Alpharian , G.T., Ismiarto , Y.D., Tiksnadi , B.T., Primadhi , A.

1. Predictive factors for Secondary Amputation in Infected Diabetic Foot Patients after Initial Major Lower Limb Amputation Alpharian, G.T., Ismiarto, Y.D., Tiksnadi, B.T., Primadhi, A. Department of Orthopedics and Traumatology Faculty of Medicine UniversitasPadjadjaran, HasanSadikin General Hospital Bandung

2. Introduction • Diabetic foot ulcer is formed in the diabetic foot as an interaction between the pathological features of the diabetic foot : • peripheral neuropathy : dysfunction of the sensoric, motoric, and autonomic components of the foot • micro-and macroangiopathy, and • deformities of the footcausing abnormal pressure points • Trauma that occurs to this state of foot (usually minor trauma) precipitate the formation of a wound  chronic ulcer due to wound healing problems in the diabetic individual • East JM, Yeates CB, HP R. The Natural History of Pedal Puncture Wounds in Diabetics : A Cross Sectional Survey. BMC Surgery. 2011;11(27):1-24. • Frykberg, RG., Zgonis, T., Armstrong, DG., Driver, VR., Giurini, JM., Kravitz, SR., et.al. Diabetic Foot Guidelines : A Clinical Practice Guideline 2006 revision. The Journal of Foot & Ankle Surgery, 2006; 45(5): S1-S58

3. Introduction • Ulceration  point of entry for microorganism  colonization  infection • Decreased wound healing + loss of protective sensation  unresolved wound & infection + spread of infection • Major limb amputation still has a place in the management of infected diabetic foot  severe or life threatening infections • Frykberg, RG., Zgonis, T., Armstrong, DG., Driver, VR., Giurini, JM., Kravitz, SR., et.al. Diabetic Foot Guidelines : A Clinical Practice Guideline 2006 revision. The Journal of Foot & Ankle Surgery, 2006; 45(5): S1-S58 • Richard, JL, Sotto, A., Lavigne, JP. New Insights in Diabetic Foot Infections. World J Diabetes2011; 2(2): 24-32 • Hotchkiss RS, Karl IE. The Pathophysiology and Treatment of Sepsis. N Engl. J Med 2003, 348; 138 -50.

4. Introduction • In a diabetic patient who had undergone major limb amputation, stump healing poses a challenge due to unfavorable intrinsic factors such as neuropathy, vascular problems, as well as extrinsic factors such as wound infection • A portion of these patients experience stump problems such as wound dehiscense, infection, or necrosis, and required a secondary amputation at a higher level before achieving a healed stump. • Falanga V. Wound healing and its impairment in the diabetic foot. Lancet 2005;366:1736-43. • ApelqvistJ, RagnarsonTennvall G, Persson U, Larsson J. Diabetic foot ulcers in a multi-disciplinary setting. An economic analysis of primary healing and healing with amputation. J Intern Med 1994;235:463-7.

5. Aim of study • Evaluate the predictive factors for a required secondary amputation at a higher level after major limb amputation of infected diabetic foot patients • The results of this study would allow clinicians to identify significant preoperative factors and thus be able to aid in their management

6. Methods • Retrospective study based on medical record within period of 2008 – 2013 to identify infected diabetic foot patients treated with major limb amputation as indicated by presence of severe infection with sepsis, the cases were classified into those who achieved a healed stump and those that required a secondary amputation at a higher level before achieving a healed stump • Data collected : demographics, Wagner classification, ABI, comorbidities, laboratoric parameters • Categorical data analyzed by Chi square, numerical data by Mann-Whitney

7. Results • 34 cases were identified, • 67,6% (n=23) cases achieved healing, • 32,4% (n=11) cases had a secondary amputation procedure at a higher level

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11. Results • Both gender and age did not show significant difference • Wagner grade did not correlate with a risk for secondary amputation • History of smoking (p=0.0006), presence of renal failure (p=0.0001), and need for hemodialysis (p=0.0005) are significantly (p<0.05) correlated with a risk for secondary amputation procedure • Below normal ABI levels, including non palpable pulses (p=0.01) is significantly (p<0.05) correlated with a risk for secondary amputation procedure

12. Increased infection markers of Leukocyte (p=0.08), ESR (p=0.08), CRP (p=0.04), as well as renal function markers of ureum (p=0.025), creatinine (0.024) were also significantly correlated with risk for secondary amputation • Decreased albumin levels (p=0.008) but not protein levels (p=0.131) was significantly correlated with risk • Increased HbA1C levels (p=0.015) are significantly correlated with risk for secondaru amputation

13. Conclusion • In our series, 32.4% of cases required a secondary amputation at a higher level • Patients with history of Smoking, has renal failure, need hemodialysis, with a lower than normal ABI is at higher risk for secondary amputation after initial amputation • Increased values of Leukocyte, ESR, CRP, Ureum and Creatinine are at higher risk for secondary amputation, while decreased values of albumin are at higher risk • Increased HbA1C levels, which indicate overall diabetes regulation is also correlated with a higher risk of secondary amputation

14. Limitations • Small series of cases in this study • Retrospective study based on medical records Suggestions • Prospective study on a larger series of cases

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