Diabetics with unilateral lower extremity amputation (LEA) have an increased risk of contralateral re-amputation. Foot care knowledge and practice has been shown to reduce the incidence of amputation. The study aims to assess the level of foot care knowledge among diabetics with unilateral LEA. Method: A questionnaire based study involving diabetics with unilateral LEA from August 2015 to August 2017. Demographic data and level of foot care knowledge were assessed. Associations between age, gender, educational level, prior amputation and duration of diabetes with level of foot care knowledge were investigated. The presence of peripheral neuropathy in the contralateral leg was also assessed. Results: A total of 64 patients had unilateral LEA within this period, but only 42 patients completed the study. Twenty-four, 24 (57.1%) were males while 18 (42.9%) were females. Mean age was 58.3 years (SD = 12.0). Fifteen, 15 (35.7%) had secondary, 15 (35.7%) had tertiary education, while 3 (7.1%) and 9 (21.4%) had none and primary education respectively. Below knee amputation (BKA) was the commonest (78.6%), and 35.7% have had a prior amputation. Peripheral neuropathy was present in 71.4% of cases. No participant had a good level of foot care knowledge, while 13 (31%) have a fair knowledge and 29 (69%) have poor knowledge. Only 18 (42%) said they have been taught on foot care. Only duration of diabetes and educational level were significantly associated with level of foot care knowledge. Conclusion: Diabetics with unilateral LEA have poor knowledge of foot care and a high prevalence of peripheral neuropathy. Efforts at education of these susceptible cohorts should be intensified.
Limb loss is a feared complication of diabetes mellitus. About 50% of diabetics with unilateral LEA will lose the contralateral limb in 4 years [
The benefits of foot care knowledge and practice in reducing the incidence of amputations in diabetics have been shown [
It is generally assumed, and rightly so, that diabetics, who had amputations in hospitals, should receive some form of foot care education before discharge, in order to prevent a re-amputation. In the absence of a dedicated foot clinic and podiatrists in our clime, this responsibility falls on the managing health team (Doctors and Nurses).
Therefore, this study aims to assess how well diabetics with unilateral LEA are being educated on foot care. We also investigated the relationship between age, gender, educational level, prior amputation and duration of diabetes with level of foot care knowledge. Finally, the presence of peripheral neuropathy in the contralateral limb was also assessed.
This was a cross-sectional study done on diabetic patients with unilateral LEA at National Orthopaedic Hospital, Enugu (NOHE), from August 2015 to August 2017. NOHE is a regional orthopaedic and trauma center which serves the South-East and South-South geo-political zones of the country. A total of 64 patients had unilateral LEA within this period. A pilot study done by the researchers showed a point prevalence of LEA of 4% among diabetics admitted in our hospital. This gives a minimum sample size of 59 patients at 5% α-level and 80% power. A convenient sampling to include all patients was used. Inclusion criteria were all diabetic patients with unilateral LEA who gave consent. Exclusion criteria were non-diabetic related amputation, bilateral amputations, patients who rejected consent. Ethical approval was obtained from the hospital ethical committee and the patients.
A 15 item questionnaire on foot care adapted from previously validated questionnaire [
The questions were worded such that “0” meant no knowledge while “1” meant appropriate knowledge. The total score for each participant was thus obtained. A total score of 13 to 15 was taken as good knowledge of foot care, 10 to 12 as fair knowledge, while a score of less than 10 was taken as poor foot care knowledge. The ages of the participant were categorized, into young (less than 45), middle age (45 to 65) and old age (greater than 65 years).
Chi-square test of independence was used to assess the relationship between gender and prior amputation with foot care knowledge, while correlation was done for age, duration of diabetes and level of education. A p value of less than 0.05 was considered significant.
Only 42 patients completed the study. Six (6) patients were unreachable by phone, while 10 patients defaulted from the scheduled clinic appointments. Four (4) patients were reported dead, while 2 patients refused consent. Twenty-four, 24 (57.1%) were males while 18 (42.9%) were females.
6 (14.3%) ray amputation, 33 (78.6%) below knee amputations, and 3 (7.1%) above knee amputations. The commonest limb involved is the right limb, 36 (85.7%).
Fifteen, 15 patients (35.7%) have had a prior amputation of the affected limb. Peripheral neuropathy was present in the contralateral limb in 30 (71.4%) of the participants. Twelve patients, 12 (28.6%) were elderly (greater than 65 years), 22 (52.4%) were middle aged while 8(19.0%) were young.
Thirty-three, 33 patients (78.6%) know that diabetics are at high risk of foot ulcer and amputation. Twenty-one, 21 patients (50%) know that they should inspect their feet daily. Thirty, 30 (71.4%) know they should see a doctor if they develop wound on their feet. Eighteen, 18 (42.9%) know they should trim their nails straight across with a clipper. Twenty-seven, 27 (64.3%) know they should keep their feet supple with moisturizers, but only 9 (21.4%) know they should keep in-between their toes dry.
Twenty-four, 24 (57.1%) know they should never walk barefoot even inside their homes. Twenty-four, 24 (57.1%) know they shouldn’t feel tight in their in their shoes. Eighteen, 18 (42.9%) know they shouldn’t wear pointed shoes or high heels. Twenty-one (50%) know they should always inspect inside their shoes before wearing them. Twenty-four, 24 (57.1%) know they should never wear shoes without socks, while 9 (21.4%) know they should never use hot water bottle on their feet.
Eighteen, 18 (42.9%) know they should never use their feet to check the temperature of an object. Twenty-four, 24 (57.1%) know they should have their feet
Characteristics | Proportion (n) |
---|---|
Age (yrs) <45 45 - 65 >65 | 8 22 12 |
Gender M F | 24 18 |
Type of amputation Above knee Below knee Ray | 3 33 6 |
Educational level None Primary Secondary Tertiary | 3 7 15 15 |
Prior amputation Yes No | 15 27 |
examined by a professional at least once a year. Eighteen, 18 (42.9%) said they have received at least some form of foot care education. Overall, 29 (69%) have poor foot care knowledge, 13 (31%) have fair knowledge while none (0%) have good knowledge score. This is shown in
There were no significant effects of age (r = 0.11, p = 0.50), gender (p = 0.34), and prior amputation (0.49) with level of foot care knowledge. However, duration of diabetes showed a strong correlation with foot care knowledge (rho = 0.56, p < 0.001). Educational level showed moderate correlation with level of foot care knowledge (rho = 0.45, p = 0.03), see
Variable | p-value |
---|---|
Age | 0.50 |
Gender | 0.34 |
Educational level | 0.03* |
Prior amputation | 0.49 |
Duration of diabetes | 0.00* |
*= significant value.
Questions | Yes (%) | No (%) |
---|---|---|
Diabetics are at high risk of foot ulcers and amputations? | 78.6 | 21.4 |
Diabetics should inspect their feet daily? | 50 | 50 |
Diabetics should see a doctor if they develop wound on their feet? | 71.4 | 28.6 |
Diabetics should trim their nails straight across with a clipper? | 42.9 | 57.1 |
Diabetics should keep their feet supple with a moisturizer? | 64.3 | 35.7 |
Diabetics should keep in-between toes dry? | 21.4 | 78.6 |
Diabetics should never walk barefoot even inside their homes? | 57.1 | 42.9 |
Diabetics should never feel tight in their shoes? | 57.1 | 42.9 |
Diabetics shouldn’t wear pointed shoes or high heels? | 42.9 | 57.1 |
Diabetics should always inspect their shoes before wearing them? | 50 | 50 |
Diabetics should never wear shoes without socks? | 57.1 | 42.9 |
Diabetics should never use hot water bottle on their feet? | 21.4 | 78.6 |
Diabetics should never use their feet to check the temperature of an object? | 42.9 | 57.1 |
Diabetics should have their feet examined by a doctor at least once a year? | 57.1 | 42.9 |
Have you received any foot care education previously? | 42.9 | 57.1 |
This study shows the abysmally poor foot care knowledge among diabetic amputees. This is worrisome for two reasons. First, the incidence of diabetes is rising and hence the incidence of complications including LEA is also expected to rise concomitantly [
While most of the patients know that diabetics are at high risk of foot ulcers and amputations (78.6%), only 50% know they should inspect their feet daily. Fifty-seven percent know they should see a doctor to examine their feet at least once per year. The poorest answers were that of keeping in-between the toes dry and never to use hot water bottle on their feet. This poor knowledge despite being aware of the risk of amputation in diabetics is likely a reflection of lack of proper education regarding foot care practices.
The commonest cause of foot trauma in diabetics is inappropriate foot wear [
Only duration of diabetes and educational level showed a significant association with foot care knowledge. It appears that the long standing diabetic might have had some time to receive some information about foot care. Most studies showed that educational level is associated with a higher level of foot care knowledge [
Peripheral neuropathy is responsible for about 60% of diabetic foot ulcerations [
It is clear that health care providers should put more effort in educating diabetic amputees on the risk factors for foot ulcerations, particularly on regular foot exam and appropriate foot wear. Giving them instructional leaflets before they are discharged from the hospitals will further cement such information in their memory. Such leaflets should be in plain and simple, easy to understand language.
Establishment of diabetic foot clinics, where periodic assessment of these patients will be undertaken cannot be over-emphasized. Such clinics have been shown to reduce the incidence of amputations [
Multicenter study to increase the number of participants would be more desirable.
The study only looked at knowledge and did not study practice. Knowledge does not automatically translate to practice and such assumption must not be made based on this study.
Ede, O., Eyichukwu, G.O., Iyidobi, E.C. and Nwachukwu, B.C. (2018) Assessment of Foot Care Knowledge among Diabetic Amputees at National Orthopaedic Hospital Enugu. Journal of Biosciences and Medicines, 6, 25-32. https://doi.org/10.4236/jbm.2018.64002