Annual Report of National Orthopaedic Malaysia (NORM) – Diabetic Foot 2009
NATIONAL ORTHOPAEDIC REGISTRY
MALAYSIA (NORM)
ANNUAL REPORT OF
NATIONAL ORTHOPAEDIC REGISTRY MALAYSIA (NORM) DIABETIC
FOOT
2009
Editors:
Dr Mohammad Anwar Hau Abdullah
Dr Ahmad Tajuddin Abdullah
Registry Committee
Dr Mohammad Anwar Hau Abdullah
Dr Se To Boon Chong
Dr Ahmad Tajuddin Abdullah
Dr Tan Boon Cheong
Dr Zulkiflee Osman
Dr Abdul Rauf Ahmad
Dr Saadon Ibrahim
Dr Mohd Zamzuri Mohd Zain
Dr Mohamad Yazid Din
Dr Pan Chee Huan
Dr Joehaimey Johari
A publication of the National Orthopaedic Registry of Malaysia (NORM) and the
Clinical Research Centre, Ministry of Health Malaysia
*********************************************************************
December 2010
© National Orthopaedic Registry of Malaysia (NORM)
Publisher:
Jointly published by the National Orthopedic Registry of Malaysia (NORM) and the
Clinical Research Centre (CRC), Ministry of Health Malaysia.
National Orthopaedic Registry of Malaysia
1st Floor MMA House,
124, Jalan Pahang,
53000 Kuala Lumpur,
Malaysia.
Tel
Fax
Email
Website
: (603) 4044 3060 / (603) 4044 3070
: (603) 4044 3080
: norm@acrm.org.my
: http://www.acrm.org.my/norm
Suggested citation: Mohammad Anwar Hau Abdullah, Ahmad Tajuddin Abdullah
(Eds). Annual Report of the NORM- Registry, 2009. Kuala Lumpur, Malaysia:
National Orthopaedic Registry of Malaysia 2009.
Disclaimer:
Data reported in this report were collected for one year period (from January to
December 2009), this report is copyrighted. Reproduction and dissemination of this
report in part or in whole for research, educational or other non-commercial purposes
are authorized without any prior written permission from the copyright holders
provided the source is fully acknowledged.
Electronic version
The
electronic
version
of
this
report
may
be
downloaded
http://www.acrm.org.my/norm or http://www.crc.gov.my/publication/report.
Funding
The National Orthopaedic Registry of Malaysia (NORM) – Diabetic Foot Registry is
funded with grants from the Ministry of Health Malaysia (MOH).
at
ACKNOWLEDGEMENTS
The National Orthopaedic Registry of Malaysia (NORM) would like to give its grateful
appreciation to everyone who has helped make this report possible.
We would especially like to thank the following:
Clinical Research Centre
Clinical Epidemiology Unit
Dr Goh Pik Pin
Dr Jamaiyah Haniff
Dr Dr Sharmini Selvarajah
Dr Lim Chioa mei
Patient Registry Unit
Dr Jaya Purany Stanley Ponniah
Nurul Shuhada Binti Mohd Ali
Scottish Hip Fracture Registry
NORM Governance Board
Chairman
Dato’ Dr Azmi Shafei
Director,
Division of Medical Development,
Ministry of Health Malaysia.
Members
Dr Jamaiyah Haniff
Head Of Clinical Epidemiology Unit,
Clinical Research Center, Hospital Kuala Lumpur.
Dr Jaya Purany Stanley Ponniah
Head of Patient Registry Unit
Clinical Research Center, Hospital Kuala Lumpur.
Dr Mohammad Anwar Hau Abdullah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Raja Perempuan Zainab II, Kota Bharu.
Dr Ahmad Tajuddin Abdullah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Sultanah Nur Zahirah, Kuala Terengganu.
Dr Saadon Ibrahim
Department of Orthopaedic and Traumatology,
Hospital Sultan Ismail, Johor Bharu.
Dr Se To Boon Chong
Department of Orthopaedic and Traumatology,
Hospital Pulau Pinang,Pulau Pinang.
Dato’ Dr Suresh Chopra,
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Sultanah Bahiyah, Alor Setar.
Dr Abdul Rauf Ahmad
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Tuanku Jaafar, Seremban.
Dato’ Dr Premchandran Menon
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Tengku Ampuan Afzan (HTAA), Kuantan.
Dr Pan Chee Huan
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Tuanku Fauziah, Kangar.
Dr Thirumal a/l Manickam
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Tengku Ampuan Rahimah, Klang.
Dr Nahulan A/L Theva Rajah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Queen Elizabeth, Kota Kinabalu.
Dato’ Dr Ramanathan A/L Ramiah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Raja Permaisuri Bainun, Ipoh.
Mr.Sivapathasundaram A/L Nadarajah
Head of Department,
Department of Orthopaedic and Traumatology
Hospital Melaka, Melaka.
Dr K. Thevarajan
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Sultanah Aminah, Johor Bharu.
Dr Faris Kamaruddin
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Umum Sarawak, Sarawak.
NORM Steering Committee members:
Chairman
Dr Ahmad Tajuddin Abdullah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Sultanah Nur Zahirah, Kuala Terengganu.
Co-Chairman
Dr Zulkiflee Osman
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Kuala Lumpur.
Members
Dr Mohammad Anwar Hau Abdullah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Raja Perempuan Zainab II, Kota Bharu.
Dr Saadon Ibrahim
Department of Orthopaedic and Traumatology,
Hospital Sultan Ismail, Johor Bharu.
Dr Se To Boon Chong
Department of Orthopaedic and Traumatology,
Hospital Pulau Pinang, Pulau Pinang.
Dr Tan Boon Cheong
Department of Orthopaedic and Traumatology,
Hospital Pulau Pinang, Pulau Pinang.
Dr Abdul Rauf Ahmad
Department of Orthopaedic and Traumatology,
Hospital Tuanku Jaafar, Seremban.
Dr Mohd Zamzuri Mohd Zain
Department of Orthopaedic and Traumatology,
Hospital Tengku Ampuan Afzan (HTAA), Kuantan.
Dr Pan Chee Huan
Department of Orthopaedic and Traumatology,
Hospital Tuanku Fauziah, Kangar.
Dr Mohamad Yazid Din
Department of Orthopaedic and Traumatology,
Hospital Sultanah Bahiyah, Alor Setar.
Dr Joehaimey Johari
Department of Orthopaedic and Traumatology,
Hospital Raja Perempuan Zainab II, Kota Bharu.
NORM SOURCE DATA PROVIDERS 2008/2009
The current source data providers for NORM are:
No.
1
2
3
Hospital
Site investigators
Second person-in-charge
Hospital Kuala
Lumpur
Mr Zulkiflee Osman
Dr Mahazura Hj Mat Lawi
Hospital Raja
Perempuan
Zainab II Kota
Bharu
Mr Mohammad Anwar Hau
Abdullah
Dr Joehaimey Johari
Hospital Sultanah
Nur Zahirah Kuala
Terengganu
Mr Ahmad Tajuddin Abdullah
Dr Mustaqim Afifi @ Apipi
Dr. Abdul Qahhar
Sister Nik Noriah Nik Ibrahim
Dr Hazulin Mohd Radzuan
Dr Muhammad Hilmi Nasir
Dr Mohd Ariff Razani Abd
Razak
4
Hospital Tengku
Ampuan Rahimah
Klang
Dr Gurjit Singh
Dr M. Thirumal
5
Hospital Sultanah
Bahiyah Alor Setar
Dr Mohamad Yazid Din
Dr Noor Mahazrinna
Hayadin
Dr Lim Chiao Yee
6
Hospital Sultanah
Aminah Johor
Bahru
Dr Yoga Raj A/L
Parameswaran
Dr Manamohan
Chandrarajan
Dr Mohd Adham Shah
Dr Teo Pock Chin
7
Hospital Melaka
Dr Rengsen Parthiban
Dr Azhar Asari
Dr Mohd. Karim Md Isa
MA Mohd Fharid Johan
SN Marina Mohamed @
Osman
8
Hospital Sultan
Ismail Johor Bahru
Dr Saadon Ibrahim
Dr Mursyida Md Nujid
Dr Jayamalar
Thurairajasingam
SN Rohayah Abdul Rahman
JM Yussilawani Mamat
9
Hospital Tuanku
Fauziah Kangar
Dr Pan Chee Huan
Mr Zakaria Yusoff
Mr Yeap Ewe Juan
Dr Badrul Hashim
Dr Zakaria Yusoff
MA Shahizam Shafiee
SN Norseha Baharom
10
11
12
Hospital Raja
Permaisuri Bainun
Ipoh
Dr Manoharan
Dr Selvynlloyd
Hospital Tengku
Ampuan Afzan
Kuantan
Dato' Dr N Premchandran
Dr Alaudin Haris Osman
Dr. Mohd Zamzuri Mohd
Zain
Dr Jeffrey Jaya Raj
Hospital Ampang
Dr Ng Yue Oon
Dr Lynn Azura Md Sham
Dr Iyngkaran Arasalingam
Dr Ahmad Hafiz bin Zulkifly
Dr Samyu Ali
13
Hospital Tuanku
Ja’afar Seremban
Dr Abdul Rauf Ahmad
Dr Ng Tiong Soon
Dr Johann Johari
Sr Khamisah A. Ghani
Sr Rohana Zakaria
14
Hospital Pulau
Pinang
Dr Se To Boon Chong
Dr Tan Boon Cheong
Dr Ooi Chee Lean
Dr Chan Kok Yu
15
Hospital Serdang
Dr Khoo Shaw Woei
Dr Imma Isniza
Dr Harminder Singh
Randhawa
16
Hospital Selayang
Dr Ng Swee Soon
Dr Ritzwan Ismayatim
Dr Amir Fariz Zakaria
17
Hospital Queen
Elizabeth Kota
Kinabalu
Dr Nahulan A/L Theva Rajah
Dr CS Kumar
18
Hospital Umum
Sarawak
Dr Faris Kamaruddin
Dr Aaron Gerard Paul
MA Mikim A/K Radem
PREFACE
The National Orthopaedic Registry Malaysia has been collecting data since mid 2008
and it is with great pleasure and pride that we see this report materialised.
I would like to thank all those who have collected, verified and analysed the data.
The co-operation and energy demonstrated in units throughout the country indicates
the importance they place on improving patient management
The success of this report is due to continuous support and cooperation from various
people and agencies. The effort of the entire group must be congratulated and it has
been my sincere hope that this registry is able to sustain in coming years.
I also take this opportunity to thank the Clinical Research Centre Ministry of Health
Malaysia, to have trust in us and to provide us with the funding for us embark in this
project. This annual report is a testament of all your combined effort.
Thank you,
Dr Ahmad Tajuddin bin Abdullah
Dr Mohammad Anwar Hau Abdullah
Chairman National Orthopaedic Registry of Malaysia
Ministry of Health Malaysia
9
ABBREVIATIONS
ASA
American Society of Anaesthesiologists
CRC
Clinical Research Centre
CRF
Case Report Form
csv
Comma separated value
Dr
Doctor
GA
General Anaesthesia
HTAA
Hospital Tengku Ampuan Afzan
ICT
Information and Communication Technology
LMWH
Low Molecular Weight Heparin
MJM
Medical Journal of Malaysia
MOH
Ministry of Health
NOHFR
National Orthopaedic Hip Fracture Registry
NORM
National Orthopaedic Registry of Malaysia
OT
Operation Theater
PTH
Parathyroid Hormone
RTA
Road Traffic Accident
SDP
Source Data Provider
SERMS
Selective Estrogen Receptor Modulators
SMS
Short Messaging System
txt
Text-delimited format
xls
Excel workbook
10
Table of Content
Table
Page
SECTION 1: PATIENT DETAILS AND DEMOGRAPHIC ..................................................................... 13
Table 1.1: Profile demographic of respondents, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009. (N=1254) ................................................................... 13
Table 1.2: Occupation of respondents, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009. (N=1254) ...................................................................................... 14
SECTION 2: ADMISSION .............................................................................................................. 15
Table 2.1: Status of admision, Diabetes Foots and Hands, National Orthopadic Registry
Malaysia (NORM) 2009. .................................................................................................................... 15
SECTION 3: DIABETES HISTORY ................................................................................................... 16
Table 3.1: Status of diabetes mellitus, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009. ...................................................................................................... 16
SECTION 4: TREATMENT OF DIABETES MELLITUS......................................................................... 17
Table 4.1: Treatment of diabetes mellitus, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009. ...................................................................................................... 17
Table 4.2: Status of compliance for treatment, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009. ................................................................................... 18
SECTION 5: TREATMENT OF CURRENT DIABETES FOOT/ HANDS ULCER ........................................ 18
Table 5.1: Treatment of current diabetes foot/ hands ulcer, Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009 ..................................................................... 18
SECTION 6: RISK FACTORS .......................................................................................................... 19
Table 6.1: Distribution of infection, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009 ....................................................................................................... 19
Table 6.2: Risk factors for upper limb (n = 60), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009 .................................................................................... 19
Table 6.3: Risk factors of lower limb (n = 1198), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009 .................................................................................... 20
Table 6.4: Risk factors (awareness), Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009 ....................................................................................................... 20
Table 6.5: Practice for past one year, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009 ....................................................................................................... 21
Table 6.6: Risk factors (co-morbidity, complications, family history), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................................................... 22
SECTION 7: PREVIOUS HANDS/FOOT PROBLEMS (PAST ONE YEAR).............................................. 23
Table 7.1: Previous hands/foot problems (past one year), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009 ..................................................................... 23
Table 7.2: Highest level of amputation, previous hands/foot problems (past one year),
Diabetes Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................... 24
SECTION 8: CURRENT UPPER LIMBS INFECTIONS ......................................................................... 25
Table 8.1: Dominance of current upper limbs infections (n=60), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009 ..................................................................... 25
Table 8.2: Infection and location of current upper limbs infections (n=60), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009 .................................................. 25
Table 8.3: Diagnosis of current upper limbs infections (n=60), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009 ..................................................................... 26
Table 8.4: Classification of current upper limbs infections (n=60), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................................................... 26
11
Table 8.5: Associated complications of current upper limbs infections (n=60), Diabetes
Foots and Hands, National Orthopaedic Registry Malaysia (NORM) 2009 ...................................... 27
Table 8.6: Precipitating factor of current upper limbs infections (n=60), Diabetes Foots
and Hands, National Orthopaedic Registry Malaysia (NORM) 2009 ................................................ 27
Detail for precipitating factor in appendix 3 ..................................................................................... 27
Table 8.7: Physical findings of current upper limbs infections (n=60), Diabetes Foots and
Hands, National Orthopaedic Registry Malaysia (NORM) 2009 ....................................................... 28
Table 8.8: Current upper limbs infections (culture), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009 .................................................................................... 28
Table 8.9: Current upper limbs infections (operations during admision), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009 .................................................. 29
Table 8.10: Current upper limbs infections (culture, operations during admission and
clinical outcome), Diabetes Foots and Hands, National Orthopadic Registry Malaysia
(NORM) 2009 .................................................................................................................................... 30
SECTION 9: CURRENT LOWER LIMBS INFECTIONS ........................................................................ 30
Table 9.1: Current lower limbs infections (infections and location), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................................................... 30
Table 9.2: Current lower limbs infections (diagnosis and classification), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................................................... 31
Table 9.3: Current lower limbs infections (associated complications, precipitating factor
and physical findings), Diabetes Foots and Hands, National Orthopaedic Registry Malaysia
(NORM) 2009 .................................................................................................................................... 32
Table 9.4: Current lower limbs infections (culture), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009 .................................................................................... 33
Table 9.5: Current lower limbs infections (operations during admision), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009 .................................................. 34
Table 9.6: Current lower limbs infections (culture, operations during admission and
clinical outcome), Diabetes Foots and Hands, National Orthopadic Registry Malaysia
(NORM) 2009 .................................................................................................................................... 35
SECTION 10: ANTIBIOTICS........................................................................................................... 36
Table 10.1: Antibiotics, Diabetes Foots and Hands, National Orthopadic Registry Malaysia
(NORM) 2009 .................................................................................................................................... 36
12
Section 1: Patient Details and Demographic
Table 1.1: Profile demographic of respondents, Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009. (N=1254)
Profile
Age
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Age group
18 – 29
30 – 39
40 - 49
50 - 59
≥6
Gender
Male
Female
Ethnicity (na=5)
Malay
Chinese
Indian
Others Malaysian
Non Malaysian
Residence (na=113)
Urban
Rural
Education level (na=467)
Primary
Secondary
Tertiary
Statistics
n
%
21
60
255
438
480
1.7
4.8
20.3
34.9
38.3
604
650
48.2
51.8
935
141
146
17
10
74.6
11.2
11.6
1.4
0.8
610
351
53.5
46.5
388
355
44
49.3
45.1
5.6
56.2 (11.6)
20, 94
13
Table 1.2: Occupation of respondents, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009. (N=1254)
Profile
Occupation
Legislator senior
Technicians
Service
Related trade
Elementary occupation
Profesional
Clerical
Agricultural
Machine operator
Housewife
Unemployed
Retired
Unknown
Others
n
%
3
3
42
4
7
10
17
21
20
431
133
166
185
163
0.2
0.2
3.5
0.3
0.6
0.8
1.4
1.7
1.7
35.8
11.0
13.8
15.4
13.5
14
Section 2: Admission
Table 2.1: Status of admision, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009.
Status of admision
Duration in days
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Duration in days by age group
Median IQR (1stQ, 3rdQ)
18 – 29
30 – 39
40 - 49
50 - 59
≥6
Previous admission (na=142)
Yes
No
Number of times (na=908)
1 time only
2–3
4–5
>5
Statistics
n
%
425
687
38.2
61.8
192
134
11
9
55.5
38.7
3.2
2.6
13.7 (68.5)
7.0 IQR (4.0, 14.0)
0, 2228
8.5 IQR (6.0, 17.5)
5.0 IQR (3.5, 10.5)
8.0 IQR (4.0, 15.0)
6.0 IQR (4.0, 12.0)
7.0 IQR (4.0, 14.5)
15
Section 3: Diabetes History
Table 3.1: Status of diabetes mellitus, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009.
Status of diabetes
Type of diabetes
Type 1
By age group:
18 – 29
30 – 39
40 - 49
50 - 59
≥6
Statistics
Type 2
By age group:
18 – 29
30 – 39
40 - 49
50 - 59
≥6
n
%
197
16.2
10
16
35
70
66
5.1
8.1
17.8
35.5
33.5
1021
83.8
9
43
211
356
398
0.9
4.2
20.7
35.0
39.1
Duration of diabetes in years:
Type 1
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Type 2
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
11.9 (7.7)
10.0 IQR (5.0, 16.0)
1.0, 40.0
10.4 (7.5)
10.0 IQR (5.0, 15.0)
1.0, 40.0
16
Section 4: Treatment of Diabetes Mellitus
Table 4.1: Treatment of diabetes mellitus, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009.
Treatment of Diabetes Mellitus
Patient on treatment
(na = 97 and missing = 2)
Yes
No
Treatment for diet
(na = 723 and missing = 176)
Yes
No
Duration for having diet
treatment (days)*
(n = 122)
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Other treatment
(na = 111 and missing = 174)
Insulin
OHA
OHA and insulin
None of the above
Duration of having other
treatment*
Insulin (n = 98)
Mean (SD)
Median (IQR)
Min, max
OHA (n = 287)
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
OHA and insulin (n = 71)
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Descriptive
summary*
n
%
1071
84
92.7
7.27
131
224
36.9
63.1
165
692
111
1
17.0
71.5
11.5
-
75.9 (74.6)
60 IQR (12, 120)
1, 300
45.5 (62.5)
20.5 IQR (7, 60)
1, 360
75.1 (87.0)
36 IQR (12, 120)
1, 480
75.8 (84.2)
48 IQR (10, 120)
1, 362
17
Table 4.2: Status of compliance for treatment, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009.
Treatment of Diabetes Mellitus
Status of compliance
(na = 197 and missing = 181)
18 – 29
30 – 39
40 – 49
50 – 59
≥6
Yes
n (%)
8 (61.5)
27 (64.3)
136 (74.7)
229 (75.3)
241 (72.4)
No
n (%)
1.3 (38.5)
4.2 (35.7)
21.2 (25.3)
35.7 (24.7)
37.6 (27.6)
Section 5: Treatment of Current Diabetes Foot/ Hands Ulcer
Table 5.1: Treatment of current diabetes foot/ hands ulcer, Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009
Treatment of current DFH
Management of the ulcer prior
to hospitalization
Nil
Self treatment
General practitioner
Private hospital
Traditional
Government hospital
Government clinic
Alternative treatment
Duration of treatment (days)
(n = 327)
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Descriptive
summary*
n
%
312
78
114
36
34
510
233
3
7.7
11.3
3.6
3.4
50.6
23.1
0.3
568.2 (1615.0)
14 IQR (5, 60)
1, 10950
*10950 is similar to 30.4 years
18
Section 6: Risk Factors
Table 6.1: Distribution of infection, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009
Infection
Upper limb infection
(na = 86 and no = 1108))
By age group
18 – 29
30 – 39
40 - 49
50 – 59
≥6
Lower limb infection
(na= 5 and no = 51)
By age group
18 – 29
30 – 39
40 - 49
50 – 59
≥6
Single
n
row%
Both
n
row%
Total
n
col%
60
100.0
0
0.0
60
100.0
4
9
17
12
17
100.0
100.0
100.0
100.0
100.0
0
0
0
0
0
0.0
0.0
0.0
0.0
0.0
4
9
17
12
17
6.8
15.3
28.8
20.3
28.8
1151
96.1
47
3.9
1198
100.0
17
50
230
414
439
100.0
98.0
96.2
96.7
95.0
0
1
9
14
23
0.0
2.0
3.8
3.3
5.0
17
51
239
428
462
1.4
4.3
20.0
35.8
38.6
Table 6.2: Risk factors for upper limb (n = 60), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009
Risk factors
Activities at work:
Use hand predominantly
Hand wet at work
n
%
46
22
76.7
36.7
19
Table 6.3: Risk factors of lower limb (n = 1198), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009
Risk factors
Activities at work:
Involve lots of
walking/standing
Feet wet at work
Footware at work:
(na = 221 and missing = 10)
Barefoot
Slippers
Shoes
Socks only
Footware at home:
(na = 126 and missing = 10)
Barefoot
Slippers
Shoes
Socks only
n
%
568
47.4
228
19.0
99
457
408
3
10.2
47.3
42.2
0.3
526
487
36
13
49.5
45.9
3.4
1.2
Table 6.4: Risk factors (awareness), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009
Risk factors
Foot/hands problem (N = 1254)
Aware of increased foot/hand problem
Aware: Inspect feet/hand
Foot problem (n = 1198)
Aware:Wash feet
Aware: Apply emollients
Aware: Use appropriate shoes
Aware: Attend diabetes foot clinic
Aware: Education on diabetes footcare (formal)
Aware: Education on diabetes footcare (informal)
Aware: Keeping on diabetes care booklet
n
%
779
627
62.1
50.0
830
278
318
211
327
595
273
69.3
23.2
26.5
17.6
27.3
49.7
22.8
20
Table 6.5: Practice for past one year, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009
Practice for past one year:
Inspect feet/hand (N = 1254)
Frequent Inspect feet/hand
Daily
Weekly
Occationally
Total
Wash feet (n = 1198)
Frequent wash feet
Daily
Weekly
Occationally
Total
Apply emollients (n = 1198)
Frequent apply emollients
Daily
Weekly
Occationally
Total
Use appropriate shoes (n = 1198)
Frequent use appropriate shoes
Daily
Weekly
Occationally
Total
Attend diabetes foot clinic (n = 1198)
Frequent attend diabetes foot clinic
Daily
Weekly
Occationally
Total
n
563
%
44.9
206
63
284
553
733
37.3
11.4
51.4
501
36
181
718
299
69.8
5.0
25.2
132
20
139
291
286
45.4
6.9
47.8
134
17
123
274
190
48.9
6.2
44.9
58
122
0
180
28.3
59.5
0.0
64.5
19.1
23.9
15.9
21
Table 6.6: Risk factors (co-morbidity, complications, family history), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Risk factors
Co-morbidity:
Unknown
Hypertension
Hypercholesterolemia
IHD
TIA
CVA
Renal disease
Retinopathy
Others
Complications:
Nil
Unknown
Retinopathy
Vascular
Neuropathy
Skin
Nephropathy
Others
Family history:
Unknown
Hypertension
DM
Hypercholesterolemia
IHD
TIA
CVA
Renal disease
Retinopathy
Others
n
%
468
685
133
102
1
39
51
54
55
61.2
11.9
9.1
0.1
3.5
4.6
4.8
4.9
216
253
205
194
420
261
101
12
17.2
16.3
35.2
21.9
8.5
1.0
636
291
538
38
65
1
18
3
7
12
29.9
55.3
3.9
6.7
0.1
1.8
0.3
0.7
1.2
Co-morbidity details refer to appendix 1
Complications details refer to appendix 2
Family history details refer to appendix 2
22
Section 7: Previous Hands/foot problems (past one year)
Table 7.1: Previous hands/foot problems (past one year), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009
Previous problems
Previous operations performed
(N = 1254)
1 time
2 – 4 times
5 – 7 times
8 – 10 times
Total
n
%
373
29.7
235
116
8
2
361
65.1
32.1
2.2
0.6
23
Table 7.2: Highest level of amputation, previous hands/foot problems (past one
year), Diabetes Foots and Hands, National Orthopadic Registry Malaysia (NORM)
2009
Highest level of amputation
None
Upper limbs (single)
Finger’s
Ray
Below wrist
Below elbow
Above elbow
Forequarter
Upper limbs (both)
Fi ger’s
Ray
Below wrist
Below elbow
Above elbow
Forequarter
Lower limbs (single)
Disarticulation
Ray
Transmetatarsal
Sy e’s
Below knee
Through knee
Above knee
Hip disarticulation
Left lower limbs (both)
Disarticulation
Ray
Transmetatarsal
Sy e’s
Below knee
Through knee
Above knee
Hip disarticulation
n
289
2
0
2
0
0
0
0
0
0
0
0
0
0
0
44
9
24
0
0
6
0
5
0
3
0
2
0
0
1
0
0
0
24
Section 8: Current Upper Limbs Infections
Table 8.1: Dominance of current upper limbs infections (n=60), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009
Right
Dominance (na=3)
n
50
%
87.7
Left
n
7
Total
%
12.3
n
57
%
100.0
Table 8.2: Infection and location of current upper limbs infections (n=60), Diabetes
Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Total
Infections
Digit
1
2
3
4
5
Arm
Forearm
Hand: Pulmer surface
Hand: Dorsum
Web space
1st
2nd
3rd
4th
Amputation stump
Below wrist
Below elbow
Above elbow
n
60
%*
100.0
7
7
11
3
3
11.7
11.7
18.3
5.0
5.0
0.0
6.7
8.3
28.3
18.3
0.0
1.7
6.7
6.7
6.7
0.0
1.7
5.0
0.0
4
5
17
11
1
4
4
4
1
3
0
% derived using denominator 60 (number of upper limb infection)
25
Table 8.3: Diagnosis of current upper limbs infections (n=60), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009
Total
Diagnosis
Cellulitis
Felon
Thenar abscess
Mid palmar abscess
Hypothenar
Collar button abscess
Flexor tenosynovitis
Radial bursae/thumb
Paronychia
Septic arthritis
Dry gangrene
Wet gangrene
Necrotising fascilitis
Ulcer
Osteomyelitis
Others
Total
n
%*
16
2
5
4
2
1
5
3
2
1
4
4
1
2
0
13
65
26.7
3.3
8.3
6.7
3.3
1.7
8.3
5.0
3.3
1.7
6.7
6.7
1.7
3.3
0.0
21.7
Diagnosis details refer to appendix 2
% derived using denominator 60 (number of upper limb infection)
Table 8.4: Classification of current upper limbs infections (n=60), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Total
Stage
Grade
n
%*
A
B
C
D
7
9
1
2
0
1
2
3
4
9
4
2
11.7
15.0
1.7
3.3
0.0
6.7
15.0
6.7
3.3
% derived using denominator 60 (number of upper limb infection)
26
Table 8.5: Associated complications of current upper limbs infections (n=60),
Diabetes Foots and Hands, National Orthopaedic Registry Malaysia (NORM) 2009
Total
Nil
Associated complications
Septicaemia
Pneumonia
Stroke
UGIB
Renal failure
CCF
Pressure sores
n
%*
56
93.3*
3
0
0
0
0
1
0
5.0
0.0
0.0
0.0
0.0
1.7
0.0
% derived using denominator 60 (number of upper limb infection)
Table 8.6: Precipitating factor of current upper limbs infections (n=60), Diabetes
Foots and Hands, National Orthopaedic Registry Malaysia (NORM) 2009
Total
Precipitating factor
Spontaneous
Minor trauma
Major trauma
Insect bite
Animal bite
Work related
Recreational related
Latrogenic
Others
Unknown
n
%*
25
22
1
0
3
0
0
1
3
5
41.7
36.7
1.7
0.0
5.0
0.0
0.0
1.7
5.0
8.3
Detail for precipitating factor in appendix 3
% derived using denominator 60 (number of upper limb infection)
27
Table 8.7: Physical findings of current upper limbs infections (n=60), Diabetes
Foots and Hands, National Orthopaedic Registry Malaysia (NORM) 2009
Physical findings
Palpable brach. artery
Palpable radial artery
Peripheral neuropathy
Total
n
%*
47
47
16
78.3
78.3
26.7
% derived using denominator 60 (number of upper limb infection)
Table 8.8: Current upper limbs infections (culture), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009
Infections
Culture:
1st culture
No growth
Mixed growth
Single growth
Mixed growth
Acinetobacter
Anaerobic
Bacteroides
Coagulase
Enterococcus
Enterobacter
Escherichia
Klebsiella
Proteus
Serratia
Pseud. aeruginosa
Pseud. spp
Staphylococcus
B-hemolytic strep.
Viridans strep.
Others
Total
n
%*
18
7
23
30.0
11.7
38.3
1
0
0
1
0
3
0
7
0
0
1
0
15
3
0
3
1.7
0.0
0.0
1.7
0.0
5.0
0.0
11.7
0.0
0.0
1.7
0.0
25.0
5.0
0.0
5.0
Mixed growth details refer to appendix 3
% derived using denominator 60 (number of upper limb infection)
28
Table 8.9: Current upper limbs infections (operations during admision), Diabetes
Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Infections
Operation during admission
Nil
Amputation
Wound debridement
Amputation
Fingers
Ray
Below wrist
Below elbow
Above elbow
Forequarter
Fi ger’s
1
2
3
4
5
Ray
(missing = 1)
1
2
3
4
5
Total
n
%*
11
19
40
2
1
7
1
3
18.3
31.7
66.7
0.0
23.3
5.0
0.0
1.7
1.7
0.0
0.0
3.3
1.7
11.7
1.7
5.0
1
0
0
0
1
0.0
1.7
0.0
0.0
0.0
1.7
14
3
0
1
1
0
% derived using denominator 60 (number of upper limb infection)
29
Table 8.10: Current upper limbs infections (culture, operations during admission
and clinical outcome), Diabetes Foots and Hands, National Orthopadic Registry
Malaysia (NORM) 2009
Infections
Clinical outcome
Wound healed by
itself
Split skin grafting
Wound clean,
granulate
Wound covered
Amputation, healed
Amputation, infected
Death, due to septic
Death, due to medical
Discharged at own
risk
Total
n
%*
0
0.0
37
61.7
2
3.3
0
0
0
1
1
0.0
0.0
0.0
1.7
1.7
0
0.0
% derived using denominator 60 (number of upper limb infection)
Section 9: Current Lower Limbs Infections
Table 9.1: Current lower limbs infections (infections and location), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Infections
n
%*
1198
100.0
1
2
3
4
5
274
176
152
139
128
22.9
14.7
12.7
11.6
10.7
Plantar, metatarsal
Dorsum
Plantar, heel area
Ankle: medial
Ankle: Lateral
Thigh
Leg
342
338
180
66
70
27
104
28.5
28.2
15.0
5.5
5.8
2.3
8.7
Infections
(no = 51, na = 5)
Digit
Total
30
Web space
1st
2nd
3rd
4th
Amputation stump
Below knee
Above knee
Sy e’s
Transmetatarsal
Hip
95
80
63
76
7.9
6.7
5.3
6.3
86
16
1
29
0
7.2
1.3
0.1
2.4
0.0
% derived using denominator 1198 (number of lower limb infection)
Table 9.2: Current lower limbs infections (diagnosis and classification), Diabetes
Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Infections
Diagnosis
Cellulitis
Paronychia
Abscess
Ulcer
Gas gangrene
Dry gangrene
Wet gangrene
Necrotising fasciitis
Osteomyelitis
Others
Stage
A
B
C
D
Grade
0
1
2
3
Total
n
%*
150
5
293
522
21
117
160
76
283
18
12.5
0.4
24.5
43.6
1.8
9.8
13.4
6.3
23.6
1.5
75
218
65
63
6.3
18.2
5.4
5.3
31
207
124
65
2.6
17.3
10.4
5.4
% derived using denominator 1198 (number of lower limb infection)
See appendix 4 for details of others diagnosis
31
Table 9.3: Current lower limbs infections (associated complications, precipitating
factor and physical findings), Diabetes Foots and Hands, National Orthopaedic
Registry Malaysia (NORM) 2009
Infections
Associated complications
Nil
Septicaemia
Pneumonia
Stroke
UGIB
Renal failure
CCF
Pressure sores
Precipitating factor
Spontaneous
Minor trauma
Major trauma
Insect bite
Animal bite
Work related
Recreational related
Latrogenic
Others
Unknown
Physical findings
Palpable dorsalis
Palpable posterior
Periph. neuropathy
Total
n
%*
1033
75
9
13
2
75
3
6
86.2
6.3
0.8
1.1
0.2
6.3
0.3
0.5
0.0
36.1
34.0
0.8
0.8
0.8
1.7
0.6
1.0
3.3
22.2
0.0
74.3
74.1
30.3
433
407
10
10
10
20
7
12
40
266
890
888
363
% derived using denominator 1198 (number of lower limb infection)
See appendix 5 for details of others diagnosis
32
Table 9.4: Current lower limbs infections (culture), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009
Infections
Culture:
1st culture
No growth
Mixed growth
Single growth
Mixed growth
Acinetobacter
Anaerobic
Bacteroides
Coagulase
Enterococcus
Enterobacter
Escherichia
Klebsiella
Proteus
Serratia
Pseud. aeruginosa
Pseud. spp
Staphylococcus
B-hemolytic strep.
Viridans strep.
Others
Total
n
%*
332
162
375
27.7
13.5
31.3
32
3
2
5
14
34
51
75
90
2
99
12
67
22
4
129
2.7
0.3
0.2
0.4
1.2
2.8
4.3
6.3
7.5
0.2
8.3
1.0
5.6
1.8
0.3
10.8
% derived using denominator 1198 (number of lower limb infection)
See appendix 6 and 7 for details of mixed growth
33
Table 9.5: Current lower limbs infections (operations during admision), Diabetes
Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Infections
Operation during admission
Nil
Amputation
Wound debridement
Bypass surgery
Amputation
Disarticulation
Ray
Transmetatarsal
Sy e’s
Below knee
Through knee
Above knee
Hip disarticulation
Not available
Disarticulation
1
2
3
4
5
Ray
1
2
3
4
5
Total
n
%*
198
405
712
0
16.5
33.8
59.4
0.0
81
242
8
2
105
1
21
2
0
6.8
20.2
0.7
0.2
8.8
0.1
1.8
0.2
0.0
33
27
21
20
11
0
82
72
62
51
60
2.8
2.3
1.8
1.7
0.9
0.0
6.8
6.0
5.2
4.3
5.0
% derived using denominator 1198 (number of lower limb infection)
34
Table 9.6: Current lower limbs infections (culture, operations during admission and
clinical outcome), Diabetes Foots and Hands, National Orthopadic Registry
Malaysia (NORM) 2009
Infections
Clinical outcome
Wound healed by
itself
Split skin grafting
Wound clean,
granulate
Wound covered
Amputation, healed
Amputation, infected
Death, due to septic
Death, due to medical
Discharged at own
risk
Total
n
%*
126
10.5
17
1.4
740
61.8
20
106
13
12
2
1.7
8.8
1.1
1.0
0.2
55
4.6
% derived using denominator 1198 (number of lower limb infection)
35
Section 10: Antibiotics
Table 10.1: Antibiotics, Diabetes Foots and Hands, National Orthopadic Registry
Malaysia (NORM) 2009
Antibiotics
1. Amikacin
2. Ampicillin
3. Ampicillin/Sulbactam
4. Amoxicillin/Clavulanate
5.Aztreonam
6. Cloxacillin
7. Cephalexin
8. Cefuroxime
9. Cefoperazone
10. Ceftriaxone
11. Ceftazidime
12. Ciprofloxacin
13.Clindamycin
14. Cotrimoxazole
15. Fucidic Acid
16. Gentamicin
17. Imipenem/Cilastatin
18. Meropenem
19. Metronidazole
20. Piperacillin/tazobactam
21. Rifampicin
22. Trimethoprim/Sulfamethoxazol
23. Vancomycin
24. Sulbactam/Cefoperazone
Others
Not Available
Total
0
n (%)
0 (0.0)
0 (0.0)
1 (0.1)
1 (5.0)
0 (0.0)
3 (2.7)
0 (0.0)
2 (1.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
1 (0.6)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
8 (0.5)
1–6
n (%)
1 (33.3)
8 (44.4)
256 (36.2)
13 (65.0)
0 (0.0)
52 (46.0)
1 (100.0)
74 (35.6)
16 (40.0)
5 (27.8)
18 (39.1)
14 (38.9)
2 (33.3)
1 (50.0)
6 (37.5)
10 (58.8)
0 (0.0)
3 (30.0)
74 (43.8)
0 (0.0)
1 (20.0)
0 (0.0)
1 (50.0)
2 (50.0)
29 (43.3)
0 (0.0)
587 (38.4)
Duration
7 – 13
n (%)
1 (33.3)
8 (44.4)
301 (42.6)
3 (15.0)
1 (100.0)
29 (25.7)
0 (0.0)
78 (37.5)
18 (45.0)
12 (66.7)
17 (37.0)
14 (38.9)
2 (33.3)
0 (0.0)
2 (12.5)
5 (29.4)
4 (80.0)
6 (60.0)
71 (42.0)
4 (57.1)
2 (40.0)
3 (60.0)
1 (50.0)
2 (50.0)
26 (38.8)
2 (100.0)
612 (40.1)
≥ 4
n (%)
1 (33.3)
2 (11.1)
149 (21.1)
3 (15.0)
0 (0.0)
29 (25.7)
0 (0.0)
54 (26.0)
6 (15.0)
1 (5.6)
11 (23.9)
8 (22.2)
2 (33.3)
1 (50.0)
8 (50.0)
2 (11.80
1 (20.0)
1 (10.0)
23 (13.6)
3 (42.9)
2 (40.0)
2 (40.0)
0 (0.0)
0 (0.0)
12 (17.9)
0 (0.0)
321 (21.0)
All
N (%)*
3 (0.2)
18 (1.2)
707 (46.3)
20 (1.3)
1 (0.1)
113 (7.4)
1 (0.1)
208 (13.6)
40 (2.6)
18 (1.2)
46 (3.0)
36 (2.4)
6 (0.4)
2 (0.1)
16 (1.1)
17 (1.1)
5 (0.3)
10 (0.7)
169 (11.1)
7 (0.5)
5 (0.3)
5 (0.3)
2 (0.1)
4 (0.3)
67 (4.4)
2 (0.1)
1528
*Column percent
36
MALAYSIA (NORM)
ANNUAL REPORT OF
NATIONAL ORTHOPAEDIC REGISTRY MALAYSIA (NORM) DIABETIC
FOOT
2009
Editors:
Dr Mohammad Anwar Hau Abdullah
Dr Ahmad Tajuddin Abdullah
Registry Committee
Dr Mohammad Anwar Hau Abdullah
Dr Se To Boon Chong
Dr Ahmad Tajuddin Abdullah
Dr Tan Boon Cheong
Dr Zulkiflee Osman
Dr Abdul Rauf Ahmad
Dr Saadon Ibrahim
Dr Mohd Zamzuri Mohd Zain
Dr Mohamad Yazid Din
Dr Pan Chee Huan
Dr Joehaimey Johari
A publication of the National Orthopaedic Registry of Malaysia (NORM) and the
Clinical Research Centre, Ministry of Health Malaysia
*********************************************************************
December 2010
© National Orthopaedic Registry of Malaysia (NORM)
Publisher:
Jointly published by the National Orthopedic Registry of Malaysia (NORM) and the
Clinical Research Centre (CRC), Ministry of Health Malaysia.
National Orthopaedic Registry of Malaysia
1st Floor MMA House,
124, Jalan Pahang,
53000 Kuala Lumpur,
Malaysia.
Tel
Fax
Website
: (603) 4044 3060 / (603) 4044 3070
: (603) 4044 3080
: norm@acrm.org.my
: http://www.acrm.org.my/norm
Suggested citation: Mohammad Anwar Hau Abdullah, Ahmad Tajuddin Abdullah
(Eds). Annual Report of the NORM- Registry, 2009. Kuala Lumpur, Malaysia:
National Orthopaedic Registry of Malaysia 2009.
Disclaimer:
Data reported in this report were collected for one year period (from January to
December 2009), this report is copyrighted. Reproduction and dissemination of this
report in part or in whole for research, educational or other non-commercial purposes
are authorized without any prior written permission from the copyright holders
provided the source is fully acknowledged.
Electronic version
The
electronic
version
of
this
report
may
be
downloaded
http://www.acrm.org.my/norm or http://www.crc.gov.my/publication/report.
Funding
The National Orthopaedic Registry of Malaysia (NORM) – Diabetic Foot Registry is
funded with grants from the Ministry of Health Malaysia (MOH).
at
ACKNOWLEDGEMENTS
The National Orthopaedic Registry of Malaysia (NORM) would like to give its grateful
appreciation to everyone who has helped make this report possible.
We would especially like to thank the following:
Clinical Research Centre
Clinical Epidemiology Unit
Dr Goh Pik Pin
Dr Jamaiyah Haniff
Dr Dr Sharmini Selvarajah
Dr Lim Chioa mei
Patient Registry Unit
Dr Jaya Purany Stanley Ponniah
Nurul Shuhada Binti Mohd Ali
Scottish Hip Fracture Registry
NORM Governance Board
Chairman
Dato’ Dr Azmi Shafei
Director,
Division of Medical Development,
Ministry of Health Malaysia.
Members
Dr Jamaiyah Haniff
Head Of Clinical Epidemiology Unit,
Clinical Research Center, Hospital Kuala Lumpur.
Dr Jaya Purany Stanley Ponniah
Head of Patient Registry Unit
Clinical Research Center, Hospital Kuala Lumpur.
Dr Mohammad Anwar Hau Abdullah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Raja Perempuan Zainab II, Kota Bharu.
Dr Ahmad Tajuddin Abdullah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Sultanah Nur Zahirah, Kuala Terengganu.
Dr Saadon Ibrahim
Department of Orthopaedic and Traumatology,
Hospital Sultan Ismail, Johor Bharu.
Dr Se To Boon Chong
Department of Orthopaedic and Traumatology,
Hospital Pulau Pinang,Pulau Pinang.
Dato’ Dr Suresh Chopra,
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Sultanah Bahiyah, Alor Setar.
Dr Abdul Rauf Ahmad
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Tuanku Jaafar, Seremban.
Dato’ Dr Premchandran Menon
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Tengku Ampuan Afzan (HTAA), Kuantan.
Dr Pan Chee Huan
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Tuanku Fauziah, Kangar.
Dr Thirumal a/l Manickam
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Tengku Ampuan Rahimah, Klang.
Dr Nahulan A/L Theva Rajah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Queen Elizabeth, Kota Kinabalu.
Dato’ Dr Ramanathan A/L Ramiah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Raja Permaisuri Bainun, Ipoh.
Mr.Sivapathasundaram A/L Nadarajah
Head of Department,
Department of Orthopaedic and Traumatology
Hospital Melaka, Melaka.
Dr K. Thevarajan
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Sultanah Aminah, Johor Bharu.
Dr Faris Kamaruddin
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Umum Sarawak, Sarawak.
NORM Steering Committee members:
Chairman
Dr Ahmad Tajuddin Abdullah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Sultanah Nur Zahirah, Kuala Terengganu.
Co-Chairman
Dr Zulkiflee Osman
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Kuala Lumpur.
Members
Dr Mohammad Anwar Hau Abdullah
Head of Department,
Department of Orthopaedic and Traumatology,
Hospital Raja Perempuan Zainab II, Kota Bharu.
Dr Saadon Ibrahim
Department of Orthopaedic and Traumatology,
Hospital Sultan Ismail, Johor Bharu.
Dr Se To Boon Chong
Department of Orthopaedic and Traumatology,
Hospital Pulau Pinang, Pulau Pinang.
Dr Tan Boon Cheong
Department of Orthopaedic and Traumatology,
Hospital Pulau Pinang, Pulau Pinang.
Dr Abdul Rauf Ahmad
Department of Orthopaedic and Traumatology,
Hospital Tuanku Jaafar, Seremban.
Dr Mohd Zamzuri Mohd Zain
Department of Orthopaedic and Traumatology,
Hospital Tengku Ampuan Afzan (HTAA), Kuantan.
Dr Pan Chee Huan
Department of Orthopaedic and Traumatology,
Hospital Tuanku Fauziah, Kangar.
Dr Mohamad Yazid Din
Department of Orthopaedic and Traumatology,
Hospital Sultanah Bahiyah, Alor Setar.
Dr Joehaimey Johari
Department of Orthopaedic and Traumatology,
Hospital Raja Perempuan Zainab II, Kota Bharu.
NORM SOURCE DATA PROVIDERS 2008/2009
The current source data providers for NORM are:
No.
1
2
3
Hospital
Site investigators
Second person-in-charge
Hospital Kuala
Lumpur
Mr Zulkiflee Osman
Dr Mahazura Hj Mat Lawi
Hospital Raja
Perempuan
Zainab II Kota
Bharu
Mr Mohammad Anwar Hau
Abdullah
Dr Joehaimey Johari
Hospital Sultanah
Nur Zahirah Kuala
Terengganu
Mr Ahmad Tajuddin Abdullah
Dr Mustaqim Afifi @ Apipi
Dr. Abdul Qahhar
Sister Nik Noriah Nik Ibrahim
Dr Hazulin Mohd Radzuan
Dr Muhammad Hilmi Nasir
Dr Mohd Ariff Razani Abd
Razak
4
Hospital Tengku
Ampuan Rahimah
Klang
Dr Gurjit Singh
Dr M. Thirumal
5
Hospital Sultanah
Bahiyah Alor Setar
Dr Mohamad Yazid Din
Dr Noor Mahazrinna
Hayadin
Dr Lim Chiao Yee
6
Hospital Sultanah
Aminah Johor
Bahru
Dr Yoga Raj A/L
Parameswaran
Dr Manamohan
Chandrarajan
Dr Mohd Adham Shah
Dr Teo Pock Chin
7
Hospital Melaka
Dr Rengsen Parthiban
Dr Azhar Asari
Dr Mohd. Karim Md Isa
MA Mohd Fharid Johan
SN Marina Mohamed @
Osman
8
Hospital Sultan
Ismail Johor Bahru
Dr Saadon Ibrahim
Dr Mursyida Md Nujid
Dr Jayamalar
Thurairajasingam
SN Rohayah Abdul Rahman
JM Yussilawani Mamat
9
Hospital Tuanku
Fauziah Kangar
Dr Pan Chee Huan
Mr Zakaria Yusoff
Mr Yeap Ewe Juan
Dr Badrul Hashim
Dr Zakaria Yusoff
MA Shahizam Shafiee
SN Norseha Baharom
10
11
12
Hospital Raja
Permaisuri Bainun
Ipoh
Dr Manoharan
Dr Selvynlloyd
Hospital Tengku
Ampuan Afzan
Kuantan
Dato' Dr N Premchandran
Dr Alaudin Haris Osman
Dr. Mohd Zamzuri Mohd
Zain
Dr Jeffrey Jaya Raj
Hospital Ampang
Dr Ng Yue Oon
Dr Lynn Azura Md Sham
Dr Iyngkaran Arasalingam
Dr Ahmad Hafiz bin Zulkifly
Dr Samyu Ali
13
Hospital Tuanku
Ja’afar Seremban
Dr Abdul Rauf Ahmad
Dr Ng Tiong Soon
Dr Johann Johari
Sr Khamisah A. Ghani
Sr Rohana Zakaria
14
Hospital Pulau
Pinang
Dr Se To Boon Chong
Dr Tan Boon Cheong
Dr Ooi Chee Lean
Dr Chan Kok Yu
15
Hospital Serdang
Dr Khoo Shaw Woei
Dr Imma Isniza
Dr Harminder Singh
Randhawa
16
Hospital Selayang
Dr Ng Swee Soon
Dr Ritzwan Ismayatim
Dr Amir Fariz Zakaria
17
Hospital Queen
Elizabeth Kota
Kinabalu
Dr Nahulan A/L Theva Rajah
Dr CS Kumar
18
Hospital Umum
Sarawak
Dr Faris Kamaruddin
Dr Aaron Gerard Paul
MA Mikim A/K Radem
PREFACE
The National Orthopaedic Registry Malaysia has been collecting data since mid 2008
and it is with great pleasure and pride that we see this report materialised.
I would like to thank all those who have collected, verified and analysed the data.
The co-operation and energy demonstrated in units throughout the country indicates
the importance they place on improving patient management
The success of this report is due to continuous support and cooperation from various
people and agencies. The effort of the entire group must be congratulated and it has
been my sincere hope that this registry is able to sustain in coming years.
I also take this opportunity to thank the Clinical Research Centre Ministry of Health
Malaysia, to have trust in us and to provide us with the funding for us embark in this
project. This annual report is a testament of all your combined effort.
Thank you,
Dr Ahmad Tajuddin bin Abdullah
Dr Mohammad Anwar Hau Abdullah
Chairman National Orthopaedic Registry of Malaysia
Ministry of Health Malaysia
9
ABBREVIATIONS
ASA
American Society of Anaesthesiologists
CRC
Clinical Research Centre
CRF
Case Report Form
csv
Comma separated value
Dr
Doctor
GA
General Anaesthesia
HTAA
Hospital Tengku Ampuan Afzan
ICT
Information and Communication Technology
LMWH
Low Molecular Weight Heparin
MJM
Medical Journal of Malaysia
MOH
Ministry of Health
NOHFR
National Orthopaedic Hip Fracture Registry
NORM
National Orthopaedic Registry of Malaysia
OT
Operation Theater
PTH
Parathyroid Hormone
RTA
Road Traffic Accident
SDP
Source Data Provider
SERMS
Selective Estrogen Receptor Modulators
SMS
Short Messaging System
txt
Text-delimited format
xls
Excel workbook
10
Table of Content
Table
Page
SECTION 1: PATIENT DETAILS AND DEMOGRAPHIC ..................................................................... 13
Table 1.1: Profile demographic of respondents, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009. (N=1254) ................................................................... 13
Table 1.2: Occupation of respondents, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009. (N=1254) ...................................................................................... 14
SECTION 2: ADMISSION .............................................................................................................. 15
Table 2.1: Status of admision, Diabetes Foots and Hands, National Orthopadic Registry
Malaysia (NORM) 2009. .................................................................................................................... 15
SECTION 3: DIABETES HISTORY ................................................................................................... 16
Table 3.1: Status of diabetes mellitus, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009. ...................................................................................................... 16
SECTION 4: TREATMENT OF DIABETES MELLITUS......................................................................... 17
Table 4.1: Treatment of diabetes mellitus, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009. ...................................................................................................... 17
Table 4.2: Status of compliance for treatment, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009. ................................................................................... 18
SECTION 5: TREATMENT OF CURRENT DIABETES FOOT/ HANDS ULCER ........................................ 18
Table 5.1: Treatment of current diabetes foot/ hands ulcer, Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009 ..................................................................... 18
SECTION 6: RISK FACTORS .......................................................................................................... 19
Table 6.1: Distribution of infection, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009 ....................................................................................................... 19
Table 6.2: Risk factors for upper limb (n = 60), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009 .................................................................................... 19
Table 6.3: Risk factors of lower limb (n = 1198), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009 .................................................................................... 20
Table 6.4: Risk factors (awareness), Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009 ....................................................................................................... 20
Table 6.5: Practice for past one year, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009 ....................................................................................................... 21
Table 6.6: Risk factors (co-morbidity, complications, family history), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................................................... 22
SECTION 7: PREVIOUS HANDS/FOOT PROBLEMS (PAST ONE YEAR).............................................. 23
Table 7.1: Previous hands/foot problems (past one year), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009 ..................................................................... 23
Table 7.2: Highest level of amputation, previous hands/foot problems (past one year),
Diabetes Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................... 24
SECTION 8: CURRENT UPPER LIMBS INFECTIONS ......................................................................... 25
Table 8.1: Dominance of current upper limbs infections (n=60), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009 ..................................................................... 25
Table 8.2: Infection and location of current upper limbs infections (n=60), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009 .................................................. 25
Table 8.3: Diagnosis of current upper limbs infections (n=60), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009 ..................................................................... 26
Table 8.4: Classification of current upper limbs infections (n=60), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................................................... 26
11
Table 8.5: Associated complications of current upper limbs infections (n=60), Diabetes
Foots and Hands, National Orthopaedic Registry Malaysia (NORM) 2009 ...................................... 27
Table 8.6: Precipitating factor of current upper limbs infections (n=60), Diabetes Foots
and Hands, National Orthopaedic Registry Malaysia (NORM) 2009 ................................................ 27
Detail for precipitating factor in appendix 3 ..................................................................................... 27
Table 8.7: Physical findings of current upper limbs infections (n=60), Diabetes Foots and
Hands, National Orthopaedic Registry Malaysia (NORM) 2009 ....................................................... 28
Table 8.8: Current upper limbs infections (culture), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009 .................................................................................... 28
Table 8.9: Current upper limbs infections (operations during admision), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009 .................................................. 29
Table 8.10: Current upper limbs infections (culture, operations during admission and
clinical outcome), Diabetes Foots and Hands, National Orthopadic Registry Malaysia
(NORM) 2009 .................................................................................................................................... 30
SECTION 9: CURRENT LOWER LIMBS INFECTIONS ........................................................................ 30
Table 9.1: Current lower limbs infections (infections and location), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................................................... 30
Table 9.2: Current lower limbs infections (diagnosis and classification), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009 ......................................................... 31
Table 9.3: Current lower limbs infections (associated complications, precipitating factor
and physical findings), Diabetes Foots and Hands, National Orthopaedic Registry Malaysia
(NORM) 2009 .................................................................................................................................... 32
Table 9.4: Current lower limbs infections (culture), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009 .................................................................................... 33
Table 9.5: Current lower limbs infections (operations during admision), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009 .................................................. 34
Table 9.6: Current lower limbs infections (culture, operations during admission and
clinical outcome), Diabetes Foots and Hands, National Orthopadic Registry Malaysia
(NORM) 2009 .................................................................................................................................... 35
SECTION 10: ANTIBIOTICS........................................................................................................... 36
Table 10.1: Antibiotics, Diabetes Foots and Hands, National Orthopadic Registry Malaysia
(NORM) 2009 .................................................................................................................................... 36
12
Section 1: Patient Details and Demographic
Table 1.1: Profile demographic of respondents, Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009. (N=1254)
Profile
Age
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Age group
18 – 29
30 – 39
40 - 49
50 - 59
≥6
Gender
Male
Female
Ethnicity (na=5)
Malay
Chinese
Indian
Others Malaysian
Non Malaysian
Residence (na=113)
Urban
Rural
Education level (na=467)
Primary
Secondary
Tertiary
Statistics
n
%
21
60
255
438
480
1.7
4.8
20.3
34.9
38.3
604
650
48.2
51.8
935
141
146
17
10
74.6
11.2
11.6
1.4
0.8
610
351
53.5
46.5
388
355
44
49.3
45.1
5.6
56.2 (11.6)
20, 94
13
Table 1.2: Occupation of respondents, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009. (N=1254)
Profile
Occupation
Legislator senior
Technicians
Service
Related trade
Elementary occupation
Profesional
Clerical
Agricultural
Machine operator
Housewife
Unemployed
Retired
Unknown
Others
n
%
3
3
42
4
7
10
17
21
20
431
133
166
185
163
0.2
0.2
3.5
0.3
0.6
0.8
1.4
1.7
1.7
35.8
11.0
13.8
15.4
13.5
14
Section 2: Admission
Table 2.1: Status of admision, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009.
Status of admision
Duration in days
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Duration in days by age group
Median IQR (1stQ, 3rdQ)
18 – 29
30 – 39
40 - 49
50 - 59
≥6
Previous admission (na=142)
Yes
No
Number of times (na=908)
1 time only
2–3
4–5
>5
Statistics
n
%
425
687
38.2
61.8
192
134
11
9
55.5
38.7
3.2
2.6
13.7 (68.5)
7.0 IQR (4.0, 14.0)
0, 2228
8.5 IQR (6.0, 17.5)
5.0 IQR (3.5, 10.5)
8.0 IQR (4.0, 15.0)
6.0 IQR (4.0, 12.0)
7.0 IQR (4.0, 14.5)
15
Section 3: Diabetes History
Table 3.1: Status of diabetes mellitus, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009.
Status of diabetes
Type of diabetes
Type 1
By age group:
18 – 29
30 – 39
40 - 49
50 - 59
≥6
Statistics
Type 2
By age group:
18 – 29
30 – 39
40 - 49
50 - 59
≥6
n
%
197
16.2
10
16
35
70
66
5.1
8.1
17.8
35.5
33.5
1021
83.8
9
43
211
356
398
0.9
4.2
20.7
35.0
39.1
Duration of diabetes in years:
Type 1
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Type 2
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
11.9 (7.7)
10.0 IQR (5.0, 16.0)
1.0, 40.0
10.4 (7.5)
10.0 IQR (5.0, 15.0)
1.0, 40.0
16
Section 4: Treatment of Diabetes Mellitus
Table 4.1: Treatment of diabetes mellitus, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009.
Treatment of Diabetes Mellitus
Patient on treatment
(na = 97 and missing = 2)
Yes
No
Treatment for diet
(na = 723 and missing = 176)
Yes
No
Duration for having diet
treatment (days)*
(n = 122)
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Other treatment
(na = 111 and missing = 174)
Insulin
OHA
OHA and insulin
None of the above
Duration of having other
treatment*
Insulin (n = 98)
Mean (SD)
Median (IQR)
Min, max
OHA (n = 287)
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
OHA and insulin (n = 71)
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Descriptive
summary*
n
%
1071
84
92.7
7.27
131
224
36.9
63.1
165
692
111
1
17.0
71.5
11.5
-
75.9 (74.6)
60 IQR (12, 120)
1, 300
45.5 (62.5)
20.5 IQR (7, 60)
1, 360
75.1 (87.0)
36 IQR (12, 120)
1, 480
75.8 (84.2)
48 IQR (10, 120)
1, 362
17
Table 4.2: Status of compliance for treatment, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009.
Treatment of Diabetes Mellitus
Status of compliance
(na = 197 and missing = 181)
18 – 29
30 – 39
40 – 49
50 – 59
≥6
Yes
n (%)
8 (61.5)
27 (64.3)
136 (74.7)
229 (75.3)
241 (72.4)
No
n (%)
1.3 (38.5)
4.2 (35.7)
21.2 (25.3)
35.7 (24.7)
37.6 (27.6)
Section 5: Treatment of Current Diabetes Foot/ Hands Ulcer
Table 5.1: Treatment of current diabetes foot/ hands ulcer, Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009
Treatment of current DFH
Management of the ulcer prior
to hospitalization
Nil
Self treatment
General practitioner
Private hospital
Traditional
Government hospital
Government clinic
Alternative treatment
Duration of treatment (days)
(n = 327)
Mean (SD)
Median IQR (1stQ, 3rdQ)
Min, max
Descriptive
summary*
n
%
312
78
114
36
34
510
233
3
7.7
11.3
3.6
3.4
50.6
23.1
0.3
568.2 (1615.0)
14 IQR (5, 60)
1, 10950
*10950 is similar to 30.4 years
18
Section 6: Risk Factors
Table 6.1: Distribution of infection, Diabetes Foots and Hands, National Orthopadic
Registry Malaysia (NORM) 2009
Infection
Upper limb infection
(na = 86 and no = 1108))
By age group
18 – 29
30 – 39
40 - 49
50 – 59
≥6
Lower limb infection
(na= 5 and no = 51)
By age group
18 – 29
30 – 39
40 - 49
50 – 59
≥6
Single
n
row%
Both
n
row%
Total
n
col%
60
100.0
0
0.0
60
100.0
4
9
17
12
17
100.0
100.0
100.0
100.0
100.0
0
0
0
0
0
0.0
0.0
0.0
0.0
0.0
4
9
17
12
17
6.8
15.3
28.8
20.3
28.8
1151
96.1
47
3.9
1198
100.0
17
50
230
414
439
100.0
98.0
96.2
96.7
95.0
0
1
9
14
23
0.0
2.0
3.8
3.3
5.0
17
51
239
428
462
1.4
4.3
20.0
35.8
38.6
Table 6.2: Risk factors for upper limb (n = 60), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009
Risk factors
Activities at work:
Use hand predominantly
Hand wet at work
n
%
46
22
76.7
36.7
19
Table 6.3: Risk factors of lower limb (n = 1198), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009
Risk factors
Activities at work:
Involve lots of
walking/standing
Feet wet at work
Footware at work:
(na = 221 and missing = 10)
Barefoot
Slippers
Shoes
Socks only
Footware at home:
(na = 126 and missing = 10)
Barefoot
Slippers
Shoes
Socks only
n
%
568
47.4
228
19.0
99
457
408
3
10.2
47.3
42.2
0.3
526
487
36
13
49.5
45.9
3.4
1.2
Table 6.4: Risk factors (awareness), Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009
Risk factors
Foot/hands problem (N = 1254)
Aware of increased foot/hand problem
Aware: Inspect feet/hand
Foot problem (n = 1198)
Aware:Wash feet
Aware: Apply emollients
Aware: Use appropriate shoes
Aware: Attend diabetes foot clinic
Aware: Education on diabetes footcare (formal)
Aware: Education on diabetes footcare (informal)
Aware: Keeping on diabetes care booklet
n
%
779
627
62.1
50.0
830
278
318
211
327
595
273
69.3
23.2
26.5
17.6
27.3
49.7
22.8
20
Table 6.5: Practice for past one year, Diabetes Foots and Hands, National
Orthopadic Registry Malaysia (NORM) 2009
Practice for past one year:
Inspect feet/hand (N = 1254)
Frequent Inspect feet/hand
Daily
Weekly
Occationally
Total
Wash feet (n = 1198)
Frequent wash feet
Daily
Weekly
Occationally
Total
Apply emollients (n = 1198)
Frequent apply emollients
Daily
Weekly
Occationally
Total
Use appropriate shoes (n = 1198)
Frequent use appropriate shoes
Daily
Weekly
Occationally
Total
Attend diabetes foot clinic (n = 1198)
Frequent attend diabetes foot clinic
Daily
Weekly
Occationally
Total
n
563
%
44.9
206
63
284
553
733
37.3
11.4
51.4
501
36
181
718
299
69.8
5.0
25.2
132
20
139
291
286
45.4
6.9
47.8
134
17
123
274
190
48.9
6.2
44.9
58
122
0
180
28.3
59.5
0.0
64.5
19.1
23.9
15.9
21
Table 6.6: Risk factors (co-morbidity, complications, family history), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Risk factors
Co-morbidity:
Unknown
Hypertension
Hypercholesterolemia
IHD
TIA
CVA
Renal disease
Retinopathy
Others
Complications:
Nil
Unknown
Retinopathy
Vascular
Neuropathy
Skin
Nephropathy
Others
Family history:
Unknown
Hypertension
DM
Hypercholesterolemia
IHD
TIA
CVA
Renal disease
Retinopathy
Others
n
%
468
685
133
102
1
39
51
54
55
61.2
11.9
9.1
0.1
3.5
4.6
4.8
4.9
216
253
205
194
420
261
101
12
17.2
16.3
35.2
21.9
8.5
1.0
636
291
538
38
65
1
18
3
7
12
29.9
55.3
3.9
6.7
0.1
1.8
0.3
0.7
1.2
Co-morbidity details refer to appendix 1
Complications details refer to appendix 2
Family history details refer to appendix 2
22
Section 7: Previous Hands/foot problems (past one year)
Table 7.1: Previous hands/foot problems (past one year), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009
Previous problems
Previous operations performed
(N = 1254)
1 time
2 – 4 times
5 – 7 times
8 – 10 times
Total
n
%
373
29.7
235
116
8
2
361
65.1
32.1
2.2
0.6
23
Table 7.2: Highest level of amputation, previous hands/foot problems (past one
year), Diabetes Foots and Hands, National Orthopadic Registry Malaysia (NORM)
2009
Highest level of amputation
None
Upper limbs (single)
Finger’s
Ray
Below wrist
Below elbow
Above elbow
Forequarter
Upper limbs (both)
Fi ger’s
Ray
Below wrist
Below elbow
Above elbow
Forequarter
Lower limbs (single)
Disarticulation
Ray
Transmetatarsal
Sy e’s
Below knee
Through knee
Above knee
Hip disarticulation
Left lower limbs (both)
Disarticulation
Ray
Transmetatarsal
Sy e’s
Below knee
Through knee
Above knee
Hip disarticulation
n
289
2
0
2
0
0
0
0
0
0
0
0
0
0
0
44
9
24
0
0
6
0
5
0
3
0
2
0
0
1
0
0
0
24
Section 8: Current Upper Limbs Infections
Table 8.1: Dominance of current upper limbs infections (n=60), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009
Right
Dominance (na=3)
n
50
%
87.7
Left
n
7
Total
%
12.3
n
57
%
100.0
Table 8.2: Infection and location of current upper limbs infections (n=60), Diabetes
Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Total
Infections
Digit
1
2
3
4
5
Arm
Forearm
Hand: Pulmer surface
Hand: Dorsum
Web space
1st
2nd
3rd
4th
Amputation stump
Below wrist
Below elbow
Above elbow
n
60
%*
100.0
7
7
11
3
3
11.7
11.7
18.3
5.0
5.0
0.0
6.7
8.3
28.3
18.3
0.0
1.7
6.7
6.7
6.7
0.0
1.7
5.0
0.0
4
5
17
11
1
4
4
4
1
3
0
% derived using denominator 60 (number of upper limb infection)
25
Table 8.3: Diagnosis of current upper limbs infections (n=60), Diabetes Foots and
Hands, National Orthopadic Registry Malaysia (NORM) 2009
Total
Diagnosis
Cellulitis
Felon
Thenar abscess
Mid palmar abscess
Hypothenar
Collar button abscess
Flexor tenosynovitis
Radial bursae/thumb
Paronychia
Septic arthritis
Dry gangrene
Wet gangrene
Necrotising fascilitis
Ulcer
Osteomyelitis
Others
Total
n
%*
16
2
5
4
2
1
5
3
2
1
4
4
1
2
0
13
65
26.7
3.3
8.3
6.7
3.3
1.7
8.3
5.0
3.3
1.7
6.7
6.7
1.7
3.3
0.0
21.7
Diagnosis details refer to appendix 2
% derived using denominator 60 (number of upper limb infection)
Table 8.4: Classification of current upper limbs infections (n=60), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Total
Stage
Grade
n
%*
A
B
C
D
7
9
1
2
0
1
2
3
4
9
4
2
11.7
15.0
1.7
3.3
0.0
6.7
15.0
6.7
3.3
% derived using denominator 60 (number of upper limb infection)
26
Table 8.5: Associated complications of current upper limbs infections (n=60),
Diabetes Foots and Hands, National Orthopaedic Registry Malaysia (NORM) 2009
Total
Nil
Associated complications
Septicaemia
Pneumonia
Stroke
UGIB
Renal failure
CCF
Pressure sores
n
%*
56
93.3*
3
0
0
0
0
1
0
5.0
0.0
0.0
0.0
0.0
1.7
0.0
% derived using denominator 60 (number of upper limb infection)
Table 8.6: Precipitating factor of current upper limbs infections (n=60), Diabetes
Foots and Hands, National Orthopaedic Registry Malaysia (NORM) 2009
Total
Precipitating factor
Spontaneous
Minor trauma
Major trauma
Insect bite
Animal bite
Work related
Recreational related
Latrogenic
Others
Unknown
n
%*
25
22
1
0
3
0
0
1
3
5
41.7
36.7
1.7
0.0
5.0
0.0
0.0
1.7
5.0
8.3
Detail for precipitating factor in appendix 3
% derived using denominator 60 (number of upper limb infection)
27
Table 8.7: Physical findings of current upper limbs infections (n=60), Diabetes
Foots and Hands, National Orthopaedic Registry Malaysia (NORM) 2009
Physical findings
Palpable brach. artery
Palpable radial artery
Peripheral neuropathy
Total
n
%*
47
47
16
78.3
78.3
26.7
% derived using denominator 60 (number of upper limb infection)
Table 8.8: Current upper limbs infections (culture), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009
Infections
Culture:
1st culture
No growth
Mixed growth
Single growth
Mixed growth
Acinetobacter
Anaerobic
Bacteroides
Coagulase
Enterococcus
Enterobacter
Escherichia
Klebsiella
Proteus
Serratia
Pseud. aeruginosa
Pseud. spp
Staphylococcus
B-hemolytic strep.
Viridans strep.
Others
Total
n
%*
18
7
23
30.0
11.7
38.3
1
0
0
1
0
3
0
7
0
0
1
0
15
3
0
3
1.7
0.0
0.0
1.7
0.0
5.0
0.0
11.7
0.0
0.0
1.7
0.0
25.0
5.0
0.0
5.0
Mixed growth details refer to appendix 3
% derived using denominator 60 (number of upper limb infection)
28
Table 8.9: Current upper limbs infections (operations during admision), Diabetes
Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Infections
Operation during admission
Nil
Amputation
Wound debridement
Amputation
Fingers
Ray
Below wrist
Below elbow
Above elbow
Forequarter
Fi ger’s
1
2
3
4
5
Ray
(missing = 1)
1
2
3
4
5
Total
n
%*
11
19
40
2
1
7
1
3
18.3
31.7
66.7
0.0
23.3
5.0
0.0
1.7
1.7
0.0
0.0
3.3
1.7
11.7
1.7
5.0
1
0
0
0
1
0.0
1.7
0.0
0.0
0.0
1.7
14
3
0
1
1
0
% derived using denominator 60 (number of upper limb infection)
29
Table 8.10: Current upper limbs infections (culture, operations during admission
and clinical outcome), Diabetes Foots and Hands, National Orthopadic Registry
Malaysia (NORM) 2009
Infections
Clinical outcome
Wound healed by
itself
Split skin grafting
Wound clean,
granulate
Wound covered
Amputation, healed
Amputation, infected
Death, due to septic
Death, due to medical
Discharged at own
risk
Total
n
%*
0
0.0
37
61.7
2
3.3
0
0
0
1
1
0.0
0.0
0.0
1.7
1.7
0
0.0
% derived using denominator 60 (number of upper limb infection)
Section 9: Current Lower Limbs Infections
Table 9.1: Current lower limbs infections (infections and location), Diabetes Foots
and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Infections
n
%*
1198
100.0
1
2
3
4
5
274
176
152
139
128
22.9
14.7
12.7
11.6
10.7
Plantar, metatarsal
Dorsum
Plantar, heel area
Ankle: medial
Ankle: Lateral
Thigh
Leg
342
338
180
66
70
27
104
28.5
28.2
15.0
5.5
5.8
2.3
8.7
Infections
(no = 51, na = 5)
Digit
Total
30
Web space
1st
2nd
3rd
4th
Amputation stump
Below knee
Above knee
Sy e’s
Transmetatarsal
Hip
95
80
63
76
7.9
6.7
5.3
6.3
86
16
1
29
0
7.2
1.3
0.1
2.4
0.0
% derived using denominator 1198 (number of lower limb infection)
Table 9.2: Current lower limbs infections (diagnosis and classification), Diabetes
Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Infections
Diagnosis
Cellulitis
Paronychia
Abscess
Ulcer
Gas gangrene
Dry gangrene
Wet gangrene
Necrotising fasciitis
Osteomyelitis
Others
Stage
A
B
C
D
Grade
0
1
2
3
Total
n
%*
150
5
293
522
21
117
160
76
283
18
12.5
0.4
24.5
43.6
1.8
9.8
13.4
6.3
23.6
1.5
75
218
65
63
6.3
18.2
5.4
5.3
31
207
124
65
2.6
17.3
10.4
5.4
% derived using denominator 1198 (number of lower limb infection)
See appendix 4 for details of others diagnosis
31
Table 9.3: Current lower limbs infections (associated complications, precipitating
factor and physical findings), Diabetes Foots and Hands, National Orthopaedic
Registry Malaysia (NORM) 2009
Infections
Associated complications
Nil
Septicaemia
Pneumonia
Stroke
UGIB
Renal failure
CCF
Pressure sores
Precipitating factor
Spontaneous
Minor trauma
Major trauma
Insect bite
Animal bite
Work related
Recreational related
Latrogenic
Others
Unknown
Physical findings
Palpable dorsalis
Palpable posterior
Periph. neuropathy
Total
n
%*
1033
75
9
13
2
75
3
6
86.2
6.3
0.8
1.1
0.2
6.3
0.3
0.5
0.0
36.1
34.0
0.8
0.8
0.8
1.7
0.6
1.0
3.3
22.2
0.0
74.3
74.1
30.3
433
407
10
10
10
20
7
12
40
266
890
888
363
% derived using denominator 1198 (number of lower limb infection)
See appendix 5 for details of others diagnosis
32
Table 9.4: Current lower limbs infections (culture), Diabetes Foots and Hands,
National Orthopadic Registry Malaysia (NORM) 2009
Infections
Culture:
1st culture
No growth
Mixed growth
Single growth
Mixed growth
Acinetobacter
Anaerobic
Bacteroides
Coagulase
Enterococcus
Enterobacter
Escherichia
Klebsiella
Proteus
Serratia
Pseud. aeruginosa
Pseud. spp
Staphylococcus
B-hemolytic strep.
Viridans strep.
Others
Total
n
%*
332
162
375
27.7
13.5
31.3
32
3
2
5
14
34
51
75
90
2
99
12
67
22
4
129
2.7
0.3
0.2
0.4
1.2
2.8
4.3
6.3
7.5
0.2
8.3
1.0
5.6
1.8
0.3
10.8
% derived using denominator 1198 (number of lower limb infection)
See appendix 6 and 7 for details of mixed growth
33
Table 9.5: Current lower limbs infections (operations during admision), Diabetes
Foots and Hands, National Orthopadic Registry Malaysia (NORM) 2009
Infections
Operation during admission
Nil
Amputation
Wound debridement
Bypass surgery
Amputation
Disarticulation
Ray
Transmetatarsal
Sy e’s
Below knee
Through knee
Above knee
Hip disarticulation
Not available
Disarticulation
1
2
3
4
5
Ray
1
2
3
4
5
Total
n
%*
198
405
712
0
16.5
33.8
59.4
0.0
81
242
8
2
105
1
21
2
0
6.8
20.2
0.7
0.2
8.8
0.1
1.8
0.2
0.0
33
27
21
20
11
0
82
72
62
51
60
2.8
2.3
1.8
1.7
0.9
0.0
6.8
6.0
5.2
4.3
5.0
% derived using denominator 1198 (number of lower limb infection)
34
Table 9.6: Current lower limbs infections (culture, operations during admission and
clinical outcome), Diabetes Foots and Hands, National Orthopadic Registry
Malaysia (NORM) 2009
Infections
Clinical outcome
Wound healed by
itself
Split skin grafting
Wound clean,
granulate
Wound covered
Amputation, healed
Amputation, infected
Death, due to septic
Death, due to medical
Discharged at own
risk
Total
n
%*
126
10.5
17
1.4
740
61.8
20
106
13
12
2
1.7
8.8
1.1
1.0
0.2
55
4.6
% derived using denominator 1198 (number of lower limb infection)
35
Section 10: Antibiotics
Table 10.1: Antibiotics, Diabetes Foots and Hands, National Orthopadic Registry
Malaysia (NORM) 2009
Antibiotics
1. Amikacin
2. Ampicillin
3. Ampicillin/Sulbactam
4. Amoxicillin/Clavulanate
5.Aztreonam
6. Cloxacillin
7. Cephalexin
8. Cefuroxime
9. Cefoperazone
10. Ceftriaxone
11. Ceftazidime
12. Ciprofloxacin
13.Clindamycin
14. Cotrimoxazole
15. Fucidic Acid
16. Gentamicin
17. Imipenem/Cilastatin
18. Meropenem
19. Metronidazole
20. Piperacillin/tazobactam
21. Rifampicin
22. Trimethoprim/Sulfamethoxazol
23. Vancomycin
24. Sulbactam/Cefoperazone
Others
Not Available
Total
0
n (%)
0 (0.0)
0 (0.0)
1 (0.1)
1 (5.0)
0 (0.0)
3 (2.7)
0 (0.0)
2 (1.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
1 (0.6)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
0 (0.0)
8 (0.5)
1–6
n (%)
1 (33.3)
8 (44.4)
256 (36.2)
13 (65.0)
0 (0.0)
52 (46.0)
1 (100.0)
74 (35.6)
16 (40.0)
5 (27.8)
18 (39.1)
14 (38.9)
2 (33.3)
1 (50.0)
6 (37.5)
10 (58.8)
0 (0.0)
3 (30.0)
74 (43.8)
0 (0.0)
1 (20.0)
0 (0.0)
1 (50.0)
2 (50.0)
29 (43.3)
0 (0.0)
587 (38.4)
Duration
7 – 13
n (%)
1 (33.3)
8 (44.4)
301 (42.6)
3 (15.0)
1 (100.0)
29 (25.7)
0 (0.0)
78 (37.5)
18 (45.0)
12 (66.7)
17 (37.0)
14 (38.9)
2 (33.3)
0 (0.0)
2 (12.5)
5 (29.4)
4 (80.0)
6 (60.0)
71 (42.0)
4 (57.1)
2 (40.0)
3 (60.0)
1 (50.0)
2 (50.0)
26 (38.8)
2 (100.0)
612 (40.1)
≥ 4
n (%)
1 (33.3)
2 (11.1)
149 (21.1)
3 (15.0)
0 (0.0)
29 (25.7)
0 (0.0)
54 (26.0)
6 (15.0)
1 (5.6)
11 (23.9)
8 (22.2)
2 (33.3)
1 (50.0)
8 (50.0)
2 (11.80
1 (20.0)
1 (10.0)
23 (13.6)
3 (42.9)
2 (40.0)
2 (40.0)
0 (0.0)
0 (0.0)
12 (17.9)
0 (0.0)
321 (21.0)
All
N (%)*
3 (0.2)
18 (1.2)
707 (46.3)
20 (1.3)
1 (0.1)
113 (7.4)
1 (0.1)
208 (13.6)
40 (2.6)
18 (1.2)
46 (3.0)
36 (2.4)
6 (0.4)
2 (0.1)
16 (1.1)
17 (1.1)
5 (0.3)
10 (0.7)
169 (11.1)
7 (0.5)
5 (0.3)
5 (0.3)
2 (0.1)
4 (0.3)
67 (4.4)
2 (0.1)
1528
*Column percent
36