 (27.5%). According to the initial clinical considerations, 60% of the patients were administered empirical antibiotic therapy for infection. The minor and major amputation rates were 110 (25.5%) and 146 (36.3%), respectively. The average glycosylated hemoglobin value was 8.9±2.3%. Peripheral arterial disease [odds ratio (OR): 2.183, 95% confidence interval (CI): 1.242-3.837, p<0.001), osteomyelitis [OR: 5.062, 95% CI: 2.296-11.161, p<0.001) and Wagner grade (OR: 62.352, %95 CI: 7854-495.021, p<0.001) were found to increase the amputation risk. Conclusion: Diabetic neuropathy is still an underlying major risk factor for the development of DFUs. The presence of peripheral arterial disease, osteomyelitis, and high Wagner degree are negative prognostic factors for the need for amputation.
ÖZET
Amaç: Diyabetik ayak ülseri ile amputasyon sonuçlarının, klinik belirleyicilerini ve hastaların yönetimini sunmaktır. Gereç ve Yöntemler: Çalışmaya, 2008 ve 2014 yılları arasında kliniğimizde izlenen diyabetik ayak ülserli 400 (273 erkek, 127 kadın) hasta dâhil edildi. Hastaların demografik özellikleri, glisemik parametreleri ve diyabetik komplikasyonları değerlendirildi. Amputasyonlar, minör (metatarsın distalinde) ve majör (Chopart ve diz altı veya diz üstü) amputasyonlar olarak sınıflandırıldı. Bulgular: Hastaların yaş ortalaması 62,4±10,5 yıl idi ve 395’i Tip 2 diyabetes mellituslu idi. Ortalama diyabet süresi 17±8 yıl idi. Kronik diyabetik komplikasyonlar olan nöropati, nefropati ve retinopati için oranlar sırasıyla %97,5; %81,3 ve %94,8 idi. Osteomiyelit ve periferik arteriyal hastalık oranları, sırasıyla 327 (%81,8) ve 265 (%66) saptandı. Ayak ülserlerinin çoğu, Wagner 3 (%53,2) ve 4 (%27,5) düzeyinde bulundu. İlk klinik değerlendirmeye göre hastaların %60’ına enfeksiyon nedeniyle ampirik antibiyotik tedavisi verildi. Minör ve majör amputasyon oranları sırasıyla 110 (%25,5) ve 146 (%36,3) idi. Hastaların ortalama glikozile hemoglobin düzeyi %8,9±2,3 idi. Periferik arteriyal hastalık (olasılık oranı: 2,183; %95 güven aralığı: 1,242-3,837; p<0,001), osteomiyelit (olasılık oranı: 5,062; 95% güven aralığı: 2,296-11,161; p<0,001) ve Wagner derecesi (olasılık oranı: 62,352; %95 güven aralığı: 7854-495,021; p<0,001), amputasyon riskini artıran faktörler olarak bulundu. Sonuç: Diyabetik nöropati, diyabetik ayak ülseri gelişimi için hâlâ temel risk faktörüdür. Periferik arteriyal hastalık, osteomiyelit ve yüksek Wagner derecesi varlığı, amputasyon ihtiyacı için negatif prognostik faktörlerdir.
KAYNAKLAR
  1. Dalla Paola L, Faglia E. Treatment of diabetic foot ulcer: an overview strategies for clinical approach. Curr Diabetes Rev. 2006;2:431-447. [Crossref]  [PubMed] 
  2. International Diabetes Federation. IDF Diabetes Atlas Eighth edition 2017. Available from: [Link] 
  3. Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg. 1998;176:5S-10S. [Crossref]  [PubMed] 
  4. Gordois A, Scuffham P, Shearer A, Oglesby A, Tobian JA. The health care costs of diabetic peripheral neuropathy in the US. Diabetes Care. 2003;26:1790-1795. [Crossref]  [PubMed] 
  5. NICE. Diabetic foot problems: prevention and management. NICE guideline [NG19]. 2015. Available from: date: 26 August 2015 [Link] 
  6. Calderini C, Cioni F, Haddoub S, Maccanelli F, Magotti MG, Tardio S. Therapeutic approach to "diabetic foot" complications. Acta Biomed. 2014;85:189-204. [PubMed] 
  7. Wagner FW Jr. The dysvascular foot: a system for diagnosis and treatment. Foot Ankle. 1981;2:64-122. [Crossref]  [PubMed] 
  8. Game FL, Apelqvist J, Attinger C, Hartemann A, Hinchliffe RJ, Löndahl M, Price PE, Jeffcoate WJ; International Working Group on the Diabetic Foot. Effectiveness of interventions to enhance healing of chronic ulcers of the foot in diabetes: a systematic review. Diabetes Metab Res Rev. 2016;32 Suppl 1:154-168. [Crossref]  [PubMed] 
  9. Zelmanovitz T, Gerchman F, Balthazar AP, Thomazelli FC, Matos JD, Canani LH. Diabetic nephropathy. Diabetol Metab Syndr. 2009;1:10. [Crossref]  [PubMed]  [PMC] 
  10. Assaad-Khalil SH, Zaki A, Abdel Rehim A, Megallaa MH, Gaber N, Gamal H, Rohoma KH. Prevalence of diabetic foot disorders and related risk factors among Egyptian subjects with diabetes. Prim Care Diabetes. 2015;9:297-303. [Crossref]  [PubMed] 
  11. Guest JF, Fuller GW, Vowden P. Diabetic foot ulcer management in clinical practice in the UK: costs and outcomes. Int Wound J. 2018;15:43-52. [Crossref]  [PubMed] 
  12. Treece KA, Macfarlane RM, Pound N, Game FL, Jeffcoate WJ. Validation of a system of foot ulcer classification in diabetes mellitus. Diabet Med. 2004;21:987-991. [Crossref]  [PubMed] 
  13. Lipsky BA; International consensus group on diagnosing and treating the infected diabetic foot. A report from the international consensus on diagnosing and treating the infected diabetic foot. Diabetes Metab Res Rev. 2004;20 Suppl 1:S68-77. [Crossref]  [PubMed] 
  14. Ikem R, Ikem I, Adebayo O, Soyoye D. An assessment of peripheral vascular disease in patients with diabetic foot ulcer. Foot (Edinb). 2010;20:114-117. [Crossref]  [PubMed] 
  15. Gerasimchuk PA, Kisil' PV, Vlasenko VG, Pavlyshin AV. [Endothelial dysfunction indicators in patients with diabetic foot syndrome]. Vestn Ross Akad Med Nauk. 2014:107-10. [Crossref]  [PubMed] 
  16. Tuttolomondo A, La Placa S, Di Raimondo D, Bellia C, Caruso A, Lo Sasso B, Guercio G, Diana G, Ciaccio M, Licata G, Pinto A. Adiponectin, resistin and IL-6 plasma levels in subjects with diabetic foot and possible correlations with clinical variables and cardiovascular co-morbidity. Cardiovasc Diabetol. 2010;9:50. [Crossref]  [PubMed]  [PMC] 
  17. Zimny S, Schatz H, Pfohl M. The role of limited joint mobility in diabetic patients with an at-risk foot. Diabetes Care. 2004;27:942-946. [Crossref]  [PubMed] 
  18. Sert M, Tetiker T, Koçak M. Çukurova yöresinde diyabetik ayak yarası olan hastaların klinik seyri. Endokrinolojide Yönelişler. 2004;8. [Link] 
  19. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic patients. JAMA. 1995;273:721-723. [Crossref]  [PubMed] 
  20. Khatri G, Wagner DK, Sohnle PG. Effect of bone biopsy in guiding antimicrobial therapy for osteomyelitis complicating open wounds. Am J Med Sci. 2001;321:367-371. [Crossref]  [PubMed] 
  21. Morrison WB, Ledermann HP. Work-up of the diabetic foot. Radiol Clin North Am. 2002;40:1171-1192. [Crossref]  [PubMed] 
  22. Kosinski MA, Lipsky BA. Current medical management of diabetic foot infections. Expert Rev Anti Infect Ther. 2010;8:1293-1305. [Crossref]  [PubMed] 
  23. Lipsky BA, Berendt AR. Principles and practice of antibiotic therapy of diabetic foot infections. Diabetes Metab Res Rev. 2000;16 Suppl 1:S42-S46. [Crossref]  [PubMed] 
  24. Ramakant P, Verma AK, Misra R, Prasad KN, Chand G, Mishra A, Agarwal G, Agarwal A, Mishra SK. Changing microbiological profile of pathogenic bacteria in diabetic foot infections: time for a rethink on which empirical therapy to choose? Diabetologia. 2011;54:58-64. [Crossref]  [PubMed] 
  25. Saltoglu N, Dalkiran A, Tetiker T, Bayram H, Tasova Y, Dalay C, Sert M. Piperacillin/tazobactam versus imipenem/cilastatin for severe diabetic foot infections: a prospective, randomized clinical trial in a university hospital. Clin Microbiol Infect. 2010;16:1252-1257. [Crossref]  [PubMed] 
  26. Demir T, Akıncı B, Yeşil S. Diyabetik ayak ülserlerinin tanı ve tedavisi. Dokuz Eylül Üniversitesi Tıp Fakültesi Dergisi. 2007;21:63-70. [Link] 
  27. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lan