Quality of life among first ray amputated diabetic foot ulcer patients


  • Humna Tariq Lahore Medical and Dental College Lahore, Pakistan
  • Mehwish Khalid Lahore Medical and Dental College Lahore, Pakistan
  • Fiza Saleem Lahore Medical and Dental College Lahore https://orcid.org/0009-0009-9559-1539
  • Aqsa Mustafa Riphah International University Islamabad
  • Iqra Yousaf Lahore Medical and Dental College Lahore, Pakistan
  • Samar Min Allah Lahore Medical and Dental College Lahore, Pakistan




Amputation, diabetic foot ulcer, Diabetes mellitus, first ray, quality of life, SF-36 questionnaire


Background: The quality of life among first-ray amputations due to diabetic foot ulcers is of paramount importance in understanding the holistic impact of this surgical intervention. 

Objective: To explore the quality of life among first-ray amputated diabetic foot ulcer patients.

Methods: A descriptive cross-sectional study was done using non-probability convenient sampling. The data was collected from Ghurki Trust Teaching Hospital and Shalamar Hospital. A total of n=68 Patients with type II diabetes with first-ray amputation six months ago who aged between 40-65 years were included in this study. The quality of life was accessed through the SF-36 questionnaire. Data analysis was done by using SPSS version 23. Informed consent was taken from every participant and told all the risks and benefits of the study.

Results: In this study of diabetic foot ulcer patients aged 45-64 with a mean age of 52±4.33 years, there were 30 females (44.12%) and 38 males (55.88%). Of the participants, 44 (64.7%) reported a good quality of life, while 24 (35.29%) reported a poor quality of life. The overall quality of life was poor, with a score of 39.92±12.89. Specifically, physical functioning (46.32±24.41), emotional well-being (44.71±16.61), social functioning (36.88±17.46), and general health (46.62±21.03) were poor, while physical (82.35±29.63), emotional (82.35±29.63), role limitations, and pain (62.17±17.77) were good.

Conclusion: The current study concluded that the overall quality of life among first-ray amputated diabetic foot ulcer patients is low.


Type II diabetes mellitus has affected 56 million people in Europe, leading to foot ulceration and amputation [1].  Diabetes causes many minor and major complications and one of the main complications is diabetic foot ulcers which are non-traumatic lesions on the skin of the foot [2] [3]. 

The prevalence of foot ulcers in the southwest is 11.6%. The overall mortality rate after amputation ranges from 13–40% at 1 year, 35–65% at 3 years, and 39–80% at 5 years [4]. Diabetic foot ulcers (DFU) require much more time to heal and can also become chronic despite treatment [5]. DFU leads to amputation in most cases. As the risk of limb amputation is higher in diabetics than in non-diabetics. First-ray amputation is the removal of first hallux and first metatarsal. It may reduce mobility and affect overall well-being [6]. 

Thus, some literature is available internationally on the quality of life of amputees, there may have been little research done specifically on Pakistani patients with diabetic foot ulcers who had first-ray amputations. This study can close the knowledge gap and help us better grasp the problems and requirements of this population.  So, the objective of the study was to explore the Quality of life among first-ray amputated diabetic foot ulcer patients.


A descriptive cross-sectional survey was conducted on n=68 diabetic foot ulcer patients. The study setting was the Department of Community Health Services, Ghurki Trust Teaching Hospital Lahore (Ref.No.LCPT/2053). The sampling technique was nonprobability convenience sampling. The duration of the study was 6 months from July 2021 to December 2021. 

Patients with type II diabetes with first ray amputation six months ago who aged between 40-65 years were included in this study. Patients with burns, tumors, infections, and traumatic patients were excluded from the study. 

The sample size was 68 which was calculated by using the World Health Organization (WHO) sample size calculator with 0.046% prevalence (P) [7], 95% confidence interval (1-α), and 0.05 precision (d). Prior informed consent from all patients was taken. The quality of life was accessed with a short form 36(SF-36) health survey questionnaire which has a 0 to 100 score, 0 with the lowest value depicting poor quality of life, and 100 with the highest value showing good quality of life. "Poor" quality of life is defined as a mean score less than 50 in any of the health domains "Good" quality of life is defined as a mean score of 50 or higher in physical and emotional role limitations. Considerable evidence was found for the reliability of the SF-36 (Cronbach's α >0.85, reliability coefficient >0.75 for all dimensions except social functioning).  The SF-36 scoring process involved two steps. Initially, numeric values were transformed to establish a higher score indicative of a more favorable health state, spanning from 0 representing the worst possible to 100 indicating the best possible[8].  Notably, the outcome data exhibited normal distribution, prompting the consolidation of items within the same scale through averaging, thereby generating eight mean health domain scale scores. Noteworthy, any items left unanswered by respondents were excluded from consideration. Consequently, the ultimate domain score represented the average across all items within a scale that participants responded to. Subsequently, these domain scores were categorized into different levels of quality of life, encompassing poor and good.

Data was entered by using Statistical Package for Social Sciences (SPSS) version 23 and the same software was used for data analysis. The study variables were presented in the form of descriptive statistics including mean, standard deviation, frequency, and percentages (tables, graphs, and percentages).


The age range of first-ray amputated diabetic foot ulcer patients was 45 to 64, with a mean age of 52 ±4.33 years. A total of n=30(44.12%) of the participants were female, while n=38 (55.88%) were male. The n=46(33.19%) of the participants have > 3 months of history of first ray amputation. 

Figure 1: Duration after First Ray Amputation

 Table 1: Descriptive Analysis of SF-36 Categories (QOL)


The study examined the quality of life among diabetic foot ulcer patients who had undergone first-ray amputations. The findings offer insights into the well-being of these patients. The study included a group of patients with an average age in their early fifties. The gender distribution was roughly equal, and a significant portion of the participants had a history of first-ray amputation exceeding three months. Some of the participants reported having a good quality of life, while others described their quality of life as poor. The overall quality of life, as measured by the SF-36 questionnaire, was relatively low. The study revealed variations in different aspects of quality of life. Participants faced challenges in areas related to physical functioning, emotional well-being, social functioning, and general health. 

The findings of this study are consistent with previously published works on the subject [9, 10]. Research has consistently demonstrated that people who have had amputations, particularly because of diabetic complications, frequently face difficulties in a variety of quality-of-life areas [11]. Physical functioning may be hampered by restrictions on mobility and daily life activities. The psychological effects of amputation and its consequences on body image and self-esteem can have an impact on emotional well-being. Reduced involvement in social and recreational activities may undermine social functioning. The mental and emotional effects of amputation may also harm general perceptions of health [12].

The participants were able to handle their responsibilities and activities despite having an amputation, according to the observed favorable outcome in the physical and emotional role-limits domains [13]. This might be explained by the availability of the right support, therapy, and coping mechanisms, all of which have been found to improve post-amputation adaption and functional results [14].

The current study's findings are comparable with those of several earlier studies, showing a pattern regarding how lower extremity amputations specifically those caused by ulcers—affect several aspects of quality of life (QOL) [15-17].

The physical domain of QOL was found to be poorer than the social domain as reported by the study conducted by Irene Aprile et al. This conclusion is in line with the current study, which also found a low quality of life in terms of physical functioning as compared to social aspect[3]. This shows that those who have their first ray amputated because of diabetic foot ulcers can encounter issues with both their physical capabilities and their ability to connect with others. 

According to previous research, ulcer amputations decrease the quality of life because they reduce physical and psychosocial functioning in the lower extremities. Except for the finding that patients with amputations had lower levels of depression and cognitive functioning, these results are comparable with those of the current study in terms of physical functioning [18]. In contrast to healed ulcers, persistent ulcers are linked to a reduction in health-related quality of life (HRQL), according to a study by Gunnel Ragnarson Tennvall et al. This conclusion, that there is a lower quality of life in the areas of physical functioning, emotional well-being, and overall health, is consistent with the findings of the current study. The study also showed that amputation can worsen the quality of life, enhancing the detrimental effects. The study also highlighted that amputation can further lower the quality of life, highlighting how detrimental amputation is across several QOL areas [2].

The study by David Boutoille et al. shed light on how ulcers and amputation affect quality of life. The study emphasized that ulcers had a higher impact on quality of life (QOL) than amputation, particularly because of things like discomfort and problems with peripheral vascular disease. The findings of the current investigation, which showed the low quality of life across some domains, including physical functioning, where pain and vascular problems may have contributed to the observed decline in QOL confirm this viewpoint[19]. These findings are consistent with those of earlier research.

According to studies by Garca-Morales et al, neuropathy, a frequent side effect of diabetic foot ulcers, significantly lowers the quality of life. Given that neuropathy can affect both physical and emotional well-being, which in turn affects multiple domains of QOL[20], this conclusion is consistent with the findings of the current study. These findings are consistent with those of earlier research.

The study by Sara L. Borkosky made clear the bad prognosis connected to partial first-ray amputation. Although not directly related to QOL domains, this research highlights the difficulties people may encounter after such amputations, which may be a factor in the QOL decline that has been found across several domains [21]. 

The current study's findings are in line with a large body of prior research, which shows that first-ray amputation brought on by diabetic foot ulcers can have a major influence on several quality-of-life categories. According to prior research that has highlighted the physical, psychological, and vascular aspects contributing to these outcomes, the domains of physical functioning, emotional well-being, social functioning, and general health were recognized as being notably affected.

However, it is important to recognize that the study has several limitations. First off, the study's sample size was very small, which would have limited how broadly the results could be applied.


The current study concluded the quality of life following first-ray amputation becomes compromised due to the multifaceted impacts of the amputation-induced changes. These effects manifest across physical, emotional, and social aspects of health among patients with diabetic foot ulcers. Notably, the results show a significant reduction in both physical and social functioning, whereas the other quality of life categories show relatively more positive results. To further understand QOL among those who have had their first ray amputated because of diabetic foot ulcers, more research with a large sample is required, as well as a thorough investigation of potential contributing factors.  


Author’s Contribution

The following format should be used for author’s contribution.

HT: substantial contributions to the conception and design of the study.

HT and MK: acquisition of data for the study.

MK and FS: interpretation of data for the study.

AM: analysis of the data for the study.

IY and SMA: drafted the work.

HT, MK, FS, AM, IY and SMA: revised it critically for important intellectual content.

HT, MK, FS, AM, IY and SMA: final approval of the version to be published and agreement to be accountable for all aspects.

of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors contributed to the article and approved the submitted version.

Ethical Statement

The study was conducted on n=68 diabetic foot ulcer patients. The study setting was Department community Health Services, Ghurki Trust Teaching Hospital Lahore (Ref.No.LCPT/2053).

Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement 

The data that support the findings of this study are available from the corresponding author upon reasonable request.


None to declare.

Conflicts of Interest 

None to declare.


None to declare.


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Author Biographies

Humna Tariq, Lahore Medical and Dental College Lahore, Pakistan


Mehwish Khalid, Lahore Medical and Dental College Lahore, Pakistan

Senior Lecturer

Fiza Saleem, Lahore Medical and Dental College Lahore


Aqsa Mustafa, Riphah International University Islamabad


Iqra Yousaf, Lahore Medical and Dental College Lahore, Pakistan


Samar Min Allah, Lahore Medical and Dental College Lahore, Pakistan









Research Article