The Journal of Diabetic Foot Complications Open access publishing

Analyzing and comparing diabetic foot between 1991, 2001, and 2011 in
a surgical unit of a tertiary centre in India
Authors: Amit Kumar C. Jain*1, Viswanath S.2
The Journal of Diabetic Foot Complications, 2014; Volume 6, Issue 3, No. 4, Pages 78-81 © All rights reserved.

Abstract:
Diabetes mellitus and its devastating complication, the diabetic foot, are among the major public health problems of
today. The prevalence of both diabetes and diabetic foot has been steadily increasing world-wide. India, which was once
regarded as the diabetic capital of the world, is one of the top three countries with a very high prevalence of diabetics.
We performed a small study at our hospital to learn the actual trend of the diabetic foot over the last three decades. We
reviewed our operating theater register to analyze the status of the diabetic foot in the department of surgery in 1991,
2001, and 2011. Diabetic foot problems accounted for 3.46% of cases in 1991. This number increased to 7.59% by
2011. The major amputation rate, however, showed a declining trend over this timeframe.

Key words: Amputation, Diabetic Foot, India

Corresponding author Affiliations
* Dr. Amit Kumar C. Jain 1
MBBS, D. Diab, F. Diab, DNB, FPS, Assistant Professor, Department
Consultant General, Diabetic Lower Limb & Podiatric Surgeon of Surgery, St. John’s Medical College
Department of General Surgery 2
MBBS, MS, Associate Professor, Department of Surgery
St. John’s Medical College and Hospital, John Nagar St. John’s Medical College, Sarjapur road, Bangalore -560034, India
Sarjapur Road
Bangalore - 560 034, Karnataka, India
Email: dramit_ak47@yahoo.co.in

INTRODUCTION
Diabetes is a silent killer disease1 which
affects all the important organs in the body.2 A
few years ago India ranked first on the list of the
ten nations most affected with diabetes.3 One
of the common and serious complications of
diabetes is the diabetic foot, which often leads to
amputation, either minor or major.
The annual incidence of diabetic foot ulcers
is around 3%4, and around 15% of diabetics will
be affected with foot ulcers during their lifetime.5,6
Individuals with diabetes have a 30-fold higher
lifetime risk of underlying lower extremity
amputation compared to those without diabetes.5
One study revealed that 40% of diabetic foot
patients will require amputations.7
The incidence, and importance of the
diabetic foot complication, are highlighted by
the fact that research papers on diabetic foot in
Pub-Med have increased from 0.7% in 1980 to
2.6% in 1998-2004.2
The aim of our study was to analyze the
diabetic foot burden over a period of three
decades in a surgical unit of a tertiary referral
hospital.
MATERIAL AND METHODS
A retrospective study was performed in the
department of surgery unit of St. John’s Medical
College, Bangalore, India, a tertiary care referral
institute, which also caters to patients from the
adjacent states.
A study was done in our surgical unit by
reviewing the data from our operating theater
register and comparing the status of diabetic foot
problems in the years 1991, 2001, and 2011. Data
obtained included age, sex, incidence of diabetic
foot in the operative surgical patient, and the type
of surgery done. The pathological lesion of most
of the cases could not be determined because
most cases were entered as “diabetic foot”,
and most files/records were not stored at our
institute after 10 years. Accordingly, they were
unable to be traced. Over the years our surgery
department gradually expanded, and in 2011
there were five functional surgical units.
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The Journal of Diabetic Foot Complications, 2014; Volume 6, Issue 3, No. 4, Pages 78-81 Open access publishing

RESULTS
As shown in Table 1, there were 25 cases
(3.46%) of diabetic foot out of 722 surgeries done
in 1991, 59 cases (7.76%) out of 760 surgeries in
2001, and 50 cases (7.59%) out of 659 cases in
2011.
Table 1. Percent of diabetic foot cases operated in a surgical
unit

Year Cases (Percent)

1991 3.46

2001 7.76

2011 7.59

In 1991, around 72% of patients with diabetic

foot disorders were males, and in 2011 it was
76%. Table 2 presents this data. Table 3 depicts
the average age among males and females
when diabetic foot presents. The average age of
males was 57.94 years in 1991, 57.62 years in
2001, and 55.03 years in 2011. The average age
for females was 55.28 years in 1991, 53.3 years
in 2001, and 52.75 years in 2011. Debridement
(48%) was the most common procedure in
2011, whereas major amputation was the most
common procedure in 1991, (Figure 1).
Table 2. Percent of diabetic foot in males and females
Males Females
Year
(Percent) (Percent)
1991 72 28
2001 66.1 33.9
Figure 1. A patient with below knee amputation. Major
amputations were very high in 1991 and gradually decreased
to 8% in 2011.
In 1991, the percent of major amputations in
diabetic foot cases was around 36.4%, and then
fell to 12.12% in 2001, and further to 8% in 2011.
This is shown in Table 4. The data clearly depicts
that the incidence of diabetic foot increased over
the decades; however, with improving health care
in developing countries, the incidence of major
amputations significantly decreased.
Table 4. Distribution of surgical procedures done in diabetic
foot
1991 2001 2011
Surgery
(Percent) (Percent) (Percent)
Debridement /I & D 21.2 59.1 48

2011 76 24 Toe amputation/

24.24 22.7 36
disarticulation
Table 3. Average age at which diabetic foot occurs in males Transmetatarsal
and females 6.06 3 4
amputation
Transtarsal
Year Males (Age) Females (Age) amputation
0 0 0

Below Knee
1991 57.94 55.28 15.15 12.12 8
Amputation
Above Knee
2001 57.62 53.3 21.2 0 0
Amputation

2011 55.03 52.75 Stump revision 12.2 3.03 4

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The Journal of Diabetic Foot Complications, 2014; Volume 6, Issue 3, No. 4, Pages 78-81 Open access publishing

DISCUSSION
The prevalence of diabetes, diabetic foot, and amputation differs across countries.8 In fact,
diabetic foot problems currently constitute 2.5% of all diabetes related admissions in the West.9
The rate of major amputations in diabetic patients ranges from 9-24% in the literature.5 In a large
multi-centre study from India,10 around 29.1% underwent major amputation, whereas 70.9% underwent
minor amputation.
In a study by Larsson et al.11 the incidence of diabetic major amputation in Sweden decreased by
78% from 1982 to 1993. In Finland,11 the incidence of major amputation in diabetic patients exhibited
23% from the beginning of the 1990s to the beginning of this millennium.
Our data also showed a huge decline in major amputations in the diabetic patient. In 1991, major
amputations were around 36.35%, then decreased to 12.12% in 2001, and then further declined to 8%
in 2011 in a surgical unit. Although, there is an increase in the percent of patients with diabetic foot
from 3.46% to 7.59%.
There are various reasons for this. An increase in the incidence of diabetes resulted in an
increased incidence of the diabetic foot. The decline in major amputations over the years was due to
improvement in overall healthcare, awareness regarding this complication, early referral to hospitals,
early intervention, and a more conservative approach towards diabetic foot patients. Nonetheless,
there was still not much of an improvement in overall diabetic foot care.12
CONCLUSION
Our study clearly shows that there is undoubtedly an increase in the prevalence of diabetic foot
problems over the three decade periods. In contrast, the overall major amputation rate has declined
significantly from 36.35% in 1991 to 8% in 2011 in a tertiary care referral teaching hospital.

This is the original article (manuscript type). All of the authors contributed to conception, design, manuscript preparation, and final approval of the
article
The authors have no conflicts of interest.

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The Journal of Diabetic Foot Complications, 2014; Volume 6, Issue 3, No. 4, Pages 78-81 Open access publishing

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