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Risk Factors for Amputation in Patients with Diabetes Mellitus: A Case-Control Study

Gayle E. Reiber, MPH, PhD; Roger E. Pecoraro, MD; and Thomas D. Koepsell, MD, MPH
[+] Article and Author Information

Grant Support: By the Centers for Disease Control Division of Diabetes Translation; the Washington State Diabetes Control Program; the Veterans Affairs Health Services Research and Development and Rehabilitation Research and Development Programs.

Requests for Reprints: Gayle E. Reiber, MPH, PhD, Health Services Research & Development (152), Seattle VA Medical Center, 1660 South Columbian Way, Seattle, WA 98108.

Current Author Addresses: Dr. Reiber: Health Services Research & Development (152), Seattle VA Medical Center, 1660 South Columbian Way, Seattle, WA 98108.

Dr. Koepsell: Departments of Epidemiology and Health Services, School of Public Health and Community Medicine, SC-37, University of Washington, Seattle, WA 98195.

Dr. Pecoraro died on 17 December 1991.


For current author affiliations and addresses, see end of text.†Dr. Pecoraro died on 17 December 1991.


Ann Intern Med. 1992;117(2):97-105. doi:10.7326/0003-4819-117-2-97
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Objective: To identify and quantify risk factors for lower extremity amputation in persons with diabetes mellitus.

Design: Case-control study.

Setting: A Veterans Affairs medical center.

Patients: Eighty patients having amputation associated with diabetes and 236 diabetic controls without limb lesions were enrolled before surgery from the 21 167 inpatient care and outpatient surgical patients seen at the Seattle Veterans Affairs Medical Center during a 30-month period.

Measurements: Selected vascular, neuropathic, environmental, health care, self care, nutritional, metabolic, lifestyle, and psychosocial risk factors were measured in all patients before surgery.

Results: Statistically significant risk factors identified from analysis included insufficient mean below-knee and foot cutaneous circulation (odds ratio, 161; 95% Cl, 55.1 to 469); ankle-arm blood pressure index < 0.45 (odds ratio, 55.8; Cl, 14.9 to 209); absence of lower leg vibratory perception (odds ratio, 15.5; Cl, 8.3 to 28.7); low levels of high-density lipoprotein (HDL) subfraction 3 ≤ 0.7 µmol/L (odds ratio, 4.9; Cl, 2.9 to 8.3); and no previous outpatient diabetes education (odds ratio, 3.2; Cl, 1.6 to 6.6). A logistic regression analysis done to control for the potentially confounding effects of age; race; socioeconomic status; diabetes duration, type, and severity confirmed these findings and added a statistically significant interaction between foot transcutaneous oxygen tension and peripheral vascular disease history. Clinical interventions to alter these risk factors were identified, including aggressive treatment of infection, diabetes education, protective footwear, and preventive footcare.

Conclusions: Multiple risk factors exist along the continuum of conditions and events leading to lower extremity amputation in diabetes. Modification of certain risk factors by patients and health professionals may reduce the risk for amputation and thus decrease the human and dollar costs that accompany limb loss in this prevalent chronic disease.

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