Optimizing risk management for post-amputation wound complications in diabetic patients: Focus on glycemic and immunosuppressive control

Abstract

This study highlights the importance of identifying and addressing risk factors associated with wound complications following transtibial amputation in diabetic patients. These amputations, often necessitated by severe diabetic foot ulcers, carry significant risks of postoperative complications such as infection and delayed wound healing. Elevated hemoglobin A1c levels, indicative of poor glycemic control, and a history of kidney transplantation, due to required immunosuppressive therapy, are key factors influencing these outcomes. This paper emphasizes the need for enhanced glycemic management and personalized postoperative care, particularly for immunocompromised individuals, to minimize complications and improve patient prognosis. Future research should focus on prospective studies to validate targeted interventions and optimize care strategies, ultimately aiming to reduce the healthcare burden associated with diabetic foot complications.

Key Words: Transtibial amputation; Diabetic foot; Wound complications; Risk factors; Glycemic control; Hemoglobin A1c; Immunosuppressive therapy; Kidney transplantation; Personalized care; Postoperative outcomes

Core Tip: Effective management of wound complications following transtibial amputation in diabetic patients relies on targeted risk factor mitigation. Maintaining optimal glycemic control, particularly by managing preoperative elevated hemoglobin A1c levels, can significantly reduce complications. Additionally, personalized postoperative care, especially for immunocompromised patients such as those with a history of kidney transplantation, is crucial. A multidisciplinary approach involving endocrinologists, surgeons, and wound care specialists is recommended to optimize patient outcomes and minimize healthcare burdens. Future research should focus on validating these strategies through prospective studies to enhance clinical practice in diabetic foot care.

TO THE EDITOR

Diabetic foot complications remain a significant public health challenge, contributing to high rates of morbidity and mortality among diabetic patients[1,2]. Diabetic foot ulcers (DFUs) are a severe consequence of poorly controlled diabetes, often leading to chronic infections, extensive tissue damage, and, in many cases, lower-limb amputations[2]. Globally, it is estimated that 15% to 25% of diabetic patients will experience a DFU during their lifetime, highlighting the substantial burden on healthcare systems[1].

We were intrigued by an article published by Park et al[1] in the World Journal of Diabetes, where their original research emphasizes that transtibial amputation is often performed for severe DFUs when conservative treatments prove ineffective[3]. This procedure aims to manage infection and excise necrotic tissue, thus safeguarding the patient’s overall health[4]. However, despite its potentially life-saving benefits, transtibial amputation carries a substantial risk of postoperative wound complications.

Postoperative complications following transtibial amputations are a critical concern, with studies indicating that nearly half of the patients undergoing this procedure face challenges like infection, wound necrosis, and delayed healing[4,5]. These complications often necessitate further surgical interventions, prolong hospital stays, and significantly impact patients' quality of life. Given these outcomes, the need for effective management and prevention strategies is paramount.

Identifying key risk factors is central to improving postoperative outcomes for diabetic patients undergoing transtibial amputations. Elevated hemoglobin A1c (HbA1c) levels, which indicate poor glycemic control, have been consistently linked to an increased risk of wound complications, reflecting the importance of blood glucose management in surgical prognosis[6]. Additionally, patients with a history of kidney transplantation are particularly vulnerable due to the immunosuppressive therapies required to prevent organ rejection. These therapies can compromise wound healing, highlighting the need for personalized care in this subgroup. Addressing these risk factors through targeted interventions can potentially enhance recovery rates and reduce the overall burden of complications in diabetic populations (Figure 1; Table 1)[1].

Figure 1 Distribution ratio of risk factors in wound complication group. HbA1c: Hemoglobin A1c.

Table 1 Risk factors, interventions, and management strategies for postoperative complications in diabetic patients.

Risk factor	Impact on outcomes	Recommended interventions	Specific implementation methods	Involved professionals	Ref.
High HbA1c levels	Increased risk of infection, delayed wound healing	Preoperative optimization of HbA1c levels, stricter glycemic control	Dietary intervention: Low-GI diet plan; exercise management: At least 150 minutes of aerobic exercise weekly; medication: Rational use of antidiabetic drugs or insulin; self-monitoring: Use of CGM systems	Endocrinologists, dietitians, exercise therapists, nursing staff	Doudkani et al[26], Shin et al[27], Xu et al[28], Uslu et al[29], Ou-yang et al[30]
Immunosuppressive therapy	Increased susceptibility to infections, slower healing	Customized wound care plans, careful monitoring of immunosuppressive therapy	Regular wound assessments; individualized anti-infection treatments; monitoring immunosuppressant levels	Transplant specialists, immunologists, wound care specialists	Coccolini et al[14], Rayman[20]
Preoperative malnutrition	Impaired immune response, reduced tissue regeneration	Preoperative nutritional support, tailored dietary plans	Oral nutritional supplements; high-protein, vitamin-rich dietary regimen; regular nutritional assessments	Dietitians, endocrinologists, nursing staff	Zhu et al[31]
Peripheral neuropathy	Increased risk of pressure ulcers, reduced sensation	Regular foot inspections, customized footwear, professional wound care	Use of protective footwear; skin inspection and care for feet; professional foot pressure distribution assessments	Podiatrists, wound care specialists	Armstrong et al[4], Boyko et al[17], Bobirca et al[18]
History of infections	Higher risk of recurrent infections	Strict infection control measures, prophylactic antibiotics	Preoperative use of prophylactic antibiotics; bacterial culture of infection sites; dynamic assessment of antibiotic efficacy	Infectious disease specialists, surgeons	Armstrong et al[4], Rayman[20]
Chronic kidney disease	Slower wound healing, increased risk of complications	Preoperative optimization of renal function, nephrology consultation	Preoperative renal function evaluation; blood pressure and electrolyte balance control; development of individualized dialysis plans	Nephrologists, endocrinologists	Boyko et al[17], Moriconi et al[32]
Insufficient knowledge of diabetes management	Large glycemic fluctuations, poor patient compliance	Provide diabetes education programs, enhance disease management skills	Organize educational sessions; emphasize the importance of glycemic control; establish long-term patient support groups	Diabetes educators, endocrinologists, psychologists	Aloudah et al[33], Yeo et al[34]

CGM: Continuous glucose monitoring; HbA1c: Hemoglobin A1c.

IMPORTANCE OF GLYCEMIC CONTROL IN REDUCING POSTOPERATIVE RISKS

Glycemic control, as indicated by HbA1c levels, plays a critical role in predicting the risk of wound complications in diabetic patients[7]. Elevated HbA1c levels are consistently associated with poor postoperative outcomes, as they reflect prolonged hyperglycemia, which impairs the body’s ability to heal wounds effectively[8]. Studies have demonstrated that higher preoperative HbA1c levels are linked to an increased risk of infections, delayed healing, and the need for additional surgical interventions[6]. For instance, patients with HbA1c levels above 7.2% have a significantly higher likelihood of wound complications following major surgeries, including amputations[9].

Evidence strongly supports the need for preoperative optimization of blood glucose levels to mitigate these risks. Reducing HbA1c to recommended levels before surgery can enhance the body's capacity to manage surgical stress and improve wound healing outcomes[8]. Clinical guidelines frequently suggest tighter glycemic control as part of a preoperative preparation strategy to reduce infection rates and expedite recovery[10]. Commonly used medications for blood glucose control are detailed in Table 2.

Table 2 Characteristics, advantages, disadvantages, and usage of common antidiabetic drugs.

Drug name	Advantages	Disadvantages	Usage	Applicable patients and considerations
Metformin	Significantly lowers HbA1c levels; aids in weight reduction; reduces cardiovascular event risks	May cause gastrointestinal discomfort (e.g., diarrhea, nausea); use with caution in patients with renal impairment due to the risk of lactic acidosis	Typically taken orally, recommended during or after meals to reduce gastrointestinal side effects	Preferred for overweight or obese patients with type 2 diabetes, especially those at high risk of cardiovascular disease
Sulfonylureas	Rapidly lower blood glucose levels; convenient, often once-daily dosing	Risk of hypoglycemia; may cause weight gain	Usually taken before meals, with the dosage adjusted based on blood glucose levels	Suitable for patients without a high risk of hypoglycemia; attention needed for weight management in obese patients
DPP-4 inhibitors	Reduce HbA1c levels with minimal risk of hypoglycemia; minimal impact on weight	Relatively weaker glucose-lowering effect; potential risk of pancreatitis	Taken orally, typically once daily	Suitable for patients struggling with weight management or at risk of hypoglycemia, particularly elderly patients and those with chronic kidney disease
GLP-1 receptor agonists	Promote weight loss and improve cardiovascular health; significantly lower HbA1c levels	Require injection, which may reduce patient compliance; may cause gastrointestinal discomfort (e.g., nausea, vomiting)	Administered subcutaneously, usually weekly or daily depending on the drug type	Ideal for obese patients needing weight management and those with type 2 diabetes and cardiovascular diseases
Insulin	Effectively controls hyperglycemia and suitable for all types of diabetes; flexible dosage adjustments	Risk of hypoglycemia and weight gain; requires patient education and regular blood glucose monitoring	Administered subcutaneously, with dosage adjustments based on blood glucose levels and dietary intake	Suitable for patients with severe conditions or inadequate control with other medications, especially those with type 1 diabetes or gestational diabetes

HbA1c: Hemoglobin A1c.

In addition to glycemic control, immunosuppressive status is a significant consideration for patients with a history of kidney transplantation[11]. Immunosuppressive therapies, essential to prevent organ rejection, can compromise immune function, thereby increasing susceptibility to infections and impairing wound healing[12,13]. Personalized postoperative care for these patients is crucial, involving frequent monitoring, customized wound care protocols, and potentially modifying immunosuppressive regimens to balance healing and immune suppression[14,15](Table 1).

Overall, the integration of individualized care plans that emphasize glycemic control and tailored postoperative strategies for immunosuppressed patients can substantially reduce wound complications and improve long-term surgical outcomes in diabetic populations.

TARGETED INTERVENTIONS FOR REDUCING POSTOPERATIVE COMPLICATIONS

To reduce the risk of wound complications in diabetic patients post-transtibial amputation, targeted interventions are essential. Enhanced glycemic control is critical, as tighter glucose management has been linked to reduced postoperative infections and improved wound healing[16]. Implementing strategies like preoperative HbA1c optimization, continuous blood glucose monitoring, and tailored insulin therapy can significantly mitigate risks[17]

For patients with a history of kidney transplantation, personalized postoperative care is crucial. Immunosuppressive therapy can hinder wound healing, necessitating specialized wound management, frequent monitoring, and possible adjustments to immunosuppressive regimens. This careful balance can improve healing outcomes without compromising transplant stability[9].

The psychological impact of amputation surgery on patients is a critical yet often overlooked aspect of care. Research indicates that poor mental health can significantly hinder the recovery process and increase the risk of complications. Therefore, providing targeted psychological counseling and support to amputees is vital. Such interventions can help patients better adapt to the life changes brought by surgery and boost their engagement in rehabilitation therapy[18].

Peripheral arterial disease is a common comorbidity among diabetic patients, often resulting in insufficient blood flow to distal limbs and impaired wound healing. Vascular surgeons and interventional physicians play an indispensable role in the management of these patients. By identifying and addressing vascular stenosis or occlusions, they can enhance blood circulation and promote postoperative recovery. To optimize patient outcomes, establishing a multidisciplinary team (MDT)-comprising endocrinologists, surgeons, vascular specialists, and wound care experts-is essential[19].

Effective multidisciplinary collaboration is central to delivering high-quality, comprehensive care. Teams that include endocrinologists, surgeons, wound care specialists, and diabetes educators can develop and implement personalized care plans, ensuring thorough monitoring and timely interventions. This integrated approach has been demonstrated to significantly reduce complication rates, improve clinical outcomes, and lower healthcare costs, thereby benefiting both patients and healthcare systems[20] (Table 1).

CURRENT STATUS AND FUTURE PROSPECTS OF RESEARCH ON DIABETIC FOOT

Limitations of existing studies

Despite notable advancements in the management of DFU complications, the current body of research remains constrained by significant limitations. Many studies rely on retrospective or observational designs, which inherently restrict the ability to establish causal relationships. This methodological bias has led to a paucity of high-quality evidence underpinning clinical interventions. For instance, treatment protocols for diabetic foot infection lack standardization, and variations in the efficacy of different antimicrobial agents remain insufficiently explored[21]. Furthermore, research often fails to address the specific needs of high-risk populations, such as individuals with elevated HbA1c levels or those with immunosuppression. Systematic reviews underscore the pressing need for robust randomized controlled trials (RCTs) to validate the effectiveness of various interventions and provide a stronger foundation for clinical practice[20,22].

Emerging research in diabetic foot management

The role of MDT in diabetic foot management has gained considerable attention in recent years[23]. Emerging evidence suggests that MDT significantly reduces clinical complications and mortality rates among hospitalized patients. Additionally, personalized interventions addressing specific risk factors such as preoperative hyperglycemia and immunosuppressive states are becoming focal points of research[24]. These tailored strategies not only enhance postoperative healing rates but also substantially mitigate infection risks, underscoring the critical clinical value of integrated management models.

Future research directions

Future investigations must prioritize high-quality, prospective studies to bridge existing evidence gaps. Two pivotal areas of focus include optimizing preoperative HbA1c levels to minimize postoperative complications and developing novel therapeutic approaches, such as immunomodulatory hydrogels, to improve wound healing outcomes[24,25]. Moreover, the management of specific risk factors such as immunosuppression monitoring and individualized postoperative care presents an opportunity for further exploration[14,20]. These strategies require validation through large-scale RCTs to establish their efficacy and long-term safety profiles.

The integration of multidisciplinary approaches in diabetic foot management also merits deeper investigation. Future studies should assess the impact of HbA1c thresholds on clinical healing outcomes through RCTs and further elucidate the benefits of MDT in delivering personalized care[20,22]. Such research has the potential to refine perioperative care strategies for diabetic patients and drive transformative changes in current treatment guidelines.

CONCLUSION

Addressing risk factors in diabetic patients undergoing transtibial amputation is essential to improving surgical outcomes and minimizing postoperative complications[26,27]. Glycemic control, as measured by HbA1c, is a critical predictor of wound healing success, highlighting the importance of preoperative optimization[28]. Studies indicate that lower preoperative HbA1c levels are associated with reduced infection rates and enhanced recovery, reinforcing the need for tight glycemic management before surgery[29-31].

In patients with a history of kidney transplantation, the impact of immunosuppressive therapies on wound healing further underscores the need for personalized care[17,32]. Tailored postoperative strategies that balance immunosuppression with optimal wound care can significantly enhance healing outcomes.

Proactive measures, such as a multidisciplinary care approach, involving endocrinologists, surgeons, and wound care specialists, are crucial for comprehensive patient management[31]. Evidence-based strategies, including the use of advanced glycemic monitoring and individualized care protocols, can lead to better patient outcomes and reduce the burden of complications associated with diabetic foot care[33,34].

ACKNOWLEDGEMENTS

Our heartfelt thanks go to Head Nurse Cheng-Jin Li from the Departments of Orthopedics II and III at the Fifth Affiliated Hospital of Zhengzhou University for her dedicated supervision and support in ensuring the excellence of this work.