Application of Amit Jain's scoring system in diabetic foot amputees.
The global prevalence of diabetes is predicted to be 366 million people by 2030. [1,2] Foot infection is considered to be the most common and feared complication of diabetes.  It is believed that 15% of all diabetic patients will develop some form of foot problems during their lifetime. [1,4] Foot ulcers carry a 25% risk of major lower extremity amputation.  In fact, the risk of amputation in diabetic patient is 10-30 times higher in comparison with general population. 
Recently, a new scoring system has been proposed by Amit Jain [Table 1] that predicts the risk of major amputation in diabetic foot complications.  We studied the risk of major amputation through the Amit Jain's classification system that studies diabetic foot in a different way, thereby creating a standard way of understanding and dealing with diabetic foot problems.
AIM OF THE STUDY
To evaluate the suitability of Amit Jain's criteria in post-amputation cases between 2013 and 2015.
METHODS AND MATERIALS
A retrospective review of the records of all patients with diabetic foot complications who underwent major lower limb amputation between 2013 and 2015 in M. S. Ramaiah Hospital was performed. Patients were identified using a computer generated search through the medical records department. Medical records were reviewed for the following: Age, gender, presence of diabetic foot complications and clinical findings as per Amit Jain's scoring system. Patients were scored and were stratified into different risk groups.
Major amputations done in other departments, major amputation done in diabetes patients due to trauma or malignancy and patients with poor data recording in the files/missing files were excluded.
Out of 32 cases, only 21 were included in this study. We excluded 11 patients in view of incomplete data in the files needed for this study.
The mean age of the study population was 56.76 years (SD 9.2). Seventeen patients [80.95%] were males and 4 patients were females [19.05%]. Mean age of females being 46.25 (SD 4.7), while that of males was 59.24 (SD 8.2).
The average score as per Amit Jain's scoring system was 15.72 (SD 5.4) for females and 22.47 (SD 4.73) for males [Figure 1]. The difference in mean score between men and women was found to be statistically significant (p<0.05).
The right lower limb was involved in 11 cases [52.38%] and left limb in 10 cases [47.62%]. In 13 cases [61.91%], the pathological lesions were confined to foot and in 8 cases [38.1%] it extended beyond foot involving leg also.
Majority [80.95%] of our patients [Table 2] had Below Knee Amputation (BKA). The ratio of BKA to above knee amputation was 4.25:1 in our series.
The commonest pathological lesion in our study was wet gangrene [Table 3] involving 11 patients [52.38%] followed by abscess [28.57%]. Out of 6 cases of abscess [Figure 2], 2 patients had presented to us with infected ulcer with purulent discharge. These patients were operated outside recently and they were primarily diagnosed as diabetic foot abscess in their discharge summary. Hence, we placed these infected wounds/ulcer in abscess category as they had short history and these cases had undergone inappropriate debridement.
The other 2 ulcer patients had prior history of non-healing ulcer, which seemed to have got infected and hence these ulcers were chronic in nature. We had a total of 3 patients who had type 3 diabetic foot complications. The third patient had peripheral arterial disease with gangrene of toes and infected ulcer on the foot. The rest had type 1 diabetic foot complications.
From the results obtained in the study, we observed that 66% of the patients who underwent amputation belonged either to high [Figure 3 and 4] or very high risk categories as per Amit Jain's Classification [Table 4]. Four patients [19.05%] belonged to category of inevitable amputation category. The lowest score in our study was 10 and the highest was 32.
This concordance with the classification validates the effectiveness of stratifying patients into various categories for deciding the need for amputation. There was no mortality in this study.
Diabetic foot is known to have a major medical, social and economic consequence.  More than 50% of lower limb amputations are performed on diabetic patients.  Once amputation is performed, the patient has to stay longer in hospital and are at a risk of further complications, mortality and increased cost. Major amputations in diabetic foot are disfiguring operations that carry a high morbidity and mortality.  Lower limb amputations however are considered a last resort when salvage is not possible. 
There was never a tool to assess major amputations in diabetic foot performed by surgeons. Amit Jain's scoring system is probably the first and the only surgical scoring system till date.  Amit Jain's scoring system for diabetic foot is a newly formulated score, which appeared in literature in 2014.  There are not many studies validating this score.
Our study showed that major amputations were common in similar to Jain et al. series.  Below knee amputation was the commonest amputation in our series and also in Jain et al. series. 
The commonest cause for major amputation in this study was wet gangrene. In a study from Kenya.  gangrene on the whole was a major cause for major and minor amputations.
Our study showed that majority of the patients belonged equally to very high risk and high risk for major amputations followed by inevitable amputation category. Around 85.7% of our patients had a score above 16, whereas in Jain et al. series had a score more than 16 in 80% of patients. 
The Amit Jain scoring system clearly states that no major amputations should be done with score less than 5 and all patients who have a score above 26 will invariably require major amputation. 
This affirmative statement would in future help us decide that patients having a score of more than 26 should not be unnecessarily investigated with higher imaging modalities/therapeutic salvage intervention. Only few more future studies would help us to determine the actual outcomes of higher scores.
We need to thoroughly understand this scoring system which has clinical, radiological and surgical factors determining an appropriate scoring. Inappropriate understanding and scoring wrongly could lead to inaccurate data. We believe that a prospective study would be more appropriate, as all the parameters would be recorded more appropriately and followed accordingly. Only hospitalized and operated diabetic foot patients could be studied by this scoring system, as operative data is essential to arrive at a final score for the patients. There were certain limitations in our study. First, our sample size was small. Further, there was a difficulty in obtaining data in view of weak case sheet recordings in some case files.
This scoring system serves us a reliable tool to study amputations performed by surgeons and also can be used to look at diabetic foot lesion prospectively and determining the risk category that they present to hospital. The score could also serve an important tool as a recording sheet of diabetic foot patients who underwent surgery.
We would like to thank Dr. B. S. Nanda Kumar, Head-Research and IPR, Division of Research and Patents and Associate Professor-Community Medicine, M. S. Ramaiah Medical College and Hospitals and Dr. K N Chidambaram Murthy, Chief Scientist, Central Research Laboratory, M. S. Ramaiah Hospital, for their support.
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Kalaivani V (1), Khyati Melanta (2)
(1) Associate Professor, Department of General Surgery, M. S. Ramaiah Hospital, Bangalore.
(2) 2nd Year Post Graduate, General Surgery, M. S. Ramaiah Hospital, Bangalore.
Financial or Other, Competing Interest: None.
Submission 02-02-2016, Peer Review 01-03-2016, Acceptance 07-03-2016, Published 05-04-2016.
Corresponding Author: Dr. Khyati Melanta, 364/1, 12th Cross, 5th Main, Dollars Colony, RMV 2nd Stage, Bangalore-560094.
Table 1: Showing the Amit Jain's Scoring System for Diabetic Foot Complications Sl. Characteristics Involvement of Foot/Characteristics No. 1. Presence of ulcer No ulcer Forefoot ulcer [right arrow] 0 [right arrow] 2 2. Osteomyelitis [O.M] No O.M Forefoot O.M [right arrow] 0 [right arrow] 2 3. Presence of pus No pus Forefoot pus/dorsum [right arrow] 0 [right arrow] 2 4. Gangrene [dry/wet] No gangrened Forefoot gangrene [right arrow] 0 [right arrow] 2 5. Peripheral arterial No P.A.D Mild [right arrow] 2 disease [P.A.D] [right arrow] 0 6. Charcot foot No [right arrow] 0 Forefoot [right arrow] 2 7. Necrosis of No [right arrow] 0 Forefoot necrosis the skin [right arrow] 2 8. Associated No [right arrow] 0 Upto forefoot cellulitis [right arrow] 2 9. Previous No [right arrow] 0 Toe amputation amputation [right arrow] 2 10. Presence of gas - No [right arrow] 0 Gas in forefoot radiologically [right arrow] 1 11. Myonecrosis No [right arrow] 0 Myonecrosis involving single muscle groups [right arrow] 2 12. Joint involvement No [right arrow] 0 Forefoot joint exposure [right arrow] 2 13. Septic shock No [right arrow] 0 14. Renal failure No [right arrow] 0 15. Smoking No [right arrow] 0 16. Surgeon factor Qualified diabetic foot specialist [right arrow] 0 Sl. Involvement of Foot/Characteristics No. 1. Midfoot ulcer Hindfoot ulcer/full [right arrow] 4 foot [right arrow] 6 2. Midfoot O.M Hindfoot O.M [right arrow] 4 [right arrow] 6 3. Midfoot pus Hindfoot pus/beyond [right arrow] 4 it [right arrow] 6 4. Midfoot gangrene Hindfoot gangrene/ [right arrow] 4 beyond [right arrow] 8 5. Moderated Severed [right arrow] 8 [right arrow] 4 6. Midfoot Hindfoot/whole foot [right arrow] 4 [right arrow] 8 7. Midfoot necrosis Hindfoot necrosis/ [right arrow] 4 beyond [right arrow] 8 8. Upto midfoot Upto hindfoot & beyond [right arrow] 4 [right arrow] 6 9. Forefoot amputation Midfoot amputation [right arrow] 4 [right arrow] 6 10. Gas in/upto midfoot Gas in/upto hindfoot [right arrow] 2 [right arrow] 3 11. Myonecrosis involving Myonecrosis of entire more than one group foot muscle with [right arrow] 4 extension to leg [right arrow] 8 12. Midfoot joint Hindfoot joint exposure exposure [right arrow] 4 [right arrow] 6 13. Present [right arrow] 2 14. Present [right arrow] 2 15. Present [right arrow] 2 16. Other surgeons [right arrow] 2 Table 2: Showing Distribution of Cases of Major Amputation Sl. No. Type of Major Amputation Number Percentage 1. Below knee amputation 17 80.95% 2. Above knee amputation 04 19.05% Total 21 100% Table 3: Showing Distribution of Cases According to Pathological Lesion Sl. No. Pathological Lesion Number Percentage 1. Wet Gangrene 11 52.38% 2. Necrotizing Fasciitis 2 9.52% 3. Infected Ulcer 2 9.52% [Chronic/Non-healing] 4. Abscess 6 28.57% Total 21 100% Table 4: Showing Distribution of Cases According to Amit Jain Scoring System Sl. No. Risk/Score Number Percentage 1. Low Risk [6-10] 1 4.76% 2. Moderate Risk [11-15] 2 9.52% 3. High Risk [16-20] 7 33.33% 4. Very High Risk [21-25] 7 33.33% 5. Inevitable Amputation [>26] 4 19.05% Total 21 100% Descriptive Statistics N Range Minimum Maximum Mean Std. Deviation AGE 21 35 40 75 56.76 9.224 SCORE 21 22 10 32 21.19 5.446 Valid N 21 (Listwise) Descriptive Statistics. (a) N Range Minimum Maximum Mean Std. Deviation AGE 4 10 40 50 46.25 4.787 SCORE 4 13 10 23 15.75 5.439 Valid N 4 (Listwise) (a.) SEX = F
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|Title Annotation:||Original Article|
|Author:||Kalaivani, V.; Melanta, Khyati|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Apr 7, 2016|
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