European Journal of Cardiovascular Medicine

Diabetic foot ulcer (DFU) is a frequent and debilitating complication of diabetes, often requiring surgical debridement and structured wound care. A recent study by Moghaddam Ahmadi et al. demonstrated that timely surgical intervention combined with standardized wound management significantly improves healing rates and reduces the risk of major amputations [1]. Similarly, Bobirca et al. emphasized that surgical management of neuropathic DFUs can achieve favorable outcomes when integrated with a multidisciplinary approach [2].

In low- and middle-income countries, however, Swaminathan et al. highlighted persistent challenges, including delayed presentation, inadequate infrastructure, and limited access to specialized wound care, all of which contribute to poor healing and higher amputation rates [3]. Earlier landmark work by Armstrong and Lipsky described a stepwise medical and surgical management pathway for diabetic foot infections, stressing the importance of systematic evaluation, debridement, infection control, and revascularization in achieving limb salvage [4]. Despite these advances, Akkus and Sert noted that DFUs remain a devastating complication of diabetes, continuing to cause substantial morbidity, amputations, and healthcare burden worldwide [5].

Given the variable outcomes influenced by ulcer severity, microbial spectrum, comorbidities, and healthcare accessibility, further data from Indian settings are required. The present study was therefore undertaken to evaluate the baseline characteristics, ulcer features, microbiological profile, surgical interventions, and outcomes in patients with DFUs managed surgically at a tertiary care hospital. Identifying predictors of adverse events such as major amputation and prolonged hospitalization may guide timely interventions and resource allocation.

Study Design and Setting

This was a prospective observational study conducted in the Department of Surgery, Father Colombo Institute of Medical Sciences, Warangal, in collaboration with Medicare General Hospital, Warangal. The study was carried out over a period of three months, from November 2024 to January 2025.

Study Population

A total of 100 consecutive patients with a diagnosis of diabetic foot ulcer (DFU) requiring surgical intervention were included. All participants were adults (≥18 years) with type 2 diabetes mellitus.

Inclusion Criteria

• Patients with clinically diagnosed DFU (Wagner grade 1–5).
• Individuals undergoing surgical management, including debridement, minor amputation, or major amputation.

Patients who provided informed consent.

Exclusion Criteria

• Patients with foot ulcers of non-diabetic etiology.
• Patients unfit for surgery due to severe systemic illness or hemodynamic instability.
• Individuals who declined participation.

Data Collection

Detailed demographic and clinical data were collected, including age, sex, duration of diabetes, comorbidities (hypertension, peripheral arterial disease, chronic kidney disease, neuropathy), smoking history, and glycemic control (HbA1c). Ulcer characteristics such as site, size, depth, and Wagner grade were documented.

Microbiological evaluation was performed using swab or tissue samples obtained from the ulcer base after debridement, and culture sensitivity was determined. Radiological imaging and laboratory tests were conducted where indicated to assess osteomyelitis and systemic involvement.

Surgical Interventions

All patients underwent surgical management as per clinical indication, ranging from sharp debridement to minor (toe or ray) or major amputations. Revascularization procedures, negative pressure wound therapy, and skin grafting were employed selectively. Antibiotic therapy was guided by culture sensitivity and institutional protocol.

Outcome Measures

The primary outcomes were limb salvage rate, type of surgical intervention, and in-hospital complications. Secondary outcomes included length of hospital stay, 30-day readmission, mortality, and wound status at 12-week follow-up. Predictors of major amputation and prolonged hospitalization were analyzed.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were presented as mean ± standard deviation (SD) or median with interquartile range (IQR), while categorical variables were expressed as frequencies and percentages. Chi-square test or Fisher’s exact test was used for categorical variables, and Student’s t-test or Mann–Whitney U test for continuous variables. Logistic regression analysis was performed to identify independent predictors of major amputation and prolonged hospital stay. A p-value < 0.05 was considered statistically significant.

Ethical Considerations

The study was approved by the Institutional Ethics Committee of Father Colombo Institute of Medical Sciences, Warangal. Written informed consent was obtained from all participants before enrollment. Patient confidentiality was strictly maintained throughout the study.

A total of 100 patients with diabetic foot ulcers (DFU) who underwent surgical intervention were evaluated. The mean age of the study population was 59.8 ± 9.6 years, with a male predominance (68%). Median diabetes duration was 10 years (IQR 6–14), and the median HbA1c was 8.6% (IQR 7.7–9.8). Hypertension (54%), peripheral arterial disease (32%), chronic kidney disease (18%), and neuropathy (71%) were common comorbidities. Current tobacco use was reported in 28% of participants (Table 1).

Table 1. Baseline characteristics (n = 100)

Ulcer characteristics and microbiology

Forefoot ulcers were most frequent (62%), followed by midfoot (22%) and hindfoot (16%). According to Wagner classification, the majority were grade 3 (38%) and grade 4 (26%), with only 6% being grade 1 and 6% grade 5. Clinical infection was observed in 82% of patients, while osteomyelitis was confirmed in 35% (Table 2). Among 82 positive cultures, Staphylococcus aureus was the predominant isolate (34%), including MRSA in 18% overall, followed by Pseudomonas aeruginosa (21%), Escherichia coli (16%), and Klebsiella species (12%). Polymicrobial infections were detected in 28% of cases, with extended-spectrum β-lactamase (ESBL) producing gram-negative isolates found in 19%.

Table 2. Ulcer features and microbiology

Surgical interventions

Sharp debridement was the most frequently performed intervention (72%), followed by minor amputations (28%; 20 toe and 8 ray). Major amputations were required in 9% (8 below-knee, 1 above-knee). Revascularization procedures were performed in 14% (10 endovascular, 4 bypass). Negative pressure wound therapy was applied in 18%, and 12% underwent split-thickness skin grafting. The median time to index surgery was 3 days (IQR 1–6), and the median antibiotic duration was 12 days (IQR 8–16) (Table 3).

Table 3. Surgical interventions and perioperative course

Figure 1. Surgical Interventions in DFU Cohort

Outcomes

Overall limb salvage was achieved in 91% of patients. Median length of hospital stay was 9 days (IQR 6–14). Postoperative complications included surgical site infections (15%), re-operations (10%), sepsis (7%), and acute kidney injury (6%). In-hospital mortality occurred in 3%. Thirty-day readmission was 12%, mainly due to wound-related complications. At 12-week follow-up, 56% of ulcers had completely healed, 24% showed granulating tissue, 11% required further procedures, and 9% were lost to follow-up (Table 4).

Predictors of adverse outcomes

On multivariable analysis, risk factors significantly associated with major amputation included peripheral arterial disease (aOR 4.2, 95% CI 1.4–12.5; p = 0.01), Wagner grade ≥ 4 (aOR 5.6, 95% CI 1.7–18.5; p = 0.004), and chronic kidney disease (aOR 3.1, 95% CI 1.1–8.7; p = 0.03). Poor glycemic control (HbA1c ≥ 9%) showed a nonsignificant trend toward increased risk (aOR 2.7, 95% CI 0.9–7.7; p = 0.08). Prolonged hospital stay (≥ 10 days) was independently associated with osteomyelitis (aOR 2.9, 95% CI 1.2–6.8; p = 0.02) and polymicrobial infection (aOR 2.5, 95% CI 1.0–6.2; p = 0.048).

Table 4. Outcomes and predictors

In this prospective observational study of 100 patients with diabetic foot ulcers (DFUs) undergoing surgical intervention, the mean age was approximately 60 years with a male predominance (68%). Similar demographic patterns have been described in recent studies, where older age and male sex were strongly associated with DFU presentation and the need for operative management [6]. The median diabetes duration of 10 years in our cohort further supports the established link between long-standing diabetes and the development of advanced foot complications [7].

Ulcer spectrum and infection profile

Forefoot ulcers were the most common presentation (62%), and the majority of patients had advanced Wagner grades (3–4, 64%). These findings are in line with tertiary care data showing that delayed presentation and severe ulcer grades remain prevalent in clinical practice [7]. Infection was present in 82% of our patients, with Staphylococcus aureus and Pseudomonas aeruginosa as the leading isolates. Comparable microbiological profiles have been reported in specialized limb preservation services, where gram-positive cocci dominate early infections, while gram-negative bacilli are more frequent in chronic cases [8]. The high proportion of multidrug-resistant organisms, including MRSA and ESBL-producing strains, highlights the growing challenge of antimicrobial resistance in DFU management [8].

Surgical interventions and outcomes

Debridement constituted the primary intervention in our series (72%), followed by minor amputations (28%) and major amputations (9%). The relatively lower major amputation rate compared with earlier reports can be attributed to early surgical debridement, selective use of revascularization, and multidisciplinary wound care. Similar trends have been observed in large reviews that emphasize the importance of aggressive conservative surgery before resorting to limb loss procedures [9]. Our limb salvage rate of 91% aligns with recent outcome studies demonstrating improved healing and functional preservation despite varying baseline patient characteristics [10].

The overall complication profile in our cohort—surgical site infection (15%), sepsis (7%), and in-hospital mortality (3%)—was comparable to published data from dedicated DFU surgical series [8,9]. At 12 weeks, more than half of the ulcers had completely healed, reflecting the benefits of a structured, combined medical and surgical approach.

Predictors of adverse outcomes

Peripheral arterial disease, higher Wagner grade, and chronic kidney disease emerged as independent predictors of major amputation in our study. These determinants are consistent with evidence from surgical and vascular literature, which underscores the prognostic value of vascular compromise and renal dysfunction in driving poor outcomes [11,12]. Osteomyelitis and polymicrobial infections were significantly associated with prolonged hospitalization, echoing earlier findings that deep-seated and complex infections increase treatment duration and healthcare resource utilization [8].

Although poor glycemic control (HbA1c ≥ 9%) did not reach statistical significance in our analysis, other studies have demonstrated its contribution to delayed healing and recurrence of ulcers [6,7]. This highlights the importance of metabolic optimization alongside surgical and antimicrobial management in comprehensive DFU care.

Implications and recommendations

Our findings highlight the need for early screening for peripheral arterial disease and renal dysfunction in patients with DFUs, as well as the importance of microbiological guidance in antibiotic therapy. Strengthening diabetic foot care services, promoting patient education, and integrating vascular surgery, infectious disease, and endocrinology expertise into multidisciplinary teams are essential to improve outcomes in Indian settings.

Strengths and limitations

The strengths of this study include prospective data collection, standardized surgical protocols, and short-term outcome assessment. However, limitations include its single-center design, relatively short follow-up period (12 weeks), and lack of long-term limb salvage or quality-of-life data. Larger multicentric studies with extended follow-up are needed to validate these findings.

This prospective observational study highlights that diabetic foot ulcers predominantly affect older males with long-standing diabetes and multiple comorbidities. Forefoot involvement and advanced Wagner grades were common, with infection present in the majority, often involving multidrug-resistant organisms. Surgical debridement remained the primary intervention, achieving a limb salvage rate of 91%, while only a minority required major amputation. Peripheral arterial disease, chronic kidney disease, and higher Wagner grade were significant predictors of adverse outcomes, whereas osteomyelitis and polymicrobial infection prolonged hospitalization. These findings underscore the importance of early diagnosis, comprehensive surgical management, and multidisciplinary care to improve outcomes and reduce amputation burden.

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