Clinician Article

Predictors of lower-extremity amputation in patients with an infected diabetic foot ulcer.

  • Pickwell K
  • Siersma V
  • Kars M
  • Apelqvist J
  • Bakker K
  • Edmonds M, et al.
Diabetes Care. 2015 May;38(5):852-7. doi: 10.2337/dc14-1598. Epub 2015 Feb 9. (Original)
PMID: 25665817
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  • Internal Medicine
    Relevance - 6/7
    Newsworthiness - 6/7
  • Family Medicine (FM)/General Practice (GP)
    Relevance - 6/7
    Newsworthiness - 5/7
  • General Internal Medicine-Primary Care(US)
    Relevance - 6/7
    Newsworthiness - 5/7
  • Surgery - Vascular
    Relevance - 5/7
    Newsworthiness - 4/7
  • Surgery - Orthopaedics
    Relevance - 5/7
    Newsworthiness - 3/7


OBJECTIVE: Infection commonly complicates diabetic foot ulcers and is associated with a poor outcome. In a cohort of individuals with an infected diabetic foot ulcer, we aimed to determine independent predictors of lower-extremity amputation and the predictive value for amputation of the International Working Group on the Diabetic Foot (IWGDF) classification system and to develop a risk score for predicting amputation.

RESEARCH DESIGN AND METHODS: We prospectively studied 575 patients with an infected diabetic foot ulcer presenting to 1 of 14 diabetic foot clinics in 10 European countries.

RESULTS: Among these patients, 159 (28%) underwent an amputation. Independent risk factors for amputation were as follows: periwound edema, foul smell, (non)purulent exudate, deep ulcer, positive probe-to-bone test, pretibial edema, fever, and elevated C-reactive protein. Increasing IWGDF severity of infection also independently predicted amputation. We developed a risk score for any amputation and for amputations excluding the lesser toes (including the variables sex, pain on palpation, periwound edema, ulcer size, ulcer depth, and peripheral arterial disease) that predicted amputation better than the IWGDF system (area under the ROC curves 0.80, 0.78, and 0.67, respectively).

CONCLUSIONS: For individuals with an infected diabetic foot ulcer, we identified independent predictors of amputation, validated the prognostic value of the IWGDF classification system, and developed a new risk score for amputation that can be readily used in daily clinical practice. Our risk score may have better prognostic accuracy than the IWGDF system, the only currently available system, but our findings need to be validated in other cohorts.

Clinical Comments

Family Medicine (FM)/General Practice (GP)

I would be interested to know how the scoring system would fare against the predictions of experienced clinicians using the "gestalt" of their physical exam of the wound and knowledge of their patient's diabetic control and comorbidities.

General Internal Medicine-Primary Care(US)

I would like to see the tool validated in a different cohort. Nevertheless, it looks simple to use and predicts an important outcome well.

Internal Medicine

The Eurodiale risk score can be useful in clinical settings to determine both treatment modalities as well as for prognostic purposes.

Surgery - Orthopaedics

May be relevant to some foot and ankle specialists but the paper is written by endocrinologists and there are no orthopaedic surgeons in extensive list of contributors - only one general surgeon. In the system I work in, vascular surgeons would carry out all of such amputations but even for them this is of limited relevance as it relates to diabetic care and prediction of the need for amputation. Useful for dynamed - just not in the field of orthopaedics.

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