European Journal of Cardiovascular Medicine

Diabetic foot is a common and serious complication of diabetes mellitus, often leading to significant morbidity, disability, and healthcare burden. It is characterized by a spectrum of conditions ranging from superficial ulcers to deep-seated infections, osteomyelitis, and gangrene, which may ultimately necessitate amputation .¹ Globally, the prevalence of diabetic foot complications has been rising due to the increasing incidence of diabetes, with approximately 15-25% of diabetic patients developing foot ulcers during their lifetime .²

The pathogenesis of diabetic foot involves a complex interplay of neuropathy, peripheral arterial disease, and impaired wound healing . ³Peripheral neuropathy results in loss of protective sensation and foot deformities, predisposing patients to repetitive trauma and ulceration. Concurrently, peripheral arterial disease reduces blood supply, delaying wound healing and predisposing ulcers to infection .⁴ Infections further exacerbate tissue destruction and may lead to systemic complications if not promptly managed.

Despite advances in medical care, diabetic foot remains a major challenge in developing countries due to late presentation, lack of awareness, and inadequate healthcare resources. ⁵ Understanding the clinical profile of patients with diabetic foot is crucial for early diagnosis, risk stratification, and implementation of effective prevention and management strategies. This study aims to analyze the clinical characteristics, associated risk factors, and outcomes of patients presenting with diabetic foot in a tertiary care setting, thereby contributing to the growing body of evidence for improved patient care.

Need for the Study

Diabetic foot complications are a leading cause of hospitalizations among individuals with diabetes, significantly contributing to the global burden of disability and healthcare costs. Despite advancements in the understanding and management of diabetes, diabetic foot remains a neglected aspect of care, especially in low- and middle-income countries, where healthcare systems face constraints in resources and accessibility .⁶ Moreover, the heterogeneity in the clinical presentation, risk factors, and outcomes of diabetic foot necessitates region-specific studies to guide tailored interventions.

Recent literature highlights that delayed presentation, poor glycemic control, and inadequate foot care practices are major contributors to poor outcomes in diabetic foot patients, including infection, limb amputation, and mortality .⁷ In addition, there is a lack of comprehensive data on the clinical profile and associated comorbidities of patients with diabetic foot in various populations, which poses a challenge to implementing targeted prevention and management strategies.

The primary goal of this research is to evaluate the clinical characteristics of individuals suffering from diabetic foot infections. The specific objectives of this study include examining the various risk factors linked to diabetic foot infections and delving into the root causes of these infections.

This study holds significant importance in filling the existing gaps in knowledge concerning the clinical manifestations, risk factors, and outcomes of patients with diabetic foot infections within the local community. A comprehensive understanding of these factors can play a crucial role in the early identification of such infections, categorizing patients at high risk, and developing evidence-based guidelines for the prevention and treatment of diabetic foot complications. Ultimately, this can lead to a notable reduction in the impact of diabetic foot infections on patients' quality of life and the healthcare system as a whole.

This prospective observational study was conducted in the Surgery Department of Basaweshwar Teaching and General Hospital (BTGH), affiliated with Mahadevappa Rampure Medical College, Kalaburagi. A total of 100 cases were included over a nine-month data collection period from March 2024 to December 2024. The inclusion criteria comprised all patients with diabetes mellitus presenting with diabetic foot-related ulcers, while patients with ulcers and foot gangrene of non-diabetic etiology or those unwilling to participate were excluded. After obtaining informed consent, detailed patient histories were recorded, and complaints were documented chronologically. Routine investigations, including complete blood count, liver and renal function tests, chest X-ray, ECG, random and fasting blood sugar levels, postprandial blood sugar, lipid profile, and lower limb arterial Doppler ultrasonography, were performed. Relevant special investigations were also conducted. Patients underwent conservative management with meticulous dressing, and major surgical interventions were carried out as required, with outcomes meticulously recorded.

Table 1 displays the data from a study in which a total of 100 patients were selected. The mean age of the participants was 57.62 years, with the maximum age being 87 years and the minimum age being 29 years. The largest proportion of patients, 37.5%, belonged to the 60-69 age group.

Table No. 1: Age Distribution

Graph no1 illustrates the distribution of gender among the 100 patients included in the current study. Of these patients, 74 were male and 26 were female.

Graph No 1: Gender Distribution

Graph no 2 illustrates that out of a total of 100 patients, 70 had a previous history of diabetic foot ulcers, while 30 had no prior history of diabetic foot ulcers.

Graph No. 2: Distribution of study subject based on their Past History of Ulcer Over Foot

Table 2 illustrates the distribution of diabetes duration among 100 patients. Of these patients, 12 were newly diagnosed, 40 had diabetes for less than 5 years, 39 were diagnosed with diabetes between 6-10 years ago, 5 had a history of diabetes for 11-15 years, and 4 had diabetes for more than 15 years. This data provides valuable insights into the varying durations of diabetes among the patient population.

Table No. 2: Distribution of study subject based on their Duration Of DM

Table 3 illustrates that out of the 40 patients observed, 17 patients exhibited Peripheral Vascular Disease (PVD) while 23 patients did not show any signs of PVD. This data highlights the prevalence of PVD within the patient population and underscores the importance of further investigation and treatment options for those affected.

Table No. 3: Distribution of study subject based on their  history of Peripheral Vascular Disease

Table 4 illustrates that out of 100 patients, the most common cause of diabetic foot ulcers was swelling that progressed to skin breakdown in 32 cases, followed by unknown causes in 16 cases, and other causes in 29 cases.

Table No. 4   : Distribution of study subject based on their  Cause Of DM Foot

Table 5 illustrates the comparison of clinical characteristics between diabetic patients who underwent amputation (AMP) and those who did not (NA), providing valuable insights into the factors contributing to the risk of amputation. The analysis reveals a complex interplay of variables, with some showing statistical significance while others do not, emphasizing the multifactorial nature of diabetic foot outcomes.

Table No. 5: Distribution of study subject based on Who Underwent Amputation (Amp.) Vs No Amputation (Na.)

Gender Distribution:

The proportion of males was slightly higher in both groups (AMP: 76.92%, NA: 72.97%). However, the difference was not statistically significant (p=0.693), suggesting that gender may not be a decisive factor in determining amputation risk in this particular cohort.

Hypertension:
The prevalence of hypertension was higher among amputees (30.76%) compared to non-amputees (20.27%). Nevertheless, this disparity was not statistically significant (p=0.273), indicating that hypertension alone may not strongly predict amputation risk in diabetic foot patients.

Gangrene:
Gangrene was significantly more prevalent in the AMP group (84.61%) compared to the NA group (8.10%), with a statistically significant difference (p=0.0001, Chi-square = 55.8). This finding underscore gangrene as a critical determinant for amputation, aligning with previous evidence that tissue necrosis necessitates surgical intervention to prevent systemic complications.

Peripheral Vascular Disease (PVD):

The prevalence of PVD was significantly higher among amputees (42.30%) compared to non-amputees (8.10%) (p=0.0001, Chi-square = 15.94). This result highlights the role of impaired blood flow in exacerbating foot ulcers and increasing the likelihood of amputation. Early identification and management of PVD may therefore be crucial in preserving limbs.

Table 7 also illustrates the prevalence of neuropathy and nephropathy in two groups, AMP and NA. Neuropathy was observed in similar proportions in both groups (AMP: 46.15%, NA: 45.94%), with no significant difference (p=0.0003). This suggests that while neuropathy may contribute to the development of diabetic foot ulcers, it may not independently dictate the need for amputation.

On the other hand, nephropathy was more prevalent in the NA group (12.16%) compared to the AMP group (7.69%), but this variance was not statistically significant (p=0.531). Despite nephropathy being a known complication of diabetes, its role in determining amputation risk remains inconclusive based on this dataset.

The findings of this study emphasize gangrene and PVD as the most significant predictors of amputation in diabetic foot patients, aligning with established evidence. Early intervention in these conditions, alongside comprehensive management of diabetes and its complications, can potentially reduce the incidence of amputations. Factors such as gender, hypertension, neuropathy, and nephropathy, although relevant in the broader context of diabetic complications, showed no statistical significance in this study

Our research findings indicate that the average age of the participants was 57.62 years, with the oldest participant being 87 years old and the youngest being 29 years old. The largest percentage of patients, 37.5%, fell within the 60-69 age bracket.

A study conducted by Mangilal Vankooth and Prasad KLN revealed that out of 240 patients, 144 were male and 96 were female. The majority of patients affected were in the 51-60 age group (86 patients), followed by the 30-40 age group (58 patients), the 41-50 age group (50 patients), and the 61-70 age group (46 patients). 8 When compared to the Wheel, Lock, and Root series, there were minimal differences in the youngest and oldest age groups.9

In another study, among 70 patients with Diabetic Foot Ulcers (DFU), 51.43% were male and 48.57% were female. The majority of patients were in the 51-60 age group, with an average age of presentation at 57.8 (±15.03) years.10

Table 2 presents the gender distribution among the 100 patients included in the current study. Out of these patients, 74 were male and 26 were female.

In the study, there were 55 patients with a mean age of 61.78±11.75 years, showing a preference for males (n=45, 81.8%) over females (n=10, 18.2%). The largest number of patients (n=27, 49.1%) fell within the 61–80 year age range.11

Another study indicated that 58% of the participants were male, with a mean age of 54.7±13.4 years.12

Our research findings indicate that among a sample of 100 patients, 70 individuals had a documented history of diabetic foot ulcers, while the remaining 30 did not have any prior instances of diabetic foot ulcers.

In a separate study, it was revealed that 50.89% of participants had been living with diabetes for over a decade. Among these individuals, 53% were diagnosed with diabetic foot syndrome, 79.2% experienced diabetic polyneuropathy, 45% had undergone lower extremity amputation in the past, and 24.8% had received revascularization treatment.13

These results highlight the significant prevalence of diabetic foot complications among individuals with long-standing diabetes. Further research and interventions are necessary to address the complex needs of these patients and improve their overall quality of life.

The duration of diabetes mellitus (DM) is a critical factor influencing the development and progression of diabetic foot complications. Prolonged exposure to hyperglycemia contributes to cumulative damage to peripheral nerves, blood vessels, and the immune system, significantly increasing the risk of foot ulcers, infections, and, eventually, amputations .14

Studies have consistently demonstrated a positive correlation between the duration of diabetes and the prevalence of diabetic foot ulcers. Armstrong et al. (2022) reported that patients with a longer duration of diabetes were more likely to develop peripheral neuropathy and peripheral arterial disease, two major contributors to diabetic foot complications .15 Furthermore, extended disease duration often indicates poorer glycemic control and a greater likelihood of comorbidities such as hypertension and nephropathy, which exacerbate diabetic foot risk.

In a recent meta-analysis by Zhang et al. (2023), patients with diabetes for more than 10 years were found to have a significantly higher risk of developing foot ulcers compared to those with shorter disease durations. This finding underscores the need for early and consistent diabetes management to delay or prevent the onset of complications .16

The duration of diabetes mellitus is a critical factor in the development and management of diabetic foot complications. Similarly, Purwanti et al.17 reported that the likelihood of ulceration increases with the duration of diabetes, emphasizing the need for regular screening and education on foot care for diabetic patients1. These findings highlight the importance of early intervention and continuous monitoring to prevent the progression of diabetic foot complications.

This was consistent with a research conducted by Nyamu et al. 18, of respondents who experienced ulcer complications after suffering from diabetes for 5 years. According to another research, there was a greater risk of recurrent ulcers in patients who suffered from diabetes over three years, which was recorded to be 35-40% and 70% suffered from diabetes over 5 years .19 Different research stated that patients with 6-7 years of suffering from diabetes would experience 8.5% of ulcer complication possibility .18

The increased risk associated with prolonged diabetes duration can also be attributed to delayed implementation of preventive measures, such as routine foot care and early screening for neuropathy and ischemia. Educating patients with a long history of diabetes about proper foot care and regular check-ups can substantially reduce the incidence of diabetic foot ulcers and associated complications.

In conclusion, the duration of diabetes is a pivotal determinant of diabetic foot complications. Emphasizing early intervention and long-term glycemic control in diabetic patients can mitigate the risks associated with prolonged disease duration and improve outcomes for patients at risk of diabetic foot.

Our research findings indicate that among 100 patients studied, the primary cause of diabetic foot ulcers was identified as swelling progressing to skin breakdown in 32 cases, with unknown causes in 16 cases, and other causes in 29 cases. In contrast, a separate study revealed that diabetic foot ulcers were the most common presentation in 50% of patients, with other presentations including cellulitis and gangrene.20

Furthermore, a study conducted by Harshal, V and Poojari demonstrated that 62% of patients reported a history of ulcers lasting more than one month, with 72% of cases presenting with a single wound. The study also found that the right foot was involved in 52% of cases, while the left foot was affected in the remaining cases.21

A study by Wang L et al 22showed that a total of 856 patients with diabetic foot were enrolled, in which 487 patients received amputation surgeries, and the amputation rate was 56.9%. There were significant differences between the two groups in gender (p=0.014), smoking history (p=0.011), ulcer duration (p=0.023), ulcer size (p=0.000), Wagner classification (p=0.000), ABI (p=0.031), peripheral arterial disease (p=0.000), HDL-C (p=0.013), osteomyelitis (p=0.000), and fibrinogen (p=0.001). A stepwise multiple logistic regression analysis revealed that male gender (p=0.003), larger ulcer size (p=0.001), higher Wagner classification grades (p=0.002), higher rate of peripheral arterial disease (p=0.02) and osteomyelitis (p=0.0001), and increased fibrinogen level (p=0.004) were independent risk factors of lower limb amputation in patients with diabetic foot.

Nanwani 23  reported  the  rate  of amputation  was  22.5%,   Jun  Ho  Lee 24 reported  the  rate of amputation was 48.4%,5  and Uysal reported the  rate  was  33.2%. 25.s

Diabetic complications typically arise in individuals above middle age, most commonly in their 50s and 60s. These complications are more prevalent in males, who are more susceptible to trauma.

In many cases, patients experience minor trauma, although they may not be aware of it due to sensory neuropathy in the lower limbs. Ulcers are the most common presentation of diabetic complications, followed by gangrene, cellulitis, and abscesses

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