LETTER
Risk Factors for Amputation in Diabetics
Lisa G. Newman and
Alex Stagnaro-Green
1 February 1993 | Volume 118 Issue 3 | Page 231
TO THE EDITOR:
We congratulate Drs. Reiber and Koepnell, and the late Dr. Pecoraro on their comprehensive research describing multiple risk factors for foot amputation in diabetics [1]. However, two issues render the data difficult to interpret.
First, the basis for the decision to amputate in both cases and controls with infection is critical. This is especially true for osteomyelitis, which underlies 68% of diabetic foot ulcers and for which clinical judgment is an insensitive diagnostic tool [2]. Early diagnosis and treatment of diabetic foot osteomyelitis in nongangrenous limbs in some cases could have altered group assignments by obviating the need for amputation, as could different preferences for treating osteomyelitis [3].
Second, because ulcers and infections are the major predisposing factors to amputation [4] the relative risks identified for amputation may actually be relative risks for ulceration and infection in the feet of diabetic patients. Data analysis using controls with and without ulcerations or infections would be of interest.
1. Reiber GE, Pecoraro RE, Koepsell TD. Risk factors for amputation in patients with diabetes mellitus. Ann Intern Med. 1992; 117:97-105.
2. Newman LG, Waller J, Palestro CJ, et al. Unsuspected osteomyelitis in diabetic foot ulcers: diagnosis and monitoring by leukocyte scanning with indium In 111 oxyquinoline. JAMA. 1991; 266:1246-50.
3. Bamgerger DM, Daus GP, Gerding DN. Osteomyelitis in the feet of diabetic patients: long-term results, prognostic factors, and the role of antimicrobial and surgical therapy. Am J Med. 1987; 83:653-60.
4. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990; 13:513-21.
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