|Year : 2016 | Volume
| Issue : 2 | Page : 102-105
Reducing diabetes-related major limb amputations: A plea for a multidisciplinary team approach
Kenneth Ezenwa Amaefule1, IO Okpe2, IL Dahiru1, AA Aruna3
1 Department of Orthopedics and Trauma Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
2 Department of Medicine, Endocrinology Unit, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
3 Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria
|Date of Submission||06-Nov-2015|
|Date of Acceptance||18-Apr-2016|
|Date of Web Publication||21-Jun-2016|
Dr. Kenneth Ezenwa Amaefule
Department of Orthopedics and Trauma Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State
Background: Diabetic foot is a challenging complication of diabetes mellitus, affecting a significant number of diabetic patients and often resulting in amputations especially in resource-poor nations. Patients and Methods: A 4-year retrospective review of clinical records of patients with diabetic foot lesions (DFLs) treated at Ahmadu Bello University Teaching Hospital, Zaria. Results: One hundred and thirty-eight patients were admitted with DFLs, but only 109 patients had complete medical records available for review. Nine patients had bilateral lesions at presentation. Seventy-three (61.9%) were male and 45 (38.1%) were female. Three (2.6%) were young adults (<40 years) while 89 (75.4%) were middle age (40-65 years) and 26 (22.0%) were elderly (>65 years). Fifty-two (44.0%) of the lesions were admitted through the diabetic clinic while 66 (56.0%) presented to the emergency room. Wagner Grade IV and V lesions constitute the majority (68.7%). The mean duration of the lesions at presentation was 6 weeks while the mean interval between first review by an endocrinologist and first surgical review was 17 days for those admitted through the diabetic clinic. Seventy-seven had surgical interventions, 30 of which were major amputations. The mortality rate was 14.6%. Conclusion: Diabetes-related foot lesions pose a great challenge in developing countries, with a significant number of the patients undergoing major amputation, an incapacitating outcome largely contributed to by late presentation and poor quality of diabetic foot care. With the impact being made by public health enlightenment programs on diabetes complications, a multidisciplinary team care approach from the outset goes a long way in reducing major amputations in these patients.
Keywords: Diabetic foot lesion, major amputations, multidisciplinary team care
|How to cite this article:|
Amaefule KE, Okpe I O, Dahiru I L, Aruna A A. Reducing diabetes-related major limb amputations: A plea for a multidisciplinary team approach. Sub-Saharan Afr J Med 2016;3:102-5
|How to cite this URL:|
Amaefule KE, Okpe I O, Dahiru I L, Aruna A A. Reducing diabetes-related major limb amputations: A plea for a multidisciplinary team approach. Sub-Saharan Afr J Med [serial online] 2016 [cited 2019 Oct 16];3:102-5. Available from: http://www.ssajm.org/text.asp?2016/3/2/102/184377
| Introduction|| |
Diabetic foot lesion (DFL) is a serious complication of diabetes mellitus. Despite modern advances in managing such feet, most of them end up with major lower extremity amputations.  It is estimated that 15-20% of diabetics will develop a DFL, and more than 15% will result in major amputation predominantly due to infection. , A corollary to this is a significant toll on the patients as they suffer social stigmatization and depression because they are seen and see themselves as incomplete humans in socially and educationally backward society as the developing countries. , They also suffer financial deprivation due to functional impairment because of inaccessibility of modern, sophisticated energy-conserving prosthetic fittings, thus making them largely dependent on their relatives for a living. , DFLs and major amputation therefore reduce the quality of life of the diabetic patient significantly.
The management of DFLs in most centers is done largely in isolation by the endocrinologists, plastic and reconstructive surgeons, and orthopedic surgeons. ,, The endocrinologists being the first contact of the diabetics in the diabetic clinic appear to seek the input of the plastic and reconstructive or orthopedic surgeons only when their patients with DFLs fail to respond to their conservative treatment with antibiotics and wound dressings; the surgeons may for one reason or the other not respond promptly to such invitation. The result is often late-grade lesions where no treatment options other than major amputation can be offered to most of them to adequately eradicate the disease, in resource-poor countries. We therefore carried out a retrospective study of diabetes-related major limb amputations in our center, with a view to comparing our findings with those from other centers.
| Patients and Methods|| |
This is a retrospective observational study. The case notes of patients with diabetic foot ulcers, gangrene, or sepsis admitted to Ahmadu Bello University Teaching Hospital, Zaria, between June 2011 and May 2015 were retrieved and reviewed.
Data on their demographics, type of diabetes mellitus, stage of the lesions at presentation, duration of the lesions, length of time from first endocrinologist's review to first surgical review (for those who had surgical review), surgical interventions and outcome were collated and analyzed.
| Results|| |
One hundred and thirty-eight patients were admitted with DFLs during the period under review, but complete medical records were available for only 109 patients and were analyzed. Nine patients had bilateral DFL at presentation, bringing the total number of DFL to 118. Fifty-two (44.0%) of them were admitted through the diabetic clinic while 66 (56.0%) presented at the emergency room (ER), 19 of which have had at least two diabetic clinic attendances since development of foot lesions much earlier. The grades of their lesions are compared in [Figure 1]. Seventy-three (61.9%) were male, and 45 (38.1%) were female. Three of the lesions (2.6%) affected young adults (<40 years) while 89 (75.4%) were in middle-aged patients (40-65 years), and 26 (22.0%) were elderly (>65 years). Four (3.4%) were Wagner Grade I, 20 (16.9%) Grade II, 13 (11%) Grade III, 44 (37.3%) Grade IV, and 37 (31.4%) Grade V. Majority of the patients, i.e., 106 (97.2%) were Type II diabetics. The mean duration of the foot lesions at presentation was 6 weeks (range: 4-12 weeks). The mean length of time from the first review by an endocrinologist to the first orthopedic or plastic and reconstructive surgical review was 17 days (range: 8-33 days), for those admitted through the diabetic clinic. Seventy-seven DFLs had surgical intervention [Table 1]. The outcome is shown in [Figure 2]. Mortalities were mainly from diabetic ketoacidosis, septicemia, and tetanus.
| Discussion|| |
Our study showed higher prevalence of DFL in males than females, which is in agreement with other studies. ,,,, This has been attributed to the higher smoking habits among males as it is said to contribute to peripheral vascular diseases and ischemic changes in vaso nervorum leading to neuropathy, with a resultant increased predisposition to injuries due to decreased sensation and the tendency not to notice minor injuries until much later. ,, Another possible contributor to the higher male predominance could also be due to the effect of traditional "manicurists" who often cause minor cuts in the course of their practice which could progress to foot sepsis. The traditional "manicurists" are usually males and are almost entirely patronized by the male folks in a largely Islamic society as ours. Third reason could be the predominant occupation of the people of our study area, which is peasant farming. Farming in a society like ours is done mainly by males, most of who go to their farms barefoot with resultant minor injuries to their feet. The high male prevalence however contrasts with a study in Barbados where a female preponderance was found. 
The mean age of diabetics affected with DFL in our study was also in keeping with other studies across Sub-Saharan Africa and the Caribbean with low per capita income ,,,, but contrasts with the relatively older mean age in economically advanced country like Germany.  This may be due to a better quality of diabetic care which makes their diabetic patients stay longer before developing foot lesions.
The relatively long duration of the foot lesions at first presentation to the hospital in our study is also comparable to the findings from some other developing countries. ,,,, This may be due to several factors, one of which is the impact of social deprivation evidenced by poor education and low socioeconomic status.  The second could be poor access to adequate medical care, as a significant number of our service population are poor rural dwellers. The third reason could be patient's beliefs and cultural practices as the Sub-Saharan African society could be divided along two belief groups: Those who believe in supernatural powers for causes and cure of ailments and those who believe in scientific basis for ailments and treatments. 
The mean interval between first endocrinologist's review and subsequent surgical review (for those admitted through the diabetic clinic) reflects a defect in the modus operandi of the diabetic foot care in our center where multidisciplinary team approach is not in practice. The endocrinologist is usually the first contact of these patients in the diabetic clinic, who uses his/her discretion to decide when to invite the other specialists involved in DFL care.
The high proportion of major limb amputations recorded in this study is partly a direct consequence of late presentation as shown by the majority (68.7%) of patients presenting with Wagner Grades IV and V lesions. Most of our patients present late when none other than a major limb amputation can guarantee salvage of their life from sepsis or eradication of the disease. The second contributor to this high amputation rate is the impact of the delay caused by our isolated approach to DFL care. This was also the finding in other studies. ,,,, A multidisciplinary team approach virtually eliminates the delay experienced in getting the benefit of other specialists' opinion, by patients who presented early to the hospital but were either not properly evaluated or were referred late to other specialists for their input. If every specialist involved in the DFL care is present at the initial visit, they can deliberate on each case to arrive at the true extent and best approach to management, rather than each specialist making isolated assessment and treatment decisions that may not be the best for that patient. This fact is buttressed by the significant number 19 (28.8%) of those who presented to ER with high-grade lesions, who have had at least two diabetic clinic visits for their foot lesions much earlier. Chi-square analysis of these 19 patients for worsening of their DFL from time of presentation with early lesions to the diabetic clinic and the eventual outcome, shows a significant relationship between time of presentation and worsening of DFL (χ2 = 46.13, P < 0.05). Some of these DFLs if they had been properly evaluated by a plastic or vascular surgeon probably could have been salvaged by a revascularization procedure earlier and not just by local wound care. The multidisciplinary approach has been shown by several studies to reduce the rate of major limb amputations in DFL significantly as it leads to improved screening and prevention program and earlier interventions. ,,,,,,
Our mortality rate of 14.6% is also comparable to those reported in a study by Chalya from Tanzania.  This may be due to the late presentation of most of our patients, some of whom present with fulminant necrotizing soft tissue infection and septicemia or with complicating tetanus as a result of local applications of traditional medications that every attempt at eradicating the infection even with a major amputation comes too late.
Our study may have some limitations. It is an inpatient-based study, thus some patients with early lesions such as Wagner 1 lesions being treated as outpatients in the diabetic clinic may have been excluded from the study. This however is unlikely to affect the major outcomes such as amputations and mortalities as such patients are quite unlikely to suffer this fate.
| Conclusion|| |
DFL is a significant cause of morbidity and mortality in the diabetic patient, and the rate of major lower extremity amputation is an important indicator of the quality of diabetic health care offered in any health facility. With the positive impact of public health enlightenment programs in eliminating most patient factors involved in such diabetes-related complications, the lapses inherent in our isolated specialist DFL care remains a major setback in our effort to improve the quality of life of the diabetic patient. The adoption of a multidisciplinary team approach to DFL care will obviously go a long way in fixing this.
Financial Support and Sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Tashkandi WA, Badri MM, Badawood SM. Lower limb amputations among diabetics admitted with diabetic foot disorder in three major hospitals in Jeddah, Saudi Arabia. J KAU Med Sci 2010;18:23-5.
Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217-28.
Reiber GE. Epidemiology and health care costs of diabetic foot problems. In: Veves A, Giurini JM, Logerfo FW, editors. The Diabetic Foot. New Jersey: Humana Press; 2002. p. 35-58.
Liu F, Williams RM, Liu HE, Chien NH. The lived experience of persons with lower extremity amputation. J Clin Nurs 2010;19:2152-61.
Livingstone W, Mortel TF, Taylor B. A path of perpetual resilience: Exploring the experience of a diabetes-related amputation through grounded theory. Contemp Nurse 2011;39:20-30.
Schaper NC, Apelqvist J, Bakker K. Reducing lower leg amputations in diabetes: A challenge for patients, healthcare providers and the healthcare system. Diabetologia 2012;55:1869-72.
Peters EJ, Childs MR, Wunderlich RP, Harkless LB, Armstrong DG, Lavery LA. Functional status of persons with diabetes-related lower-extremity amputations. Diabetes Care 2001;24:1799-804.
Musa AA. Diabetic foot lesions as seen in Nigerian teaching hospital: Pattern and a simple classification. East Afr J Public Health 2012;9:50-2.
Chalya PL, Mabula JB, Dass RM, Kabangila R, Jaka H, McHembe MD, et al.
Surgical management of Diabetic foot ulcers: A Tanzanian university teaching hospital experience. BMC Res Notes 2011;4:365.
Hjelm K, Beebwa E. The influence of beliefs about health and illness on foot care in ugandan persons with diabetic foot ulcers. Open Nurs J 2013;7:123-32.
Isiguzo CM, Jac-Okereke C. Diabetic foot ulcers -12 months prospective review of pattern of presentation at Enugu state university of technology teaching hospital, Parklane, Enugu: A basis for diabetic foot clinic? Niger J Med 2015;24:125-30.
Doumi A. Diabetic septic foot in El Obeid, Western Sudan. Sudan J Med Sci 2007;2:119-21.
Anderson JJ, Boone J, Hansen M, Spencer L, Fowler Z. A comparison of diabetic smokers and non-smokers who undergo lower extremity amputation: A retrospective review of 112 patients. Diabet Foot Ankle 2012;3:2681-93.
Venermo M, Manderbacka K, Ikonen T, Keskimäki I, Winell K, Sund R. Amputations and socioeconomic position among persons with diabetes mellitus, a population-based register study. BMJ Open 2013;3. pii: e002395.
Nyamu PN, Otieno CF, Amayo EO, McLigeyo SO. Risk factors and prevalence of diabetic foot ulcers at Kenyatta National Hospital, Nairobi. East Afr Med J 2003;80:36-43.
Hennis AJ, Fraser HS, Jonnalagadda R, Fuller J, Chaturvedi N. Explanations for the high risk of diabetes-related amputation in a Caribbean population of black African descent and potential for prevention. Diabetes Care 2004;27:2636-41.
Cawich SO, Islam S, Hariharan S, Harnarayan P, Budhooram S, Ramsewak S, et al.
The economic impact of hospitalization for diabetic foot infections in a Caribbean nation. Perm J 2014;18:e101-4.
Morbach S, Lutale JK, Viswanathan V, Möllenberg J, Ochs HR, Rajashekar S, et al.
Regional differences in risk factors and clinical presentation of diabetic foot lesions. Diabet Med 2004;21:91-5.
Muquim R U, Ahmed M, Griffin S. Evaluation and management of diabetic foot according to Wagner′s classification. A study of 100 cases. J Ayub Med Coll Abbottabad 2003;15:39-42.
Famuyiwa OO, Edozien EM, Ukoli CO. Social, cultural and economic factors in the management of diabetes mellitus in Nigeria. Afr J Med Med Sci 1985;14:145-54.
Hjelm K, Mufunda E. Zimbabwean diabetics′ beliefs about health and illness: An interview study. BMC Int Health Hum Rights 2010;10:7.
Newark K, Scotland S, Seepersaud O, Persaud N. Lower extremity amputations in diabetic patients with foot ulcers at Georgetown Public Hospital Cooperation (2003-2006). West Indian Med J 2008;57 Suppl 2:27.
Aksoy DY, Gürlek A, Cetinkaya Y, Oznur A, Yazici M, Ozgür F, et al.
Change in the amputation profile in diabetic foot in a tertiary reference center: Efficacy of team working. Exp Clin Endocrinol Diabetes 2004;112:526-30.
Rubio JA, Aragón-Sánchez J, Jiménez S, Guadalix G, Albarracín A, Salido C, et al.
Reducing major lower extremity amputations after the introduction of a multidisciplinary team for the diabetic foot. Int J Low Extrem Wounds 2014;13:22-6.
Ogrin R, Houghton PE, Thompson GW. Effective management of patients with diabetes foot ulcers: Outcomes of an Interprofessional Diabetes Foot Ulcer Team. Int Wound J 2015;12:377-86.
Nteleki B, Njokweni M. Want to avoid DFUs? A multidisciplinary team approach works best. J Wound Care 2015;24 5 Suppl 2:8-14.
Aydin K, Isildak M, Karakaya J, Gürlek A. Change in amputation predictors in diabetic foot disease: Effect of multidisciplinary approach. Endocrine 2010;38:87-92.
Krishnan S, Nash F, Baker N, Fowler D, Rayman G. Reduction in diabetic amputations over 11 years in a defined U.K. population: Benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care 2008;31:99-101.
Lowe J, Sibbald RG, Taha NY, Lebovic G, Rambaran M, Martin C, et al.
The Guyana Diabetes and Foot Care Project: Improved diabetic foot evaluation reduces amputation rates by two-thirds in a lower middle income country. Int J Endocrinol 2015;2015:920124.
[Figure 1], [Figure 2]