Journal List > J Korean Foot Ankle Soc > v.23(1) > 1130346

TOOLS
Chung, Bae, Shin, and Lee: Statistical Analysis of the Risk Factors for Single Toe Amputation Patients in Wound Healing
Original Article

J Korean Foot Ankle Soc 2019;23(1):18-23.

Published online: 14 January 2019

DOI: https://doi.org/10.14193/jkfas.2019.23.1.18

Statistical Analysis of the Risk Factors for Single Toe Amputation Patients in Wound Healing

Hyung-Jin Chung, Su-Young Bae, Woo-Jin Shina, Jun-Ho Lee

Department of Orthopedic Surgery, Inje University College of Medicine, Seoul, Korea

Corresponding Author: Hyung-Jin Chung Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, 1342 Dongil-ro, Nowon-gu, Seoul 01757, Korea Tel: 82-2-950-1399, Fax: 82-2-950-1398, E-mail: orthoman@paik.ac.kr ORCID: https://orcid.org/0000-0002-7745-7194

aCurrent affiliation: Department of Orthopedic Surgery, Gwangju Veterans Hospital, Gwangju, Korea

Received 1 February 2019       Revised 6 March 2019       Accepted 6 March 2019

Copyright © 2019 Korean Foot and Ankle Society

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose:

This study compared and analyzed the risk factors that affect a wound healing group and healing failure group.

Materials and Methods:

From 2010 to 2018, 39 patients who had suffered a single toe amputation were evaluated retrospectively. The patients were divided into two groups (wound healing group and healing failure group - within at least 3 months following the amputation). Regarding the possible risk factors, age, gender, Wagner and Brodsky classifications, duration of diabetes mellitus, whether the patient had peripheral arterial occlusive disease (PAOD) or cardiovascular disease, body mass index, HbA1c, total cholesterol, estimated glomerular filtration rate (eGFR), blood urea nitrogen (BUN), smoking, and alcohol were investigated.

Results:

The mean duration of diabetes mellitus was 140 months in the healing group and 227 months in the healing failure group, and the duration of diabetes was significantly longer in the failure group (p=0.009). A significant difference in eGFR was observed between the two groups (59.17 mL/min/1.73 m2 in the healing group and 31.1 mL/min/1.73 m2 in the failure group) (p=0.022). Sixteen patients with PAOD were found, all 10 patients in the healing failure group were PAOD patients.

Conclusion:

To reduce the additional complications in single toe amputation patients, the underlying disease and appropriate treatment are the most important factors. In addition, a more proximal level of amputation also should be considered in cases of patients with PAOD, high BUN and low eGFR, and patients with long-term diabetes.

Keywords: Toe amputation, Diabetes mellitus, Arterial occlusive disease

REFERENCES

1.Bae JI., Won JH., Han SH., Lim SH., Hong YS., Kim JY, et al. Endo-vascular revascularization for patients with critical limb ischemia: impact on wound healing and long term clinical results in 189 limbs. Korean J Radiol. 2013. 14:430–8.
crossref
2.Myerson MS., Bowker JH., Brodsky JW., Trevino S. Symposium: partial foot amputations. Contemp Orthop. 1994. 29:139–42. 146-57.
3.Canaud L., Alric P., Berthet JP., Marty-Ané C., Mercier G., Branchereau P. Infrainguinal cutting balloon angioplasty in de novo arterial lesions. J Vasc Surg. 2008. 48:1182–8.
crossref
4.Sharp CS., Bessman AN., Wagner FW Jr., Garland D. Microbiology of deep tissue in diabetic gangrene. Diabetes Care. 1978. 1:289–92.
crossref
5.Brodsky JW. Evaluation of the diabetic foot. Instr Course Lect. 1999. 48:289–303.
6.Roon AJ., Moore WS., Goldstone J. Below-knee amputation: a modern approach. Am J Surg. 1977. 134:153–8.
crossref
7.Dickhaut SC., DeLee JC., Page CP. Nutritional status: importance in predicting wound-healing after amputation. J Bone Joint Surg neuropathy. Baseline analysis of neuropathy in feasibility phase of Diabetes Control and Complications Trial (DCCT). Diabetes. 1988. 37:476–81. Am. 1984;66: 71-5.
8.Wagner FW Jr. Management of the diabetic neurotrophic foot part II. A classification and treatment program for diabetic, neuropathic, and dysvascular foot problems. The American Academy of Orthopaedic Surgeons. editor.Instructional course lectures. St. Louis: C.V. Mosby;1979. p. 143–65.
15.Lee WC., Park HS., Kim HC., Kim CS., Choi DS., Rha JD. Influence of neuropathy and ischemia in the development and treatment of the diabetic foot. J Korean Orthop Assoc. 1999. 34:749–53.
crossref
16.Mayfield JA., Reiber GE., Nelson RG., Greene T. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care. 1996. 19:704–9.
crossref
17.National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002. 39(2 Suppl 1):S1–266.
10.Singh N., Armstrong DG., Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005. 293:217–28.
crossref
11.Swaminathan A., Vemulapalli S., Patel MR., Jones WS. Lower extremity amputation in peripheral artery disease: improving patient outcomes. Vasc Health Risk Manag. 2014. 10:417–24.
18.Kwon SH., Han DC. Diagnosis and screening of chronic kidney disease. Korean J Med. 2009. 76:515–20.
19.Miyajima S., Shirai A., Yamamoto S., Okada N., Matsushita T. Risk factors for major limb amputations in diabetic foot gangrene patients. Diabetes Res Clin Pract. 2006. 71:272–9.
crossref
12.Adler AI., Boyko EJ., Ahroni JH., Smith DG. Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care. 1999. 22:1029–35.
crossref
20.Armstrong DG., Frykberg RG. Classifying diabetic foot surgery: toward a rational definition. Diabet Med. 2003. 20:329–31.
crossref
13.Maser RE., Steenkiste AR., Dorman JS., Nielsen VK., Bass EB., Man-joo Q, et al. Epidemiological correlates of diabetic neuropathy. Report from Pittsburgh Epidemiology of Diabetes Complications Study. Diabetes. 1989. 38:1456–61.
crossref
21.Nehler MR., Whitehill TA., Bowers SP., Jones DN., Hiatt WR., Rutherford RB, et al. Intermediate-term outcome of primary digit amputations in patients with diabetes mellitus who have forefoot sepsis requiring hospitalization and presumed adequate circulatory status. J Vasc Surg. 1999. 30:509–17.
crossref
14.The DCCT Research Group. Factors in development of diabetic.

Table 1.
Status Table of 39 Toe Amputation Patients
Patient no. Sex Age (yr) Wound healing PAOD Cardiovascular disease Pulmonary disease Liver disease Renal disease Dialysis Smoking Alcohol Wagner classification Brodsky (depth) Brodsky (ischemia) Amputation level
1 M 51 Y N Y N N N N Y N 4 1 C 2nd MP
2 M 75 N Y N N N N N Y Y 2 2 B 1st PP
3 M 60 N Y Y N N N N N N 4 1 C 4th DP
4 M 66 N N Y N N N N Y Y 2 1 C 1st PP
5 M 63 Y Y Y N Y Y Y N N 4 3 C 1st MP
6 F 63 Y N Y N N Y N N N 4 3 C 1st MP
7 M 70 Y N N N N N N Y Y 4 3 C 4th MP
8 M 48 Y N N N N N N Y Y 3 3 B 1st DP
9 M 73 Y N Y N N N N N N 2 2 B 2nd PP
10 F 72 Y N N N N N N Y N 4 3 C 4th PP
11 F 64 Y N Y N N Y Y N N 4 3 C 4th PP
12 M 64 Y Y N N N N N Y N 3 3 C 4th PP
13 M 48 Y N Y N N N N N N 3 3 C 1st PP
14 M 51 Y N N N N N N Y N 4 3 C 1st PP
15 M 68 Y N Y N N N N N N 3 3 B 5th PP
16 M 64 Y N N N N N N N N 2 2 B 3rd PP
17 M 74 N Y Y N N Y N N N 4 3 C 1st PP
18 M 58 Y N N N N N N N N 4 3 C 1st PP
19 M 87 N Y Y N N Y Y N N 4 3 C 3rd PP
20 F 77 N Y Y N N Y Y N N 3 2 B 1st PP
21 F 47 Y N N N N N N N N 3 3 B 2nd MP
22 F 52 Y Y N N N N N Y Y 4 3 C 1st PP
23 M 43 Y Y N N N N N N N 4 3 C 1st PP
24 M 88 Y Y N N N Y Y N N 4 3 C 2nd MP
25 M 76 N N Y N N Y Y N N 3 2 B 4th MP
26 M 69 Y Y N N N N N Y Y 4 3 C 3rd MP
27 M 84 Y N N N N N N N N 4 3 B 1st MP
28 F 66 N N Y Y N N N N N 2 3 B 2nd PP
29 M 80 Y N N N N Y N N N 2 2 B 1st PP
30 M 70 N N Y N N N Y N N 2 2 B 4th MP
31 M 56 Y N N N N N N N N 4 3 C 2nd PP
32 F 85 Y N N N N N N N N 3 3 B 4th MP
33 M 82 Y N N N N N N N N 4 3 B 2nd DIP
34 M 57 N Y N N N N N Y Y 2 2 B 2nd MP
35 M 58 Y Y Y N Y Y N Y Y 3 3 C 4th MP
36 M 58 Y Y N N N Y N Y Y 3 3 C 4th PP
37 F 78 Y Y N N N Y Y N N 3 3 C 2nd MP
38 F 57 Y Y N N N N Y N N 2 2 B 3rd PP
39 M 84 Y N N N N N N N N 2 2 B 2nd PP

PAOD: peripheral arterial occlusive disease, M: male, F: female, Y: yes, N: no, MP: metatarsophalaneal joint, PP: proximal phalanx, DP: distal phalanx, DIP: distal interphalangeal joint.

Table 2.
Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Patients Factors
Variable HG (n=29) FG (n=10) p-value
Age (yr) 63.37 (43~88) 70.09 (56~87) 0.123
Male:female 20:9 9:1 0.189
Smoker/non-smoker 8 (27.6) 5 (50.0) 0.195
Drinker/non-drinker 6 (20.7) 3 (30.0) 0.363
BMI (kg/m2) 23.22±3.56 21.49±2.34 0.161

Values are presented as mean (range), number only, number (%), or mean±standard deviation. BMI: body mass index.

Table 3.
Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Diabetes Mellitus (DM) Factors
HG (n=29) FG (n=10) p-value
DM duration (yr) 11.68±7.70 18.92±0.25 0.009
HbA1c (%) 8.17±2.71 7.04±0.84 0.206
Treatment of DM
PO 24 9 0.100
Insulin 5 1

Values are presented as mean±standard deviation or number only.

Table 4.
Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Comorbidity Factors
HG (n=29) FG (n=10) p-value
Cardiovascular disease 14 (93.3) 5 (50) 0.084
PAOD Pulmonary disease 6 (26.1) 0 (0) 10 (100) 1 (11.1) 0.0001 0.072
Liver disease 2 (6.8) 0 (0) 0.424
Renal disease 8 (27.6) 4 (40) 0.348
Dialysis 6 (26.1) 3 (30) 0.441

Values are presented as number (%). PAOD: peripheral arterial occlusive disease.

Table 5.
Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Laboratory Factors
HG (n=29) FG (n=10) p-value
Hemoglobin (g/dL) 11.31±2.08 11.91±1.91 0.427
White blood cell (103/μL) 10.26±3.37 10.41±5.63 0.151
Neutrophil count (103/μL) 6.30±3.13 6.45±3.09 0.896
C-reactive protein (mg/dL) 4.33±5.54 5.18±7.65 0.707
Protein (g/dL) 7.10±0.70 7.41±0.84 0.258
Albumin (g/dL) 3.56±0.52 3.78±0.33 0.220
Total cholesterol (mg/dL) 146.65±32.07 152±42.30 0.678
BUN (mg/dL) 25.78±11.28 31.76±6.96 0.0001
eGFR (mL/min/1.73 m2) 59.17±34.93 31.1±20.04 0.022

Values are presented as mean±standard deviation. BUN: blood urea nitrogen, eGFR: estimated glomerular filtration rate.

Table 6.
Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Wound-related Factors; Infection and Wound
HG (n=29) FG (n=10) p-value
Infection 26 (89.7) 10 (100) 0.051
Wound culture 0.263
Staphylococcus group 8 (27.6) 5 (50.0)
Streptococcus group 2 (6.9) 1 (10.0)
Pseudomonas group 2 (6.9) 2 (20.0)
Others 11 (37.9) 2 (20.0)

Values are presented as number (%).

Table 7.
Comparison between Wound Healing Group (HG) and Healing Failure Group (FG) in Wound-related Factors; Wound Classification
HG (n=29) FG (n=10) p-value
Wagner (2+3/4+5) 14/15 7/3 0.240
Brodsky
Depth (1+2/3) 6/23 7/3 0.281
Ischemia (A+B/C+D) 11/18 6/4 0.230
TOOLS
Similar articles