Sudan Medical Journal

Transcription

1 : Sudan Medical Journal ا غ ا طج ٤ ا غ دا ٤ Pattern, management and outcome of diabetic foot in Wad Medani Teaching Hospital from January to December 2016 Mohamed SM SaadEldein, MD, Ahmad A Alshaikh, FRCS, Gamal M Ahmed, MD University of Gazira, Wad Medani, Sudan ظ وإداسة و تائح قذو انغكش يغتشف واد يذ انتعه ي ا ش إن د غ بش د. دمحم عؼ د دمحم عؼذ ا ذ ٣ ة عب ؼخ ا غض ٣ شح اد ذ ٢ ا غ دا أؽ ذ األ ٤ ا ش ٤ خ د. ع ب ظطل ٠ اؽ ذ يهخض انبحث خ ل ٤ خ:رؼزجش هذ ا غ ش ١ اال زب ٤ خ أخطش ؼبػلبد شع ا غ ش ١ ظبؽجخ ث ؼذالد اػزال د شرلؼخ. األهذاؾ: ٣ ذف ا جؾش ذساعخ ا ؾ ا غش ٣ ش ١ شع ا وذ ا غ ش ٣ خ اال زب ٤ خ ع ؼب غخ ا غزخذ خ ثبإلػبكخ إ ٢ ا زؼشف ػ ٢ زبئظ ا ؼب غخ وذ ا غ ش ١ ك ٢ غزشل ٠ د ذ ٢ ا زؼ ٢ ٤ ك ٢ ا لزشح ٣ ب ٣ شإ ٠ د ٣ غ جش ا شػ ٠ ا طشم:دساعخ طل ٤ خ روذ ٤ خ عؾ ا شػ ٠ ا ز ٣ ٣ ؼب شع ا وذ ا غ ش ١ ث غزشل ٠ د ذ ٢ ا زؼ ٢ ٤ ك ٢ ا لزشح ٣ ب ٣ ش إ ٠ د ٣ غ جش ٢٠١٦.ر ع غ ا ج ٤ ب بد ثأعزخذا اعزج ٤ ب بد ا شػ ٢ ا لش ٣ ن ا غشاؽ ٢ زبثؼخ ا شػ ٢ لزشح صالس اش ش. ر رؾ ٤ االعزج ٤ ب بد ثأعزخذا ثش ب ظ ا زؾ ٤ اإلؽظبئ ٢ SPSS ا غخخ ٢٢. ان تائح: ر رؼ ٤ ١٥٩ ش ٣ غ ٣ ؼب ا وذ ا غ ش ٣ خ اال زب ٤ خ ك ٢ ا ذساعخ. ٣ ض ا شػ ٠ ا ز س) 77.4 %( ا ؼ ٤ خ غجخ اإل بس إ ٠ ا ز س 3.4:1. ب ز عؾ ا ؼ ش 12.1±57.2 ع خ.أص ب ص ب ك ٢ ا بئخ ب ا شػ ٠ ا غ ش ١ ا ع ا ضب ٢ ب ؼظ ظبث ٤ ث شع ا غ ش ١ أل ضش ١٥ ع خ( 31.5 % (. ٣ عذ ذ )96.3 %( ا شػ ٠ روشؽبد ك ٢ ا وذ. كوب زظ ٤ ق كبؿ ش ب ذ ١ ؼظ ا شػ ٢ هشػ ا شؽ خ ا ضب ٤ خ )35.8 %( ص ا شؽ خ ا ضب ضخ) 24.5 %(. ب ذ ١ ) 15.7 %(أػشاع وض ا زش ٣ خ ك ٢ ؽ ٤ أ ) 80.5 %( ذ ٣ إؽغبط ؼ ٤ ت ثب ؼؾ. هذ ش ا ز بة ا ؼظ ا و ٢ ك 43.1(٢ %( ط س االشؼخ ا غ ٤ ٤ خ. غجخ )٩٩.%4( ا شػ ٠ خؼؼ ا زغش ٣ ذ ا غشاؽ 84.3( ٢ %( اعزخذا ا ٤ بساد ا ج خ ث ؼ ا طؼب )88.1 %( اعزخذ ا ا ؼبداد ا ؾ ٣ ٤ خ )7.6 %( ٣ غزخذ أع ضح رخل ٤ ق ا ؼؾ ػ ٢ ا وذ ٤ ث ٤ بأعزخذ ذ ا شهؼخ ا غ ذ ٣ خ ا غضئ ٤ خ ك ٢ )٤.٤%(.. ب ذ ز ٤ غخ ا ؼب غخ )32.1 %( ر شلبئ )1.3 %( ذ ٣ هشؽخ ز شسح أ عذ ٣ ذح )%10.7( ذ ٣ روشؽبد صبثزخ. هذ ر ا جزش ك ٢ )54.7 %( ا شػ ٠.رؼشع ( 23.3 %( جزش ا ضب ١ ث ٤ ب رؼشع )31.4 %( جزش ا شئ ٤ غ ٢. ب ثزش األطبثغ ا طش ٣ وخ ا شبئؼخ ك 22.6(٢ ( ا شػ ٠. ث ذ غجخ ا ك ٤ بد) %3.1 (. االعت تاج: ب ا ؼشع ا زأخش ثؼذ س ا وذ اال زب ٤ خ ا غ ش ٣ خ ا غجت ا شئ ٤ غ ٢ السرلبع ؼذ ثزش األػؼبء.رؼ ٤ ا شػ ٠ اعزخذا ػ ٤ بداد ا ؼ ب ٣ خ ثب وذ ا ؼالط ػ ؽش ٣ ن ا لش ٣ ن ا زؼذد ا زخظظبد ٣ و ؽبالد االػزال ا ك ٤ بد. Abstract Background: Diabetic foot is a serious complication of diabetes mellitus. Diabetic foot patients are at high risk of amputations and surgical hazards. Patients and Methods: This is a prospective descriptive hospital based study among patients with diabetic foot admitted to Wad Medani Teaching Hospital in the interval from January to December Results: A total of 159 patients with diabetic foot lesions were included in the study. Seventy-Seven were males (n=123) with Corresponding author Mohamed Soud Mohamed SaadEldein mohamedsaud944@gmail.com female to male ratio 1:3.4. The mean age was 57.2±12.1 years. Type II diabetes was present in (82.4%) most had diabetes for more than 15 years (31.4%). Most of the patients presented with ulcers (95.6%). According to Wagner classification patients were distributed into stage 0 (4.4%), stage 1(13.2%), stage 2 (35.8%), stage 3 (24.5%), stage 4 (18.9%), stage 5 (3.1%). The majority (80.5%) had defective pressure sense using 10-g monofilament while (15.7%) of the patients developed ischaemic symptoms. Osteomyelitis was demonstrated in (43.1%) of the patients by clinical examination and foot X-rays. Most of the patients (99.4%) underwent surgical debridement, (84.3%) used saline soaked dressing, and (88.1%) had

2 empiric antibiotic management. Only (7.6 %) use offloading devices while (4.4%) had split thickness graft. The mean hospital stay was 13.3±15.6 days, after three months of follow up (32.1%) were cured without amputation, (1.3%) had recurrence and (10.7%) had persistent ulcers. Amputations were encountered in (54.7%) of the patients with (23.3%) were minor amputations and (31.4%) were major amputations. Ray's amputation was the common modality done in (22.6%) of the patients. The incidence of death in this study was (3.1%). Conclusion: Late presentation after onset of diabetic foot was the main cause of high incidence of amputation. Patients education, foot care clinics and multidisplinary team management reduces incidence of morbidity and mortality. Keywords: Diabetes, diabetic foot, diabetic foot ulcer, amputation. Introduction Diabetes mellitus is one of the main problems in health systems and a global public health threat that has increased dramatically over the past two decades. (1) Diabetic foot ulcer is a common complication of diabetes with estimated lifetime incidence may be as high as 25%. (2) Infection is a frequent (40% 80%) and costly complication of those ulcers and represents a major cause of morbidity and mortality. (3) It is estimated that approximately 50% 70% of all lower limb amputations are due to diabetic foot ulcers. (4) The cost of management of diabetic foot ulcers represents (7% 20%) of the total expenditure on diabetes in North America and Europe. (5) Chronic foot ulcers and amputations have devastating effects on the individual's physical and psychosocial status. (6) Survival rates after amputation are generally lower for diabetic versus non diabetic patients. The 3- and 5-year survival rates are about 50% and 40%, respectively, with cardiovascular disease being the major cause of death. (7) In Sudan, diabetes mellitus is a common public health problem. The International Diabetic Federation estimated the number of diabetic patients in 2014 to be 1.4 million, with prevalence of 7.74% among adult 217 population (20 79 years). (8) Diabetic foot accounts for 3.3% of all surgical load in Omdurman Teaching Hospital (9) and 10.2% of all complications reported from private clinics in Khartoum state. (10) The reported rate for major lower limb amputation in Jabir Abu Eliz Diabetic Centre (JADC) was 14%. (11) One study had shown that septicaemia due to diabetic foot infection was the second cause of death (13%) in diabetic patients. (12) the case mortality of diabetic foot patients was reported to be 7.4% in Al-Obeid Hospital - western Sudan. (13) This research was conducted in Wad Medani Teaching Hospital (WMTH) to study the pattern of presentation, modalities of investigations, local management protocols and outcome of management of diabetic septic foot. Patients and Methods A prospective descriptive hospital based study was conducted in WMTH over one year from January to December It included all diabetic foot patients who agreed to participate in the study and followed for three months in WMTH outpatient clinic during study period. Verbal consent obtained from all patients. A non probability consecutive sampling with total coverage during the study period was done. Data was collected using a constructed structure questionnaire. Questionnaires were filled using face to face interview and clinical examination all done by the same team group Patient s demography, history of diabetes, pattern of clinical presentation, risk factors, and social habits which was collected by direct interviewing of the patients. Socioeconomic status was evaluated from the income of the family using Gumaa et al. (14) study scale: Poor: Illiterate or primary education ± income < 750 SD/month, Moderate: Secondary or university education ± income SD/month, and Good: Post university education ± income > 2000 SD/month. Foot examination was conducted by general surgery registrars. General features of neuropathy (including muscle atrophy, loss of hair, shiny skin and nail changes) and

3 infection (including fever, pus discharge, redness and swelling) were observed. Peripheral sensory evaluation included Pressure sense was obtained using 10 gm monofilament on the planter aspect until the monofilament buckles, vibration sense by128 Hz tuning fork applied to the bony prominence at the dorsum of the first toe, pin prick sensation using a pin applied to the tip of the big toe. Peripheral circulation was evaluated by palpation for peripheral pulses; ankle-brachial index was not done due to the absence of Doppler probe in the hospital. The ulcers' size, site were recorded and then classified according to Wagner's grading system. Laboratory investigations results including random blood glucose level, HbA1c, renal function test were obtained from patients records. Renal function impairment group included patients with urinary albumin excretion of 300 mg or more per 24 hours or diagnosed as chronic renal disease in nephrology department with estimated GFR less than 70 ml per minute (15) Imaging studies including chest X-ray, and duplex ultrasound scan reported by specialized radiologist were documented in the study. Management of study group according to different surgical units policy in WMTH was observed. Initial control of diabetes included either management of diabetic ketoacidosis or use of sliding scale with regular insulin. Types of debridement and dressing which was conducted by registrars or medical officers in surgical units were recorded. The use of antibiotic and utilization of culture and sensitivity were documented. The study also described types of offloading techniques used either therapeutic shoes, cast walker or Total contact cast. In addition the use of plastic surgical procedure was recorded. The outcome of management of diabetic foot after three months was categorized into healing without amputation, healing with amputation, persistent ulcer, new or recurrent ulcer and death. Analysis obtained using SPSS package version 22. Results were expressed in tables and graphs. Results The number of patients in this study in the period between January to December 2016 was 159 patients who were admitted, treated and followed in WMTH. Males were 77.4% (n=123) with female to male ratio 1:3.4 while mean age was 57.2 ± 12.1 year. The geographical distribution of patients shows that most of the patients came from rural areas (57.9 %). Most of the patients 47.8% (n=76) were educated till primary school while15.1% (n=24) were illiterate.the occupation among subjects of the study shows that most of the males 27.7% (n=44) were retired and most of the females were Housewives 22.6% (n=36). Fifty-eight percent (n=92) had poor socioeconomic status, 33.3% (n=57) had moderate socioeconomic status. Most of the patients were type II diabetes 82.4% (n=131). The majority were on oral hypoglycemic drugs 60.4% (n=96). Most of the patients had diabetes more than 15 years 31.4% (n=50). Only 36.5 % (n=58) of the patient had regular follow up with 26.4% (n=42) of the patient had their follow up in primary health centres. The results of diabetic control on admission showed that 45% (n=72) of the patient had random blood glucose between mg/dl. HbA1c was done in 57.2% (n=91) patient. HbA1c was more than 8 % in 76.9% (n=70) of them. The initial control of diabetes on admission included management of diabetic ketoacidosis in 16% (n=26) of the patients and sliding scale with regular insulin according to RBG level measured every 6 hr in 83.6% of them. Thirty-four percent of the patients (n=55) were known hypertensive, retinopathy was reported in 18.2% (n=29), ischaemic heart disease was prevalent in 6.3% (n=10) of the study group while 13.8% (n=22) had hyperlipidaemia. Twelve percent (n=19) had chronic kidney disease. Regarding social habits 28% (n=45) were smokers while 1.3% (n=2) were alcohol abusers. Sixty-one percent (n=98) had history of trauma, 52.8% (n=84) of the patients had previous diabetic foot ulcer with 50.3% 218

4 (n=80) of the patient had previous foot surgery or amputation (Table 1). Table 1: Types, duration & control of diabetes among diabetic foot patients in Wad Medani Teaching Hospital between January to December 2016 (n=159) Frequency/ Category Type of diabetes Duration of diabetes Type of hypoglycaemic Control Random blood glucose on admission HbA1c Percent Type 1 28(17.6%) Type 2 131(82.4%) < 5 yrs 34(21.4%) 5-9yrs 29(18.2%) 10-14yrs 46(28.9%) >15yrs 50(31.4%) Oral hypoglycaemic drugs 96(60.4%) Insulin 54(34.0%) Diet control 4(2.5%) Refuse any type of 5(3.1%) control <150 12(4.9%) (10.2%) (29.4%) (41.2%) (9.8%) >350 5(5.4%) Total 159(100%) < 6 % 6 (6.6%) 6%-7.9% 15(16.5%) 8% 70(76.9%) Total 91(100%) Most of the patients presented after 4 weeks from the onset of ulcer 32.1% (n=51).most of the patients 81.1 % (n=129) were admitted through the emergency room. Mean hospital stay (measured from admission of the patient to discharge with clean wound) was 13.3days ±15.6 SD. Trophic changes associated with diabetic foot included change in skin texture 89.3% (n=142), muscle wasting 88.1% (n=140), hair loss 78.6% (n=125), fissure 51.6% (n=82) and callus formation in 36.5% (n=58). Eighty percent (n=128) had defective pressure sense using 10g monofilament, 23.6% (n=36) had defective pin prick sensation, and 40.8% (n=65) had defective vibration sense using 128 Hz. Ischaemic symptoms among diabetic foot patient in the study included intermittent 219 claudication in 15.7% (n=25) while rest pain was also reported in 4.4% (n=7). Examination of the peripheral pulses showed intact peripheral pulses in 84.9% (n=135) of the patients, while 7.3% (n=18) had absent dorsalis pedis. Duplex scan was done in 138 patients, showing features of atherosclerosis in 13.7% (n= 19) of the patients and absence of signal waves in 5.0% (n=8) hem at most of them at the level of dorsalis pedis and posterior tibial 4.4% (n=7). Diabetic foot ulcer was the most common presentation in 95.6 % (n=152) of diabetic foot patients. Most of the patients developed planter ulcers in 40.9% (n=62) of them, followed by big toe and lateral toe lesions with incidence of 26.4% (n=42) and 17% (n=27) respectively. The diameter of the ulcer ranged from 1 to 12 cm with mean diameter of the ulcers was 4.6±.9 cm. Most of the patients are more than 4 cm in diameter 71.7% (n=109). According to Wagner classification patients are distributed into stage 0(4.4%), stage 1(13.2%), stage 2 (35.8%), stage 3 (24.5%), stage 4 (18.9%), stage 5 (3.1%). With most of the patients were stage 2 and 3. (Table 2) Table 2: Wagner classification among diabetic foot patients in Wad Medani Teaching Hospital between January To December 2016 (n=159). Category Frequency/ Percent Wagner Stage 0 7(4.4%) Classification Stage 1 21(13.2%) Stage 2 57(35.8%) Stage 3 39(24.5%) Stage 4 30(18.9%) Stage 5 5(3.1%) Total 159(100%) The study of symptoms and signs of diabetic foot infection showed that 27% (n=43) had fever, 46.5% (n=74) had pus discharge, 22% (n=35) had gangrene, 50.9% (n=81) had cellulites and 5.7% (n=9) had Tinea paedis. Foot X-ray was done in 153(n=96.2) patient, osteomyelitis was diagnosed in 43.1% (n=69) of them based on X-ray findings and clinical examination.

5 Most of the patients 88.1% (n=140) used empiric systemic antibiotics. Only 15.1% (n=24) had changed to antibiotics according to culture and sensitivity. The most cultured organism from 24 wound swabs was Staphylococcus aureus 45.8% (n=11) followed by E. coli 16.7% (n=4). Most of the patients had surgical debridement 99.4% (n=158), only one patient received mechanical debridement before surgical one. Regarding type of dressing saline soaked gauze was used in the majority of patients 84.3% (n=134) followed by antibiotic impregnated gauze (containing fucidic acid) 14.5% (n=23). Only 7.6% (n=12) had offloading technique used, Therapeutic shoes was the most used modality of offloading technique used in 6.3% (n=10) and Cast walker in 1.3% (n=2). Plastic surgical procedure was used in 4.4% (n=7) of the patients in a form of split thickness skin graft. The outcome of management after Three months of follow up showed that 32.1% (n=51) of the patients were cured without amputation. Healing with lower extremity amputations was reported in 54.7% (n=87) with 31.4% (n=50) underwent major amputations and 23.3% (n=37) underwent minor amputation. Ray's amputation was the commonest modality 22.6% (n=36). (Table 3) Table 3: Outcome of management of 159 diabetic foot patient admitted in Wad Medani Teaching Hospital between January to December Category Frequency/ Percent Cured without Amputation 51(32.1%) Cured with Minor Amputation 37(23.2%) - Ray's amputation 36 (22.6%) - Syme's 1 (0.6%) amputation Cured with Major Amputation - Below knee amputation - Above knee amputation 35(22%) 14(8.8%) 49(30.8%) Persistent ulcer 17(10.7%) Recurrent ulcer/new ulcer 2(1.3%) Death 3(1.9%) Total 159(100%) The causes of amputation included severe sepsis in 22.1 % (n=19), osteomyelitis in 37.2% (n=32) and gangrene in 40.7 % (n=35) of the cases of amputation. The study reported that 10.7% (n=17) of the patients had persistent ulcers while 1.3% (n=2) had recurrent ulcers during 3months of follow up in the outpatient clinic.death was reported in 3.1% (n=5) of the cases. Two of them were due to septic shock, two due to ischaemic heart diseases and one of them was due to renal failure. Discussion In this study a total of 159 patients with diabetic foot lesions were included. Males were more affected than female with male to female ratio of 3.4:1. In our study most of the patients were between (50 59 years) age group, with a mean age of 57.2±12.1 year. The results of gender and mean age is similar to other studies in Sudan like Adam et al. (9) and Bella et al. (10) The majority of the patients came from rural areas, unemployed, with low level of education and low Socio-economic status. This demarcated increasing burden of diabetes mellitus and its complications on family members, society, and government. Ngim et al., (16) study in Southern Nigeria found that 58% of diabetic foot patients had informal education while Naeem et al,. (17) study from Egypt showed that patients living in rural areas and those with poor socioeconomic conditions were at higher risk for the development of diabetic foot ulcer due to the lack of foot care. In this study, most of the patients had type II diabetes for long duration (>15 years) with the majority were using oral hypoglycemic drugs and this results agree with a research by Andrew et al. (18) from Nigeria as well as Bakheit et al. and Adam et al. studies from Sudan (19-20). It was noticed that only about one third of the patients had regular follow up of diabetes mainly in the primary health centers. The rates of regular follow up was similar to Alawad et al., (11) study in JADC but lower than Calle- Pascual et al., (21) study from Spain 220

6 where 71% compliances were reported. This rise the need for proper training of health personnel on diabetic foot management and the crucial role of follow up in reducing the incidence of diabetic foot. Random blood glucose ranged between mg/dl in the majority of the patients. HbA1c which was done in 57.2% patients, showed most of them had HbA1c equal or more than 8%. These results showed that most of the patients in the study they had poor control of diabetes at time of admission that agree with Mohieldein et al., (22) study in JADC which found that the mean level of HbA1c was raised in diabetic patients with foot sepsis compared with diabetic patients without sepsis (9.9% vs 7.9%). The initial control of diabetes on admission was management of diabetic ketoacidosis in 16% (n=26) of patients while 83% (n=133) were on sliding scale with regular insulin. The presence of ketoacidosis made the surgical debridement and amputation a lifesaving procedure in order to treat sepsis. In this study, the incidence of hypertension was similar to Naeem et al., (17) study in Egypt in the incidence hypertension but less in the incidence of heart diseases. Near one fifth of the patients report to have retinopathy which was similar to Andrew et al., (18) study in Nigeria showing visual impairment in (21.3%).The high incidence is probably attributed to poor compliance for follow up and control of diabetes. Twenty-eight percent were smokers while 1.3% were alcohol abusers. Adam et al., (23) study from Sudan find that a strong significant association between heavy smoking (>10 cigarettes /day) and amputation. He also found that heavy alcohol drinkers were at a higher risk of amputation compared to light drinkers. Half of the patients had previous diabetic foot ulcer while half of the study group had previous foot surgery or amputation. This result is slightly higher than Bella et al., (10) study in Military hospital, Khartoum showing that 46.6% have previous diabetic foot ulcer or amputation. That could be explained by low compliance of the patients with foot care 221 and regular follow up in high risk patients. The majority of the patients had history of trauma (61%). A research in JADC found the commonest direct cause of foot ulcers to be blisters of unknown cause (28.4%), followed by sharp injuries (23.1%). (24) The high incidence of trauma as a cause of diabetic foot was probably due to high proportion of patients were farmers from rural areas where walking bare foot is a common practice and this agreed with another study conducted in Southern Nigeria. (16) One of the crucial factors of the outcome is time of presentation from onset of diabetic foot lesion. Most of the patients in our study presented after 4 weeks from the onset of ulcer. The time of presentation was late in comparison with a study in Military hospital, Khartoum, Sudan reports that 70% of the patients presented to the hospital after 1-2 weeks, while only 6.7% after 2 months. (10) Similar results were found by Chalya et al., (25) study in Tanzania which was attributed to low socioeconomic status, poverty, lack of diabetes education (regarding the importance of general foot care, the significance of diabetes and its complications), in addition to lack of training health care providers in managing diabetic foot ulcers and the delay in referring patients to specialized diabetes care centers also contribute to the late presentation. Hospitalization is the most expensive part of treating a diabetic foot infection, and deciding on its necessity requires consideration of both medical and social issues. In this study the mean hospital stay was 13.3days±15.6 SD which was nearly the same to the mean hospital stay of diabetic patients with foot lesion in USA (11.9 days) reported by the CDC in 2005 (6) and less than Tanzanian study (36.24±12.62). (25) Examination of the patients revealed that 51.6% had fissure, 36.5% had callus formation. It showed higher incidence compared with Bakri et al., (26) study from Jordan showing calluses in 43.7%, fissures in 26.5%. It was attributed to higher incidence of neuropathy in our study group. It is reported that loss of sensation to the 10- filament was associated with a 10-fold risk of

7 foot ulceration and a 17-fold risk of amputation over 32 months follow up period. (27) Our study shows defective pressure sensation in eighty percent of the patients evaluated by the 10-g monofilament, and nearly half of them had defective vibration sense using 128Hz. Higher than other studies by Alawad et al. and Bakheit et al. studies. (19,12) This high result was explained by long duration of poorly controlled diabetes (>15 years ) in most of the patients. Regarding ischaemic symptoms intermittent claudications were reported in 15.7% and lower extremity pain at rest in 4.4%, Examination of the peripheral pulses were intact in 75.5% of the patients while the most affected vessel was dorsalis pedis in 7.3% of the patients. This incidence was lower than Widattalla et al., (28) study in JADC (24%) which also showed that critical limb ischemia was significant risk factor for major amputations. Nearly all of the patients had foot ulcers with the majority of ulcers were developed on planter aspect of the foot which also agreed with Widattalla et al., (28) study showing that (83.5%) of the patients presented with foot ulcers and Plantar ulcers were the most common. (28) According to Wagner classification patients present to hospital at stage 2 (35.8%). The percentage of patients presenting at late stages (stage 3, stage 4, and stage 5) were (24.5%), (18.9%), and (3.1%) respectively which collectively equal 46.5%. This percentage of patients presenting at late stages was less than previous studies in done Sudan by El Bushra et al., (13) 74.1%, Adam et al., (9) 72.6% and Bella et al. (10) 83.3% but higher when compared to a study in Jordan by Al-Ebous et al. 42%. (29) Osteomyelitis was diagnosed in 43.1% based on foot X-rays finding in addition to clinical findings (pus discharge and positive probe to bone test). The incidence of osteomyelitis was high in our study due to late presentation (>4weeks), large size of ulcers (>4cm) in most of the patients but less than Gadepalli et al. study (62.5%) in India. (30) Most of the patients had empiric intravenous 222 antibiotics. Swab for culture and sensitivity was only done in 24 cases (15.1%) which reflect that the use of swab and biopsy based antibiotics is not a common practice in WMTH. The most common detected organism was staphylococcus aurous fallowed by E. coli. This result agreed with El- Nazeer (31) study showing that Staph aureus was the most common isolated bacteria in 48.46% of the patients. Most of the patients had surgical debridement 99.4%. Mechanical debridement was done in one patient with ulcer around the heel using Normal saline under pressure with hydrogen peroxide and changing of dressing from dry to wet. Hassan (32) study in JADC using surgical debridement in diabetic foot patients showed higher rate of healing without amputations 81% and lower rate of major amputations 4 % which reflect the effect of management with specialized team in diabetic centers like JADC on the outcome of diabetic foot. Dressings serve to protect the wound from trauma and contamination, and facilitate healing by absorption of exudates and protection of healing surfaces. Most of the patients had dressing with saline soaked gauze (90.2%) while (9.8%) had antibiotic soaked gauze containing (fucidic acid). Lipsky et al. recommended the use of topical antibiotics for mildly infected open wounds with minimal cellulitis, despite limited data to support the use of topical antimicrobial therapy. (33) Only 7.6% had offloading technique used and the most used method was the therapeutic shoes in 6.3%. No use of total contact cast as most of the patients had infected wounds which required frequent dressing. Musa et al. (34) study showed shorter duration of healing in TCC offloading group. Only 2.8% of the patient had split thickness graft and that was related to the late presentation of the patient. Mahmoud et al. (35) showed significantly shorter healing time in skin graft group vs. dressing group (p=0.001). In this study 25.3% of our patients underwent minor amputation, the majority being of Ray's excision in 24.9% of the patients. It was higher than Widattalla et al. (28) in JADC and Chalya et al. (25) ranging from %.

8 The rate of major amputation in our study after a follow up period of 3 months was found to be 26.1 %, which is high compared with El Bushra et al. (13) in El-Obeid 24% and with a study in JADC 10%. (28) The causes of amputations included gangrene, osteomyelitis and severe sepsis. This high rate of amputation could be attributed to late presentation of the patients, poorly controlled diabetes, high incidence of neuropathy and osteomyelitis and lack of offloading technique. With proper foot care program implementation the incidence of amputation can be reduced to 3.5% minor amputation and 2.9% major amputation; as reported by Alawad et al., (11) study in JADC. Recurrence or new ulcers were reported in 1.3% of study sample while 10.7% had persistent ulcer. Orneholm et al., (36) in Sweden reported higher incidence of recurrence than our study 8%. The low incidence of recurrence is probably attributed References 1. Shahbazian H, Yazdanpanah L, Latifi SM. Risk assessment of patients with diabetes for foot ulcers according to risk classification consensus of International Working Group on Diabetic Foot. Pak J Med Sci. 2013;29(3): Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. Jama. 2005;293(2): Prompers L, Huijberts M, Schaper N et al. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia. 2008;51(10): Leone S, Pascale R, Vitale M, Esposito S. Epidemiology of diabetic foot. Infez Med. 2012;20(Suppl 1): Centers for Disease Control and Prevention. Data and Trends: National Diabetes Surveillance System, Vol. 2006, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, to short follow up interval (3 months). The mortality rate reported by our study was 3.1% (n=5) mainly due to septic shock, ischaemic heart diseases and renal failure. The mortality rate was low compared with studies in Sudan like El Bushra et al. (13) and Suliman et al. (37) (20%). The incidence was also found to be lower compared with other studies from Nigeria (18) and Manchester, (38) which may be attributed to low incidence of ischaemic heart diseases a major cause of death in diabetic foot patients. (7) Management of diabetic foot patients in this study depends on different surgical units policies in WMTH. There is no unified protocol used. The aim of the study was to describe local management practices in WMTH and compare it with other local and international centers. Conflict of Interest: None. Ethical Clearance: Obtained.. 6. Van Houtum WH. Institutionalization following diabetes-related lower extremity amputation. Am J Medicine. 1997;103(5): Frykberg RG, Habershaw GM, Chrzan JS. Epidemiology of the diabetic foot. In: Clinical management of diabetic neuropathy.totowa, NJ:Humana Press p Beatriz Y J, Sheree D, Courtney S, Olivier J. Global diabetes scorecard tracking progress for action. Brussels: International Diabetes Federation;2014.p Adam MA, Hamza AA, Ibrahim AE. Diabetic septic ffoot in Omdurman Teaching Hospital. Sudan J Med Sci. 2009;4(2): Balla SA, Ahmed H A, Alhassan SF. Factors associated with diabetic septic foot among patients attending the diabetic septic foot unit in the Military Hospital, Khartoum State. Saudi Journal of Medicine and Medical Sciences. 2013;1(2):

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10 31. El Nazeer Osman. Bacteriology of diabetic foot infections in Sudan. Diss. Khartoum. University of Khartoum ;2015.p Hassan HS. Types and techniques of surgical debridement in diabetic foot infection. Khartoum. Sudanese Medical Specialization Board, Lipsky BA, MacDonald D, Litka PA. Treatment of infected diabetic foot ulcers: Topical MSI-78 vs. oral ofloxacin. Diabetologia. 1997;74: Musa HG, Ahmed ME. Associated risk factors and management of chronic diabetic foot ulcers exceeding 6 months duration. Diabet Foot Ankle. 2012;3(1): Mahmoud SM, Mohamed AA, Mahdi SE, Ahmed ME. Split-skin graft in the management of diabetic foot ulcers. J Wound Care. 2008;17(7): Orneholm H, Apelqvist J, Larsson J, Eneroth M. Recurrent and other new foot ulcers after healed plantar forefoot diabetic ulcer. Wound Repair Regen. 2017;25(2): Suliman MO, Salim O E, Ahmed M E. Major lower limb amputation in diabetics. Khartoum Medical Journal. 2012; 5(1): Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care. 2001;24(1):