Amputations at the Middle Level of the Foot A Retrospective and Prospective Review

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Open Access

Peer-reviewed

Research Article

Diabetic Pes Complications and Their Hazard Factors from a Large Retrospective Cohort Report

• Khalid Al-Rubeaan,
• Mohammad Al Derwish,
• Samir Ouizi,
• Amira M. Youssef,
• Shazia Northward. Subhani,
• Heba M. Ibrahim,
• Bader N. Alamri

x

• Published: May 6, 2015
• https://doi.org/10.1371/journal.pone.0124446

Figures

Abstract

Background

Foot complications are considered to be a serious upshot of diabetes mellitus, posing a major medical and economic threat. Identifying the extent of this trouble and its risk factors volition enable wellness providers to ready better prevention programs. Saudi National Diabetes Registry (SNDR), being a big database source, would exist the all-time tool to evaluate this problem.

Methods

This is a cross-sectional study of a cohort of 62,681 patients aged ≥25 years from SNDR database, selected for studying human foot complications associated with diabetes and related risk factors.

Results

The overall prevalence of diabetic foot complications was 3.3% with 95% confidence interval (95% CI) of (3.sixteen%–three.44%), whilst the prevalences of foot ulcer, gangrene, and amputations were ii.05% (1.94%–2.16%), 0.19% (0.sixteen%–0.22%), and ane.06% (0.98%–one.14%), respectively. The prevalence of human foot complications increased with age and diabetes duration predominantly amongst the male patients. Diabetic foot is more commonly seen among type 2 patients, although it is more prevalent amongst blazon one diabetic patients. The Univariate assay showed Charcot joints, peripheral vascular disease (PVD), neuropathy, diabetes duration ≥10 years, insulin use, retinopathy, nephropathy, age ≥45 years, cerebral vascular disease (CVD), poor glycemic control, coronary artery disease (CAD), male gender, smoking, and hypertension to be significant take a chance factors with odds ratio and 95% CI at 42.53 (xviii.sixteen–99.62), fourteen.47 (8.99–23.31), 12.06 (x.54–xiii.80), 7.22 (6.10–8.55), 4.69 (4.28–5.14), 4.45 (4.05–4.89), ii.88 (2.43–three.40), 2.81 (2.31–three.43), 2.24 (i.98–ii.45), 2.02 (1.84–ii.22), one.54 (1.29–1.83), and ane.51 (ane.38–one.65), respectively.

Conclusions

Risk factors for diabetic foot complications are highly prevalent; they take put these complications at a higher rate and warrant primary and secondary prevention programs to minimize morbidity and mortality in addition to economic touch on of the complications. Other measurements, such every bit decompression of lower extremity nerves, should be considered among diabetic patients.

Citation: Al-Rubeaan K, Al Derwish G, Ouizi S, Youssef AM, Subhani SN, Ibrahim HM, et al. (2015) Diabetic Foot Complications and Their Take a chance Factors from a Large Retrospective Accomplice Study. PLoS ONE 10(5): e0124446. https://doi.org/10.1371/journal.pone.0124446

Bookish Editor: Fabio Santanelli, di Pompeo d'Illasi, Sapienza, University of Rome, School of Medicine and Psycology, ITALY

Received: February 17, 2015; Accustomed: March 14, 2015; Published: May vi, 2015

Copyright: © 2022 Al-Rubeaan et al. This is an open up access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted utilize, distribution, and reproduction in any medium, provided the original author and source are credited

Data Availability: Information are from Saudi National Diabetes Registry and readers can send requests to krubeaan@dsrcenter.org to obtain the data.

Funding: This project was funded by King Abdulaziz city for science and applied science (KACST). The funders had no function in written report design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors take alleged that no competing interests be.

Introduction

Diabetic foot complications are contributing to both bloodshed and morbidity among the diabetic population leading to substantial physical, physiological and fiscal burden for the patients and customs at large. It is estimated that 24.4% of the full health care expenditure amid diabetic population is related to foot complications [1] and the total cost of treating diabetic human foot complications is budgeted 11 billion USD in United states of america [two] and 456 million USD in UK [3].

The chance of ulceration and amputation among diabetic patients increases by 2 to four folds with the progression of age and duration of diabetes regardless of the type of diabetes [4]. It has also been proven by many longitudinal epidemiological studies that amidst diabetic patients, the life time foot ulcer chance is about 25%[5,6], thereby accounting for two thirds of all non-traumatic amputations [7].

Foot ulceration is a preventable condition, where simple interventions can reduce amputations by up to 70%through programs that could reduce its run a risk factors [8]. Identifying the office of risk factors contributing to this condition will enable health providers to gear up better prevention programs that could effect in improving patients' quality of life and henceforth, reducing the economical burden for both the patient and the wellness care system.

Disease registries are currently considered to be a reliable source to monitor chronic diseases, such every bit diabetes, and their complications. Countries similar Denmark, Sweden, Singapore, Malaysia, Saudi Arabia, and Thailand have adopted diabetes registries to monitor this disease [9–14].In this study, the Saudi National Diabetes Registry (SNDR), being one of the largest diabetes registries, was used to study the prevalence of human foot ulcer, gangrene, and amputation and their risk factors among Saudi type 1 and blazon 2 diabetic patients aged 25 years and above.

Textile and Methods

Study population

SNDR is a particularly designed electronic web-based data system which incorporates demographic data and diabetes related clinical and biochemical parameters. The design and development of the web-based SNDR has already been explained in a previously published paper [15].

A cross-exclusive sample of anonymous 65,534 Saudi diabetic patients was selected from the commencement of SNDR in 2000 till December 2012. In this observational hospital-based study, a cohort of 62,681 diabetic patients aged ≥25 years were selected to study foot complications and related risk factors. A total of two,071(iii.3%) diabetic patients were found to accept current or history of diabetic foot ulcer, gangrene or diabetes related lower limb amputation as shown in Fig one.

Case identification

Information were nerveless from patients' hospital charts including demographic, social and anthropometric data. Diabetes mellitus related data including type, duration and the near recent management i.e. oral hypoglycemic agents, insulin, or both, were also collected. Diabetes glycemic parameters namely; HbA1c, fasting claret sugar (FBG) and random blood carbohydrate (RBS) were collected from patients' laboratory information according to their latest infirmary visit. Whatsoever associated diseases including hypertension and hyperlipidemia were also reported.

Chronic complications namely vasculopathy including PVD, CVD and CAD, retinopathy, nephropathy, and neuropathy were reported for their presence. PVD was divers based on either clinical and physical examination documented in patient'south file, i.due east. absent-minded or diminished pulses, abnormal skin colour, poor pilus growth, and absurd pare. or through ABI measurements, where ABI value of 0.70–0.90 was considered every bit mild occlusion and ABI value of <forty every bit a sever apoplexy. CVD; was defined based on the neurological assessment documented in the patients' files, CVD was considered if clinical symptoms indicated a rapid developing neurological arrears that persisted for more than 24 hours, or led to death in the absence of other conditions that could explain the symptoms. CAD was defined based on the history of hospital admission for either myocardial infarction (MI) or angina, positive ECG for prior MI or angina, and positive history of coronary artery featherbed grafting or percutaneous transluminal coronary angioplasty. Retinopathy was defined as non-proliferative diabetic retinopathy (NPDR) and proliferative diabetic retinopathy (PDR) according to the clinical diagnosis documented in patients' file, while the level of retinopathy was based on the grading of the worst center. Nephropathy was defined by the albumin excretion in urine as microalbuminuria when albumin was between xxx–299 μg\mg creatinine, and macroalbuminuria when albumin excretion was≥300 μg\mg creatinine. Patients were identified with ESRD if they had GFR <30 ml\min per i.73 m² body expanse. Neuropathy was considered when the patients was suffering from any forms of diabetic neuropathy mainly diabetic polyneuropathy presented past numbness or hurting or through clinical examination using monofilament, vibration and position and temperature sensation represented by current or past history of foot ulcer, gangrene or amputation. Foot ulcer was considered in diabetic patients with current or history of non-healing or poorly healing partial or full skin thickness wound below the ankle. Foot gangrene was diagnosed when there was tissue death and disuse, as a result of ischemia related to the human foot, proven by Doppler study. Charcot joint was considered when basic, joints, and soft tissues of the foot and ankle are inflamed in the presence of neuropathy with or without history of trauma leading to variable degrees of bone destruction, subluxation, dislocation, and deformity [xvi]. Amputation was reported, if the patient had a pocket-sized distal or a major proximal amputation that was related to diabetes [17].

SNDR is one of the strategic research projects of Kingdom of saudi arabia that was funded by King Abdulaziz City for Science and Technology (KACST) and canonical past KACST institutional review board. SNDR can be accessed at http://world wide web.diabetes.org.sa. This spider web application, however, is bachelor for authorized users only. The data used in this publication was non consented since it does non compromise anonymity or confidentiality or alienation local data protection laws. In improver, the patients' records / data were anonymized and de-identified prior to analysis.

Statistical analysis

The written report was designed and reported in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. All data were analyzed using SPSS program version 17.0. Chi square test (χ2) was used for chiselled variables such equally gender and smoking status, while t-examination was used for continuous variables. A p-value of 0.05 or less was used as a level of significance. Odds ratio(OR) with their 95% confidence interval (CI)were used as for assessing the risk factors of diabetic foot complications using the univariate analysis, while age and gender adjusted in add-on to multivariate logistic regression assay were used to control for whatever potential confounders.

Results

Prevalence

The overall prevalence of diabetic human foot complications among the diabetic patients cohort was constitute to be at 3.3%wherein, it was distributed as 2.05%, 0.19%, and ane.06% for foot ulcer, gangrene, and amputation respectively regardless of their gender or type of diabetes (Fig 1). Out of the total of 2071 registered diabetic foot cases,1285 (62.05%) were foot ulcer cases divided into 39.30% cases with by history of ulcer and 60.70% cases with electric current ulcer, while 119 (5.75%) and 667 (32.20%) were foot gangrene and amputation cases.

Demographic characteristics

Diabetic foot ulcer, gangrene, and amputation cases were significantly older than the not affected diabetic patients at 62.97±12.seventy, 63.66±12.52, and 65.35±12.37 years respectively, and had significantly lower BMI at 29.23±6.26, 28.77±seven.38, and 29.47±half dozen.19 kg/thousand²respectively. The elapsing of diabetes was significantly college in human foot ulcer, gangrene, and amputation cases when compared with the non-affected patients. HbA1c was as well found to exist significantly higher in all the three different types of diabetic pes complications when compared with not-affected patients, and the results were too the aforementioned for FBS and RBS. See Table 1.

As shown in Table ii, the percentages of the affected cases were found to exist 7.xx%, 40.80% and 52.00% for age groups 25–44, 45–64, and ≥65 years respectively. Foot ulcer and gangrene percentages did not differ much betwixt the historic period groups, except for amputation which had shown increased percent amidst older age groups. The frequency of unlike diabetic human foot complications was institute to exist like for both the genders, although males were affected more than females presented past 68.57% and 31.43%. The majority of cases were married bookkeeping for 91.45% and family history of diabetes was forty.42% for the total afflicted cases which is similar to non-afflicted patients and the total sample. Smoking was significantly higher among diabetic foot cases at 10.14% versus 6.72% for non-affected cases, and the percent of smokers was significantly higher among foot ulcer and gangrene cases, but not among amputees. There were more than affected diabetic foot cases with higher BMI at 23.23%, 36.02%, and 40.75% in BMI groups <25, 25–29.9, ≥ 30 kg/m² respectively, and more obesity was observed amidst ulcer cases when compared with gangrene and amputation. There were more type 2 diabetic patients amidst total diabetic pes cases (94.27%), who also had more gangrene and amputation cases. Out of the total diabetic foot cases, 88.99% had diabetes duration of more than 10 years. The number of cases for foot ulcer, gangrene, and amputation increased with longer duration, although the percentage between each duration group decreased for ulcer and gangrene, but increased amongst the amputation cases.

Retinopathy and nephropathy were also more prevalent among diabetic foot cases than not-affected at 46.64% and 29.36% versus 16.99% and nine.31% respectively. Total vasculopathic cases were 33.12% among diabetic foot cases versus only 16% in not-afflicted cases. Among diabetic foot cases, CAD was the most prevalent blazon of vasculopathy at 23.56% followed by CVD and PVD at x.nineteen% and ii.41% respectively. However, PVD prevalence was loftier among unlike types of diabetic human foot cases at a rate of xxx% among total human foot ulcer cases and 54% amidst amputation cases.

Hypertension affected 56.78% of the diabetic foot cases versus 46.56% for non- affected cases, which was not the case for hyperlipidemia, where more percentage of hypelipidemic patients were found in non-afflicted cases at 36.twoscore% versus 30.95% for affected cases. There were more percentages of hypertensive patients in gangrene and amputation pes cases than ulcer ones. The pct of oral hypoglycemic agents' users was college amidst non-affected cases when compared with diabetic foot cases who were frequent insulin users. This was too the same observation among gangrene and amputation cases, just non for human foot ulcer cases who were more on oral agents and insulin combination therapy

Neuropathy is the almost frequent chronic complication in foot ulcer, amputation and gangrene cases followed by retinopathy, vasculopathy, and nephropathy respectively as shown in Fig 2A. At the same time, all these chronic complications were more frequent in foot ulcer cases followed by amputation and gangrene. When analyzing all cases with vasculopathy totaling to 749 cases, the same observation was noted, wherein foot ulcer cases had the highest percentage of CAD, CVD, and PVD followed by amputation and so gangrene cases, except for the percentage of PVD with amputation cases as shown in Fig 2B.

Historic period and gender specific prevalence

Fig three demonstrates age specific prevalence of diabetic human foot ulcer, amputation and gangrene according to gender, where foot ulcer prevalence increased with age, peaking at 4.2% for males ≥75 years of age and 2.5% for females in the age grouping 65 to 74 years. Foot ulcer prevalence was significantly higher among males in all historic period groups except for the age group from 25 to 34 years. The prevalence of foot amputation was too observed to be increasing with age but at a lower charge per unit, being more among males peaking at two.8% for males at ≥75 years of historic period and i.2% for females aged 65 to 74 years. Among amputation cases, prevalence was significantly college in males than females in the historic period grouping ≥65 years and the age group 45–54 years. Gangrene was the everyman in prevalence in all age groups, where information technology had started to increase afterward the age of ≥65 years with no meaning difference between the two genders in all age groups.

Risk factors

The presence of Charcot joint was the well-nigh of import and significant risk factor when all types of diabetic foot conditions were included with OR (95% CI) at 42.53 (18.16–99.62), which was also true for both foot ulcer and amputation at 52.81 (21.42–130.19) and 30.42 (8.22–112.62). PVD was the 2d of import risk factor for all affected, gangrene and amputation cases with OR (95% CI) at 14.47 (8.99–23.31), 62.07 (24.17–59.xl), and 2.14 (x.24–39.61) respectively. Peripheral neuropathy was the second meaning chance factor for human foot ulcer with OR (95% CI) of 15.61 (13.41–18.18), but the 3rd for all affected and gangrene cases at 12.06 (ten.54–13.80) and 6.55 (3.51–12.22). Duration of Diabetes ≥x years was a meaning risk factor for all afflicted, pes ulcer, and gangrene cases, with higher OR in amputation cases at ix.74 (vi.99–13.59). CVD had a pregnant OR for all affected human foot ulcer, and amputation cases, with college OR in gangrene cases at vii.62 (four.34–13.36). Insulin utilize, presence of nephropathy, and age ≥45 years have demonstrated a significant increased take chances with OR more than ii in all afflicted, foot ulcer, gangrene, and amputation cases. Other significant risk factors were poor glycemic control, CAD, male gender, smoking, and hypertension that had shown a pregnant p value except for smoking in the amputation cases. Hyperlipidemia, overweight, and obesity were associated with significantly decreased risk for all afflicted, ulcer, gangrene, and amputation cases, except for hyperlipidemia in gangrene cases and overweight amid amputees. Encounter Table 3.

In logistic regression model adapted for age and gender for the whole studied accomplice, these take a chance factors were found in the same order as in the univariate assay with a pregnant OR, except for smoking which showed a non-pregnant OR (95% CI) of 1.15 (0.96–1.37). When performing a multivariate logistic regression assay, peripheral neuropathy demonstrated the highest significant OR (95% CI) at viii.03 (five.47–xi.78) followed by insulin usage, historic period ≥45 years, diabetes elapsing ≥10 years, retinopathy, and poor glycemic control. Charcot articulation, PVD, and nephropathy had high, but non-significant OR, whilst CVD, CAD, and hypertension did not demonstrate any meaning take a chance for diabetic foot complications, meet Table 4.

Discussion

This retrospective registry-based study shows the prevalence of diabetic foot complications amongst the diabetic patients cohort to be at 3.iii%, out of which 2.05% were diabetic foot ulcer cases, which is within the estimated international range (1.eight% to seven%) [18,nineteen]. Amputation in this accomplice was at a rate of 1.06% which is likewise similar to the findings reported elsewhere (0.9% in Slovakia and 3% in Canada) [20,21]. This written report reported the prevalence of foot gangrene at a much lower charge per unit than what has been reported by the Rochester, MN study, at 0.8% in United states [22] or by Rabia et al., at 3% in Malaysia [23]. This could be explained by the fact that the diabetic population in this study was selected from different hospital departments including principal care clinics compared to only diabetes or pes clinics in the other studies.

Age and gender effect

The prevalence of all diabetic foot complications increased conspicuously with age and diabetes duration, regardless of its types, as observed by others [iv, 24–26]. The mean age played an important role in the occurrence of pes ulcer or gangrene, wherein 50% of the cases were older than 65 years. This was also the observation from other studies, where the prevalence of diabetic foot ulcer varied between 1.7 to 3.3% in younger patients and 5 to 10% amid older patients [27]. Amputation rate also increased with age similar to what has been reported by Katsilambros et al., where it was one.half-dozen% in the age 18–44 years, 3.iv% in the age 45–64 years, and 3.half-dozen% in patients older than 65 years [4]. The vast bulk of diabetic foot cases in the electric current analysis had diabetes elapsing more ten years similar to Moss et al. findings [26], which besides holds true for foot ulcer, gangrene, and amputation cases.

The total and historic period-specific prevalence of foot ulcer, gangrene and amputation was significantly college in males than females equally shown in many studies [28,29] and could by explained on the basis that, males are known to take limited articulation mobility and higher pes force per unit area. Higher mean height and peripheral insensate neuropathy found more frequently in males could contribute to this difference [30,31]. In dissimilarity, women are more self-caring and have a positive mood in terms of existence active with torso care, while males express fear and negative attitudes [32]. This is in addition to the fact that, males are more than exposed to trauma and tend to vesture improper footwear, specially in our civilization [33,34]. Nevertheless, this was not the case with the age-specific gangrene prevalence, where there was no meaning difference between the two genders, which could exist the effect of the small number of cases in each age group.

Diabetes type, duration, and control effect

As expected, and reported past others, the pct of type 2 diabetic patients was more among diabetic human foot cases in the current written report [35,36], while the prevalence of diabetic human foot was college among type 1 diabetic patients at 4.53% versus 3.55% in type ii diabetic patients. This could exist explained past longer diabetes duration and college rate of chronic complications, specially neuropathy among type 1 diabetic patients [37]. There has been a articulate and pregnant relation between the three diabetic foot weather and the caste of glycemic command, which is in consistence with the observation that, poor glycemic control was associated with ii-fold increment in the risk of foot lesions amid diabetic patients [38]. In terms of diabetes management, the human foot cases were frequent users of insulin, which is consistent with other studies [39,40], and as expected, since poorly controlled foot cases volition require insulin handling.

Chronic complications

The frequency of chronic complications was significantly higher among our diabetic foot cases, especially neuropathy which affects 61.98% of foot ulcer cases as reported by Grunfeld [41]. Cases with CAD showed the highest percent among vasculpoathic patients for foot ulcer, amputation and gangrene. This finding could be explained on the basis of high prevalence of CAD among our diabetic population contributing to 23.56% of affected patients, in addition to the fact that CAD is known to be highly prevalent amongst diabetic foot cases [42]. However, PVD contributed to one third of foot ulcer cases in the studied cohort, which is similar to what has been previously reported [43] and was responsible for more than than 50% of the amputation cases.

Diabetic retinopathy and nephropathy increased the percentage of the three foot complications in the current study, that could be explained past microangiopathic changes [44], which is also the same observation from other studies [26,29]. Renal impairment could contribute to foot lesion and/or delay healing process [45], while decreased vision associated with retinopathy might increase the chance of pes trauma [46].

In line with other observations, our study showed that more 50% of ulcer, gangrene, and amputation cases occurred in hypertensive patients [39,forty]. On opposite, hyperlipidemia was found to be less prevalent in the total cases affected with human foot ulcer, gangrene and amputation when compared with the non-affected cases. This could be explained by the fact that, bulk of cases were controlled with lipid lowering agents during the time of analysis.

The current assay constitute smoking to exist associated with foot ulcer and gangrene which was also observed from several studies [47,48], whilst information technology was not the case for amputees. Although this was the same findings of Akha et al among Iranian population [49], this observation contradicts with many other studies that reported significantly college frequency of smokers among amputees [50,51]. This could be explained past the fact that, all these patients were identified as foot ulcer or gangrene cases before they went for amputation which may accept contradistinct their smoking habits [52]. This is in addition to the fact that, smoking amidst females is socially unacceptable in our society which would patently decrease the percentage of smokers in the full cohort [53].

The mean BMI was significantly lower among diabetic foot ulcer, gangrene, and amputation cases, which was also observed with the Americans and Costa Ricans [35,39]. This could exist explained by the fact that, weight loss is associated with chronic complications like nephropathy which is observed in about one third of all afflicted cases, in improver to the fact that, these affected cases are having a significantly higher mean peak that would lower their BMI value [54].

Take chances factors

The presence of Charcot joint significantly increased the risk for foot ulcer and amputation, but not gangrene in the univariate model. This was consistent with the findings of Sohn et al., that showed 7 folds increment in the relative gamble for amputation among Charcot joint patients [54]. Boyako et al., on the other hand, showed almost four-folds increment in foot ulceration risk with patients suffering from Charcot joints [55]. Charcot disease is not associated with any risk for human foot gangrene since it is a neuropathic disorder as shown by our study. However when adjusting for other take chances factors using multivariate assay this potent clan has reduced with a non- meaning association. As reported in many other studies [29,forty], our study also showed that PVD was associated with significantly increased hazard of all types of diabetic foot complications. This was true for univariate, age and gender adjusted, and multivariate models, but this association was not found to exist significant in the multivariate assay, as previously reported in our society past Abolfotouh et al. [40]. Peripheral neuropathy is one of the strongest chance factors for all the foot complications amongst the studied cohort, with this clan also being significant in age and gender adjusted and multivariate logistic regression models as having establish in Danish and Saudi populations [29,40]. This strong association of the PVD and peripheral neuropathy with diabetic pes complications could reflect the high prevalence of peripheral nerve decompression amidst Saudi diabetic patients, especially when it has been reported elsewhere that, 33% of diabetic patients are suffering from chronic nerve compression [56]. However, this observation could shed light on the importance of because screening for lower extremities nervus compression among diabetic patients and applying the recently addressed concept of surgical nervus decompression at lower extremity (neurolysis of tibial nervus and its branches in tarsal tunnel) that has been proven to significantly prevent new ulcers and amputations through improving nerve office and increasing microcirculation [57,58], which can be evaluated and followed up by transcutaneous oximetry that overpassed the limit defined of tissue hypoxia [59].

Other chronic diabetes complications, namely nephropathy, retinopathy, CVD and CAD were significantly associated with increased take chances of diabetic foot ulcer, gangrene, and amputation. This positive association was also observed amidst Danish, Mexican, and Turkish populations [29,35,36]. However, this association remained pregnant simply with diabetic retinopathy in the multivariate model, which was also the aforementioned observation amongst the Danish population [29]. The positive and stiff clan betwixt diabetes duration and gamble of foot complications as seen in our study is consistent with the findings of Moss et al. and Lavery et al. [26,35] wherein, diabetes duration of ≥10 years significantly increased the risk for foot ulceration and amputation by iii to 4 folds.

Pursuant with the findings of other researchers [40,35], historic period ≥45 years and male gender were significant non-modifiable run a risk factors that showed increased risk for all types of human foot complications in both univariate and multivariate logistic regression models. Insulin use and poor glycemic command increased the run a risk of diabetic foot complications in our study past almost five-folds and 3-folds in univariate analysis, and this significant risk remained in the multivariate adjusted model like to the Seattle diabetic human foot study and Lavery et al., findings [55,35]. Hypertension and smoking in our study, significantly increased the run a risk for foot ulcer and gangrene as similar to the observational findings amongst the Taiwanese and Turkish populations [47,36]. On the other hand, smoking was non a pregnant risk cistron for amputation for the reason explained earlier, which is consequent with the findings of a prospective study conducted in Costa-Rica [39]. In the univariate assay, obesity was associated with significantly reduced risk for all diabetic foot complications. This finding is supported by the miracle chosen " obesity paradox" observed past Ledoux et al., wherein, v Kg/mⁱⁱ increment in BMI was associated with reduced risk for human foot ulcer [lx], and also supported by the findings of Sohn et al., where they reported the everyman take a chance among overweight and class I obesity (BMI 25–34.9 kg/m²) [61]. Additionally, this ascertainment was found amidst amputees contradicting with what other researchers accept reported [62], but consistent with the most recent findings of Sohn et al. in a large male person cohort [63], and can be explained by Biasucci et al findings that obese people may have better wound healing [64].

Our report is limited past its hospital-based retrospective nature that lacks certain specific information and beingness a cross-sectional study which is not the correct ready for determining causality. Despite these limitations, our report is derived from a large spider web-based electronic registry focusing on diabetes and its complications with frequent follow ups and data validation. This big accomplice provided enough number of cases for better analysis.

Conclusions

In decision, the prevalence of diabetic foot complications in Saudi population from this large database sets within what is reported internationally. Diabetic human foot ulcer cases contributed to more than than l% of the total diabetic foot cases. The presence of peripheral neuropathy and PVD is considered to be the nigh pregnant take chances factors for all types of diabetic human foot complications. This report has confirmed the importance of previously known risk factors for diabetic foot complications, in add-on to demonstrating the importance of diabetic retinopathy equally a pregnant independent gamble gene that has to be taken into account during screening for foot bug in diabetic patients. Since those risk factors are highly prevalent in our diabetic population, primary and secondary prevention programs are urgently needed to minimize both morbidity and cost from this chronic complication. In addition to controlling take chances factors, other measurements like decompression of lower extremity nerves should be considered among diabetic patients who are most likely suffering from unrecognized lower extremity chronic nerve compression that would have a positive issue on improving nerve role and microcirculation.

Acknowledgments

The authors would like to give thanks King Abdulaziz urban center for science and engineering science (KACST) for their fiscal support and King Faisal Specialist Hospital and Inquiry Center (KFSH &RC) for their technical support. We also admit all the registry staff for their efforts in data management.

Author Contributions

Conceived and designed the experiments: KA MAD So. Performed the experiments: MAD SO AMY HMI BNA. Analyzed the information: KA SNS. Contributed reagents/materials/analysis tools: KA SNS. Wrote the paper: KA AMY HMI. Designed figures: KA. Interpreted data: KA MAD SO AMY HMI BNA SNS. Critically revised the article: KA MAD Then AMY HMI BNA SNS. Researched data: AMY HMI BNA. Designed SNDR system: SNS.

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