Diabetes mellitus (DM) stands as a pervasive and significant contributor to chronic illnesses and the alarming incidence of limb loss on a global scale. At present, this metabolic disorder affects approximately 362 million individuals, with projections indicating a staggering surge to an estimated 598 million by the year 2035 [1]. A particularly distressing consequence of diabetes is the development of foot ulcers, with nearly 15% of individuals with diabetes encountering this complication at some point in their lives. Alarmingly, among these cases, 15 to 25% eventually undergo lower extremity amputations [2].

In developed nations, diabetic foot conditions have evolved into the leading cause of non-traumatic lower extremity amputations, underscoring the urgency of comprehending and addressing the multifaceted challenges posed by diabetes-related complications [3]. This phenomenon not only poses severe health risks but also exerts a substantial economic burden on healthcare systems globally. Key risk factors contributing to the development of foot ulcers in diabetic patients encompass the loss of protective sensation due to neuropathy, prior history of ulcers and amputations, excessive pressure, external injuries, infections, and impaired blood flow stemming from peripheral artery disease [4].

Against this backdrop, our current study represents a focused investigation into the clinical attributes and influential factors associated with amputation among patients grappling with diabetic foot ulcers. Specifically, we have directed our attention to individuals seeking urgent care in emergency units. By delving into the intricacies of this patient population, we aim to unravel critical insights that can inform targeted interventions, ultimately mitigating the alarming prevalence of amputations within this vulnerable demographic. Our inquiry extends beyond conventional epidemiological considerations, delving into the nuanced interplay of clinical factors that significantly impact the trajectory of diabetic foot complications and the resultant necessity for amputations.

Our study was conducted through a retrospective analysis of the medical records of patients referred to the Emergency Unit. Upon admission, the initial care for the patients was administered in the emergency unit. Depending on their specific medical indications, patients were transferred to other specialties such as infectious diseases, endocrinology, plastic surgery, or orthopedics for continued treatment. Patients with incomplete data or those presenting with foot ulcers or gangrene unrelated to diabetes mellitus were excluded from the analysis. Our assessments relied on the laboratory data documented during the patient’s initial admission to the emergency unit.The data analyzed in this study encompassed a range of variables, including age, gender, disease duration, comorbidities such as coronary artery disease, hypertension, chronic obstructive pulmonary disease, cerebrovascular disease, chronic kidney failure, peripheral artery disease, osteomyelitis, extremity amputation, antidiabetic treatments, duration of hospital stay, and laboratory parameters such as albumin, glucose, hemoglobin (Hb), hematocrit (Htc), white blood cell count (WBC), neutrophils, lymphocytes, neutrophil-to-lymphocyte ratio, hemoglobin A1c (HbA1c), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Foot ulcer localization was meticulously documented and assessed using the Wagner-Meggitt Classification and University of Texas Classification methods, as outlined in Tables 1 and 2 ([5, 6]). Patients were subsequently categorized into two groups: those who required amputation and those who did not. Using this dataset, the study then examined factors influencing the need for extremity amputation.

The chi-square (\(\chi^{2}\)) test was employed to compare qualitative data between the groups. All hypotheses were two-sided, and a \(p\)-value of \(\leq0.05\) was considered statistically significant.

nd 26 (46.6%) were female. The average age was 61.43\(\pm\)11.584 years, ranging from 41 to 85 years. Most patients, 35 (60.3%), were under the age of 65. The mean duration of the disease was 11.83\(\pm\)5.78 years.

Among the patients, 26 (44.8%) had comorbidities. Comorbid conditions associated with diabetic foot, listed by frequency, included coronary artery disease in 11 patients (19%), hypertension in 20 (31%), chronic obstructive pulmonary disease in one (1.7%), cerebrovascular disease in two (3.4%), chronic renal failure in seven (12.1%), and peripheral artery disease in three patients (5.2%). Among the patient cohort, extremity amputation was not required for 34 patients (58.6%), whereas 26 patients (41.4%) did undergo amputation. Several factors exhibited statistically significant impacts on extremity amputation, including disease duration, the presence of coronary artery disease, the duration of hospital stay, and the presence of osteomyelitis (\(p<0.05\)).

Additionally, among the laboratory findings, parameters such as albumin, hemoglobin (Hb), white blood cell count (WBC), neutrophils, neutrophil-to-lymphocyte ratio, hemoglobin A1c (HbA1c), and elevated erythrocyte sedimentation rate (ESR) were found to have a significant association with extremity amputation (\(p<0.05\)). Based on the Wagner-Meggitt Classification, the distribution of patients revealed that the majority fell into Grade 2 (27 patients, 46.6%) and Grade 4 disease (17 patients, 29.3%). Grade 2 disease had a significantly lower likelihood of amputation (\(p<0.001\)). Conversely, Grade 4 disease was identified as a significant factor contributing to extremity amputation (\(p<0.01\)).

According to the University of Texas Classification, most patients were categorized as having Stage B (28 patients, 48.3%) and Stage D disease (26 patients, 44.8%), along with Grade 1 (20 patients, 34.5%) and Grade 3 disease (27 patients, 46.6%). Stage B and Grade 1 were significantly linked to a reduced likelihood of amputation (\(p<0.001\)). Conversely, Stage D and Grade 3 were found to be primary factors associated with extremity amputation (\(p<0.01\)), see Table 2.

Furthermore, concerning ulcer localization, most patients exhibited ulcers located on the 1-5th metatarsals, and this localization was also identified as a significant factor influencing extremity amputation (\(p<0.01\)).

Diabetic foot is commonly observed among elderly individuals, with previous studies reporting mean patient ages ranging from 57 to 76 years [7, 8, 9, 10, 11, 12, 13, 14]. Interestingly, the impact of age on amputation has yielded mixed findings in the literature, with some studies showing a significant effect and others failing to demonstrate such an association [15, 16]. In our current study, where the mean age exceeded 60, age was not identified as a statistically significant factor influencing the likelihood of amputation. It is worth noting that previous studies have generally not reported significant effects of sex or diabetes duration on amputation [15, 16]. In our study, we found that sex did not have a discernible impact on amputation outcomes. However, we did observe a significant association between diabetes duration and the likelihood of amputation, with shorter durations of diabetes being significantly less common among the non-amputated group. This finding could be explained by suboptimal glucose control in patients with diabetes of less than five years, as reflected in the higher mean HbA1c levels observed in this subgroup within our study.

In the study by Beaney et al. [17], hypertension was identified as a significant factor influencing amputation. At the same time, peripheral artery disease was not considered a comorbidity that significantly affected amputation outcomes. In our present study, however, we found that coronary artery disease was the sole comorbidity with a significant impact on the likelihood of amputation. These variations in findings between different studies underscore the complex interplay of comorbidities and their impact on diabetic foot-related outcomes, highlighting the need for comprehensive and context-specific investigations. In the study by Wukich et al. [18], among 230 patients, 150 were diagnosed with osteomyelitis, and a significant association was observed between amputation and osteomyelitis, with 96 of those patients ultimately undergoing amputation. In our present study, we similarly found that osteomyelitis significantly affected the likelihood of amputation.

Furthermore, among the patients who required amputation, a significant majority were at an advanced disease stage, with as many as 87.5% of them presenting with osteomyelitis. These findings emphasize the importance of timely diagnosis and management of osteomyelitis in diabetic foot ulcers to mitigate the risk of amputation. Moreover, it is important to note that several classification systems are used to predict diabetic foot amputations. For instance, Pemayun et al. [19] highlighted the significant impact of the Wagner-Meggitt Classification, particularly Grade 4, on amputation outcomes. Similarly, Jeon et al. [20] employed five different classification systems for diabetic foot ulcers and found that all effectively predicted the likelihood of amputation. These diverse classification systems offer valuable tools for risk assessment and management decisions in diabetic foot care.

The authors declare no conflicts of interest.

All authors contributed equally to this paper. They have all read and approved the final version.

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