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Predictors of lower-extremity amputation in patients with an infected diabetic foot ulcer

K. Pickwell, V. Siersma, M. Kars, J. Apelqvist, K. Bakker, M. Edmonds, P. Holstein, A. Jirkovská, E. Jude, D. Mauricio, A. Piaggesi, G. Ragnarson Tennvall, H. Reike, M. Spraul, L. Uccioli, V. Urbancic, K. van Acker, J. van Baal, N. Schaper,

. 2015 ; 38 (5) : 852-7. [pub] 20150209

Language English Country United States

Document type Journal Article, Multicenter Study, Observational Study, Research Support, Non-U.S. Gov't

Persistent link   https://www.medvik.cz/link/bmc16000307

OBJECTIVE: Infection commonly complicates diabetic foot ulcers and is associated with a poor outcome. In a cohort of individuals with an infected diabetic foot ulcer, we aimed to determine independent predictors of lower-extremity amputation and the predictive value for amputation of the International Working Group on the Diabetic Foot (IWGDF) classification system and to develop a risk score for predicting amputation. RESEARCH DESIGN AND METHODS: We prospectively studied 575 patients with an infected diabetic foot ulcer presenting to 1 of 14 diabetic foot clinics in 10 European countries. RESULTS: Among these patients, 159 (28%) underwent an amputation. Independent risk factors for amputation were as follows: periwound edema, foul smell, (non)purulent exudate, deep ulcer, positive probe-to-bone test, pretibial edema, fever, and elevated C-reactive protein. Increasing IWGDF severity of infection also independently predicted amputation. We developed a risk score for any amputation and for amputations excluding the lesser toes (including the variables sex, pain on palpation, periwound edema, ulcer size, ulcer depth, and peripheral arterial disease) that predicted amputation better than the IWGDF system (area under the ROC curves 0.80, 0.78, and 0.67, respectively). CONCLUSIONS: For individuals with an infected diabetic foot ulcer, we identified independent predictors of amputation, validated the prognostic value of the IWGDF classification system, and developed a new risk score for amputation that can be readily used in daily clinical practice. Our risk score may have better prognostic accuracy than the IWGDF system, the only currently available system, but our findings need to be validated in other cohorts.

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$a Pickwell, Kristy $u Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands k.pickwell@mumc.nl.
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$a OBJECTIVE: Infection commonly complicates diabetic foot ulcers and is associated with a poor outcome. In a cohort of individuals with an infected diabetic foot ulcer, we aimed to determine independent predictors of lower-extremity amputation and the predictive value for amputation of the International Working Group on the Diabetic Foot (IWGDF) classification system and to develop a risk score for predicting amputation. RESEARCH DESIGN AND METHODS: We prospectively studied 575 patients with an infected diabetic foot ulcer presenting to 1 of 14 diabetic foot clinics in 10 European countries. RESULTS: Among these patients, 159 (28%) underwent an amputation. Independent risk factors for amputation were as follows: periwound edema, foul smell, (non)purulent exudate, deep ulcer, positive probe-to-bone test, pretibial edema, fever, and elevated C-reactive protein. Increasing IWGDF severity of infection also independently predicted amputation. We developed a risk score for any amputation and for amputations excluding the lesser toes (including the variables sex, pain on palpation, periwound edema, ulcer size, ulcer depth, and peripheral arterial disease) that predicted amputation better than the IWGDF system (area under the ROC curves 0.80, 0.78, and 0.67, respectively). CONCLUSIONS: For individuals with an infected diabetic foot ulcer, we identified independent predictors of amputation, validated the prognostic value of the IWGDF classification system, and developed a new risk score for amputation that can be readily used in daily clinical practice. Our risk score may have better prognostic accuracy than the IWGDF system, the only currently available system, but our findings need to be validated in other cohorts.
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$a Siersma, Volkert $u Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
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$a Kars, Marleen $u Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.
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$a Apelqvist, Jan $u Department of Endocrinology, University of Malmö, Malmö, Sweden. $7 gn_A_00007730
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$a Bakker, Karel $u International Diabetes Federation, Consultative Section and International Working Group on the Diabetic Foot, Heemstede, the Netherlands.
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$a Edmonds, M. E. $7 mzk2004248664 $u Diabetic Department, Kings College Hospital, London, U.K.
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$a Holstein, Per $u Copenhagen Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark.
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$a Jirkovská, Alexandra $u Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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$a Jude, Edward $u Diabetes Centre, Tameside General Hospital, Ashton-under-Lyne, U.K.
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$a Mauricio, Didac $u Department of Endocrinology and Nutrition, Hospital de Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.
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$a Piaggesi, Alberto $u Sezione Dipartimentale Piede Diabetico, Dipartimento di Area Medica, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
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$a Ragnarson Tennvall, Gunnel $u Swedish Institute for Health Economics, Lund, Sweden.
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$a Reike, Heinrich $u Innere Abteilung, Mariannen Hospital, Werl, Germany.
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$a Spraul, Maximilian $u Mathias-Spital, Diabetic Department, Rheine, Germany.
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$a Uccioli, Luigi $u Policlinico Tor Vergata, Department of Internal Medicine, Rome, Italy.
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$a Urbancic, Vilma $u Department of Endocrinology, University Medical Centre, Ljubljana, Slovenia.
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$a van Acker, Kristien $u Department of Endocrinology, H Familie Ziekenhuis and Centre de Santé des Fagnes, Rumst and Chimay, Belgium.
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$a van Baal, Jeff $u Department of Surgery, Twenteborg Ziekenhuis, Almelo, the Netherlands.
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$a Schaper, Nicolaas $u Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.
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