, Volume 8, Issue 4, pp 286–295 | Cite as

Predictors of amputation in diabetics with foot ulcer: Single center experience in a large Turkish cohort

  • Sena Yesil
  • Baris AkinciEmail author
  • Serkan Yener
  • Firat Bayraktar
  • Ozalp Karabay
  • Hasan Havitcioglu
  • Nur Yapar
  • Atay Atabey
  • Yasin Kucukyavas
  • Abdurrahman Comlekci
  • Sevinc Eraslan
Research paper



Prediction of diabetic foot ulcer outcome may be helpful for clinicians in optimizing and individualizing management strategy. The aim of the present study was to examine the possibility of predicting the outcome of patients with diabetic foot ulcers by using easily assessed clinical and laboratory parameters at baseline.


In this observational study, data were collected prospectively in 670 consecutive diabetic foot ulcer episodes in 510 patients examined between January 1999 and June 2008 and were used to evaluate potential predictors of amputation retrospectively. After exclusion of patients who did not come to the hospital for follow-up for a minimum of six months, data of 574 foot ulcer episodes were evaluated.


Limb ischemia, osteomyelitis and presence of gangrene and ulcer depth, determined by the Wagner classification system, were the major independent predictors of overall and major amputations. Older age, presence of coronary artery disease, smoking and ulcer size were found to be associated with either overall or major amputations. Baseline levels of acute phase reactants (white blood cell count, polymorphonuclear leukocyte count, platelet count, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) and albumin) and decreased hemoglobin levels were associated with amputation risk. Multivariate analysis showed that one standard deviation increase in baseline CRP and ESR levels were independent predictors of overall and major amputations, respectively.


The presence of limb ischemia, osteomyelitis, local and diffuse gangrene and ulcer depth were independent predictors of amputation. Baseline levels of ESR and CRP appeared to be helpful for clinicians in predicting amputation.


Acute phase reactants Amputation Diabetes Foot ulcer Ischemia Osteomyelitis 


  1. 1.
    Jeffcoate WJ, Harding KG, 2003 Diabetic foot ulcers. Lancet 361: 1545–1551.CrossRefGoogle Scholar
  2. 2.
    1999 Consensus Development Conference on Diabetic Foot Wound Care: 7–8 April 1999, Boston, Massachusetts. American Diabetes Association. Diabetes Care 22: 1354–1360.Google Scholar
  3. 3.
    Armstrong DG, Lavery LA, Quebedeaux TL, Walker SC, 1997 Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults. South Med J 90: 384–389.CrossRefGoogle Scholar
  4. 4.
    Lavery LA, Ashry HR, van Houtum W, et al, 1996 Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care 19: 48–52.CrossRefGoogle Scholar
  5. 5.
    Most RS, Sinnock P, 1983 The epidemiology of lower extremity amputations in diabetic individuals. Diabetes Care 6: 87–91.CrossRefGoogle Scholar
  6. 6.
    Pecoraro RE, Reiber GE, Burgess EM, 1990 Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 13: 513–521.CrossRefGoogle Scholar
  7. 7.
    Oyibo SO, Jude EB, Tarawneh I, et al, 2001 A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care 24: 84–88.CrossRefGoogle Scholar
  8. 8.
    Winkley K, Stahl D, Chalder T, Edmonds ME, Ismail K, 2007 Risk factors associated with adverse outcomes in a population-based prospective cohort study of people with their first diabetic foot ulcer. J Diabetes Complications 21: 341–349.CrossRefGoogle Scholar
  9. 9.
    Faglia E, Favales F, Morabito A, 2001 New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up. Diabetes Care 24: 78–83.CrossRefGoogle Scholar
  10. 10.
    Lipsky BA, Berendt AR, Deery HG, et al, 2004 Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 39: 885–910.CrossRefGoogle Scholar
  11. 11.
    Reiber GE, Pecoraro RE, Koepsell TD, 1992 Risk factors for amputation in patients with diabetes mellitus. A case-control study. Ann Intern Med 117: 97–105.CrossRefGoogle Scholar
  12. 12.
    Mayfield JA, Reiber GE, Nelson RG, Greene T, 1996 A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care 19: 704–709.CrossRefGoogle Scholar
  13. 13.
    Flores Rivera AR, 1998 Risk factors for amputation in diabetic patients: a case-control study. Arch Med Res 29: 179–184.PubMedGoogle Scholar
  14. 14.
    Eneroth M, Apelqvist J, Stenstrom A, 1997 Clinical characteristics and outcome in 223 diabetic patients with deep foot infections. Foot Ankle Int 18: 716–722.CrossRefGoogle Scholar
  15. 15.
    Diamantopoulos EJ, Haritos D, Yfandi G, et al, 1998 Management and outcome of severe diabetic foot infections. Exp Clin Endocrinol Diabetes 106: 346–352.CrossRefGoogle Scholar
  16. 16.
    Treece KA, Macfarlane RM, Pound N, Game FL, Jeffcoate WJ, 2004 Validation of a system of foot ulcer classification in diabetes mellitus. Diabet Med 21: 987–991.CrossRefGoogle Scholar
  17. 17.
    Armstrong DG, Lavery LA, Harkless LB, 1998 Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 21: 855–859.CrossRefGoogle Scholar
  18. 18.
    Calhoun JH, Cantrell J, Cobos J, et al, 1988 Treatment of diabetic foot infections: Wagner classification, therapy, and outcome. Foot Ankle 9: 101–106.CrossRefGoogle Scholar
  19. 19.
    Volaco A, Chantelau E, Richter B, Luther B, 2004 Outcome of critical foot ischaemia in longstanding diabetic patients: a retrospective cohort study in a specialised tertiary care centre. Vasa 33: 36–41.CrossRefGoogle Scholar
  20. 20.
    Lipsky BA, Sheehan P, Armstrong DG, et al, 2007 Clinical predictors of treatment failure for diabetic foot infections: data from a prospective trial. Int Wound J 4: 30–38.CrossRefGoogle Scholar
  21. 21.
    Akanji AO, Famuyiwa OO, Adetuyibi A, 1989 Factors influencing the outcome of treatment of foot lesions in Nigerian patients with diabetes mellitus. 73: 1005–1014.Google Scholar
  22. 22.
    Armstrong DG, Lavery LA, Sariaya M, Ashry H, 1996 Leukocytosis is a poor indicator of acute osteomyelitis of the foot in diabetes mellitus. J Foot Ankle Surg 35: 280–283.CrossRefGoogle Scholar
  23. 23.
    Pittet D, Wyssa B, Herter-Clavel C, et al, 1999 Outcome of diabetic foot infections treated conservatively: a retrospective cohort study with long-term follow-up. Arch Intern Med 159: 851–856.CrossRefGoogle Scholar
  24. 24.
    Kaleta JL, Fleischli JW, Reilly CH, 2001 The diagnosis of osteomyelitis in diabetes using erythrocyte sedimentation rate: a pilot study. J Am Podiatr Med Assoc 91: 445–450.CrossRefGoogle Scholar
  25. 25.
    Butalia S, Palda VA, Sargeant RJ, Detsky AS, Mourad O, 2008 Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA 299: 806–813.CrossRefGoogle Scholar
  26. 26.
    Roine I, Faingezicht I, Arguedas A, Herrera JF, Rodriguez F, 1995 Serial serum C-reactive protein to monitor recovery from acute hematogenous osteomyelitis in children. Pediatr Infect Dis J 14: 40–44.CrossRefGoogle Scholar
  27. 27.
    Cassar K, Bachoo P, Ford I, Greaves M, Brittenden J, 2005 Markers of coagulation activation, endothelial stimulation and inflammation in patients with peripheral arterial disease. Eur J Vasc Endovasc Surg 29: 171–176.CrossRefGoogle Scholar
  28. 28.
    Violi F, Criqui M, Longoni A, Castiglioni C, 1996 Relation between risk factors and cardiovascular complications in patients with peripheral vascular disease. Results from the A.D.E.P. study. Atherosclerosis 120: 25–35.CrossRefGoogle Scholar

Copyright information

© Hellenic Endocrine Society 2009

Authors and Affiliations

  • Sena Yesil
    • 1
  • Baris Akinci
    • 1
    Email author
  • Serkan Yener
    • 1
  • Firat Bayraktar
    • 1
  • Ozalp Karabay
    • 2
  • Hasan Havitcioglu
    • 3
  • Nur Yapar
    • 4
  • Atay Atabey
    • 5
  • Yasin Kucukyavas
    • 6
  • Abdurrahman Comlekci
    • 1
  • Sevinc Eraslan
    • 1
  1. 1.Division of Endocrinology and Metabolism, Department of Internal MedicineDokuz Eylul University Medical SchoolInciralti, IzmirTurkey
  2. 2.Department of Vascular SurgeryDokuz Eylul University SchoolInciralti, IzmirTurkey
  3. 3.Department of OrthopedicsDokuz Eylul University SchoolInciralti, IzmirTurkey
  4. 4.Department of Infectious DiseasesDokuz Eylul University SchoolInciralti, IzmirTurkey
  5. 5.Department of Plastic and Reconstructive SurgeryDokuz Eylul University SchoolInciralti, IzmirTurkey
  6. 6.Department of General Internal MedicineDokuz Eylul University SchoolInciralti, IzmirTurkey

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