| ObjectiveDiabetic foot ulcers (DFU) were one of the common chronic diabetic complications. The pathogenesis of DFU was complex. Multiple factors are involved in the emergence and development of the ulcers,and ulcers in various stages were associated with different clinical markers. Therefore, it is important to analyze relevant indicators with diabetic foot ulcers of Wagner grade and explore the factors associated with the DFU amputation for the appropriate treatment of these patients and for the right judgment on the possibility of the diabetic foot ulcer. This study was conducted for the professional staff in the diabetic foot care who can choose the suitable treatment for the patients with DFU and for reducing the diabetic amputation by the way to control most important related factors associated with the DFU and diabetic amputation.Method1. Patients, who were hospitalized in the 306th of PLA hospital from January 2000 to November 2008, were all diagnosed of type 2 diabetes mellitus, according to the WHO diagnosis and classification of diabetes in 1999. 436 patients were collected, including 274 males and 162 females. Foot ulcers were classified base on the Wagner system. All patients were treated with insulin and insulin combined oral hypoglycemic agents for the blood glucose control, with the agents which improved the peripheral vascular perfusion, anti-infected or adopted other comprehensive treatment. Patients with DFU were immobilized and the ulcers managed by debridement and appropriate dressing.2. Clinical data were collected as follows: age, duration of diabetes mellitus and diabetic foot, history of smoking, hypertension, chronic complications (coronary artery disease (CAD), diabetic neuropathy (DN), diabetic kidney disease (DKD), diabetic retinopathy (DR), diabetic peripheral arterial disease (PAD) history). Blood routine, erythrocyte sedimentation rate (ESR), fasting blood glucose (FBG), postprandial blood glucose (PBG), hemoglobinA1c (HbA1c), albumin (Alb), serum creatinine (Cr), uric acid (UA), triglycerides (TG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), high sensitive C reactive protein (S-CRP), urinary albumin / creatinine (A / C), ankle brachial index (ABI) and so on.3. Protocols:(1) According to the Wagner classification system, there were 84 cases (19.3%) in Wagner grade 1 (superficial ulcers, no clinical infection),116 cases (26.6%) in grade 2 (deep ulcers, often associated with soft tissue infection, no abscesses or bone infections), 122 cases (28%) in grade 3 (the deep infection associated with bone lesions or abscess or myelitis), 114 cases (26.1%) in grade 4 (limited gangrene) ~ grade 5 (whole foot gangrene), in respectively.(2) Depending on whether infection and / or combined malnutrition, the 436 cases were divided into: no malnutrition and no infection group, no infection but combined malnutrition group, infection but no malnutrition group, infection and malnutrition group.(3) Based on whether amputation, all patients were divided into amputation group and no- amputation group.Result1. Clinical data associated with the severity of diabetic foot ulcers were as following:(1)White blood cell counts (WBC), percentage of neutrophilic granulocyte, high sensitive C reactive protein(S-CRP), erythrocyte sedimentation rate(ESR), and other inflammatory markers were paralleled increasingly with the severity of the diabetic foot ulcers, but hemoglobin(Hb), serum albumin(Alb), serum total cholesterol(CHO), high density lipoprotein cholesterol(HDL-C) were significantly decreased.(2) The prevalence of DN, PAD, DR, DKD and other chronic complications were parallel with severity of foot ulcers, the more serious of foot ulcers were, the higher prevalence of these complications. PAD and proteinuria also were more severe.(3)Rank correlation analysis showed that: the prevalence of PAD, WBC, neutrophil percentage, S-CRP, ESR, urinary A / C, infection combined malnutrition were positively associated with the foot ulcer severity based on Wagner classification, but Hb, Alb, TC , HLD-C were negatively correlated with Wagner grade. (P <0.05)2. Risk factors related with the amputation of diabetic foot ulcers were as following:(1) The prevalence of PAD, levels of WBC, S-CRP were significantly higher in amputation group than no-amputation group.(p <0.05)(2) Alb, Hb, TC, TG, HLD-C, LDL-C, which displayed nutritional status, were significantly lower in the amputation group than the no-amputation group.(3) The severity of ulcer was significantly correlated with amputation, in the amputation group of 97 patients, there was 0 cases in Wagner grade 1, 3 cases in Wagner grade 2, 22 cases in Wagner grade3, 72 patients in Wagner grade 4 ~ 5, in respectively.(4) Male patients with DFU had higher amputation rate than the females (p <0.000).(5) Stepwise Logistic regression analysis showed that: the prevalence of PAD, WBC, S-CRP, TC were independent risk factors for amputation.Conclusion1. Patients with DFU usually suffered from DN, PAD, DR, DKD, infection and other chronic complications, and the prevalence of these complications were paralleled with the severity of foot ulcers. Especially, severity of infection, ischemia, DKD, with the increasing severity of DFU, was also important risk factors for the diabetic foot deterioration or amputation.2. In generally, patients with severe DFU (Wagner grade 3 and above Wagner grade 3) and the amputee were accompany with malnutrition, which negatively impact the ulcers healing.
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