Published online Sep 15, 2020. doi: 10.4239/wjd.v11.i9.391
Peer-review started: May 7, 2020
First decision: May 24, 2020
Revised: June 6, 2020
Accepted: August 15, 2020
Article in press: August 15, 2020
Published online: September 15, 2020
Processing time: 127 Days and 5.3 Hours
There is no previous systematic review and meta-analysis undertaken particularly in long-term outcomes of patients who undergo lower limb amputation (LEA) for diabetic foot ulcers (DFU). Although multiple studies describing short-term outcomes under 12 mo are available, conclusions for long-term outcomes are needed to support clinical decision-making in relation to patient characteristics.
Since DFU account for significant complications in patients with diabetes mellitus, the assessment of their long-term outcomes is necessary. The review of long-term outcomes following LEA is essential for decision-making and risk stratification for individual patients.
The aim of this paper is to establish a systematic review of long-term studies undertaken in patients who underwent LEA as a treatment modality for DFU. The focus of the review is on re-ulceration, re-amputation and the impact on the quality of life of patients. These parameters, particularly in the longer-term setting pave way for future research in larger cohorts, various demographics and relation to co-morbidities.
Key search terms such as “diabetes”, “foot ulcers”, “amputations” and “outcomes” were searched on PubMed/MEDLINE and Google Scholar. A follow-up of 12 mo, age > 18 and LEA post DFU were inclusion criteria. Paediatric patients were excluded. Two co-authors selected studies based on the inclusion criteria and search results were limited to the English language. A total of 22 publications with a total of 2334 patients were selected. There were no randomised controlled trials with the majority of studies being cohort studies.
Our results show a significant re-amputation and mortality rates at 1, 3 and 5 years after initial LEA for DFU. A positive correlation was also noted for previous other major amputation and ischemic cardiomyopathy. We attempted to standardise patients for co-morbidities, however, this was not possible in a minority of studies. Therefore, future research should be aimed at delineating the nature of association between LEA post DFU and patient co-morbidities.
Our systematic review and meta-analyses support our key hypotheses of a significant positive association of re-amputation, mortality and quality of life in our set of patients on a long-term basis. The pivotal purpose of this study is data to assist patient selection and decision-making. It also supports the uniformity of similar rates of re-amputation and mortality in various studies globally with no significant outliers.
Future research should be aimed at assessing the significance of co-morbidities on patients with DFU undergoing LEA. This will allow a closer risk stratification and aid patient decision-making individualised to their situation. In addition to this, as outcomes in diabetes mellitus often depend on patient compliance influenced by their socio-economic or cultural backgrounds, further studies are needed in these groups. The best methods for future studies would be larger, multi-center prospective studies.