The study, led by Fatimah Z. Alenazi of Qassim University together with colleagues in Saudi Arabia, Lebanon, South Africa, and Portugal, set out to answer a deceptively simple question: which factors independently predict whether a patient’s feet fall into the danger zone, and whether they have already developed an active ulcer? The team focused on three candidate variables with strong clinical plausibility: glycated hemoglobin (HbA1c), the standard laboratory marker of average blood sugar over the preceding two to three months; age; and sex. Using a census sampling approach, they extracted every eligible record with a confirmed diabetes diagnosis and a documented foot assessment between January 2022 and December 2024, excluding only nine records with missing or non-numeric HbA1c values.

The technical backbone of the analysis was a pair of multivariable binary logistic regression models, one for each outcome. The primary outcome was at-risk diabetic foot status, defined as an IWGDF risk category of 1 or higher under the 2019 stratification system, which grades patients from category 0 (no loss of protective sensation or arterial disease) up to category 3 (previous ulceration or amputation). The secondary outcome was active foot ulceration, defined as a full-thickness wound distal to the ankle identified by the treating clinician during the same visit. Age and HbA1c were entered as continuous variables, with the HbA1c estimate expressed per 1% increase, and the models were assessed for calibration using the Hosmer–Lemeshow test and for explanatory power using the Nagelkerke R-squared statistic.

The results delivered a clear verdict on two of the three variables. Older age emerged as the strongest predictor of at-risk foot status, with each additional year of life raising the odds by 2.8% (odds ratio 1.028; 95% confidence interval 1.016–1.039; P < 0.001). The descriptive data traced the same gradient: at-risk status affected 39.6% of patients under 50, 55.3% of those aged 50 to 65, and 62.1% of those over 65. Male sex carried an independent 40% increase in the odds of at-risk status (OR 1.403; 95% CI 1.036–1.901; P = 0.029), with 58.3% of men classified as at risk compared with 48.4% of women. Both findings align with established biology: aging brings cumulative microvascular and macrovascular damage, progressive peripheral neuropathy, worsening peripheral arterial disease, thinner skin, slower tissue repair, and a heavier comorbidity burden, while men in many cohorts show higher rates of arterial disease and less favorable cardiovascular risk profiles.

The surprise came from HbA1c. Despite its reputation as the master metric of diabetes control, the glycemic marker showed no independent association with at-risk foot status (OR 1.037; P = 0.422) and fell short of statistical significance for active ulceration (OR 1.224; P = 0.077). Yet the raw descriptive numbers told a more suggestive story. Foot ulcer prevalence climbed steadily across HbA1c categories, from 1.9% among patients with HbA1c below 7.0% to 2.6% in the 7.0–9.0% band and 6.3% among those exceeding 9.0%. The authors argue that this gradient is biologically plausible and consistent with the known pathophysiology of wound breakdown, which involves chronic inflammation, immune dysfunction, endothelial impairment, and delayed repair, all of which are sensitive to current metabolic state.

Why might a single HbA1c reading fail to predict foot risk while still tracking ulceration descriptively? The researchers offer a mechanistic explanation rooted in the different time scales of the two outcomes. The IWGDF classification is built on structural, cumulative risk factors, including peripheral neuropathy, peripheral arterial disease, foot deformity, previous ulceration, and amputation, which develop over years or decades of glycemic exposure and vascular injury. A single recent HbA1c measurement captures only a snapshot of that long arc. Active ulceration, by contrast, represents acute tissue breakdown and impaired healing, processes that may respond more directly to current metabolic control. In other words, the foot risk category reflects the accumulated damage of the past, while the open wound may reflect the metabolic environment of the present.

The authors are careful, however, not to overstate what their data can support. The dataset lacked a long list of variables that any foot specialist would consider essential: diabetes duration, severity of neuropathy and peripheral arterial disease, renal function and chronic kidney disease, diabetic retinopathy, body mass index, smoking status, medication use, nationality, and socioeconomic status. Because these potential confounders could not be adjusted for, residual confounding cannot be excluded, and the independent role of HbA1c in diabetic foot risk cannot be confirmed or ruled out on the basis of this study alone. The team also notes that the most recent HbA1c value may not correspond in time to the foot assessment, introducing possible exposure misclassification, and that a single measurement may poorly represent long-term glycemic variability.

Several other quirks in the data deserve cautious reading. Active ulceration was recorded in only 21 patients, or 3.0% of the cohort, and its distribution across subgroups was uneven in ways that resist simple interpretation. Ulcer prevalence peaked in the 50-to-65 age group at 4.4% rather than among the over-65s at 2.6%, a pattern the authors attribute plausibly to survivor bias, more intensive surveillance of older patients, and reduced mobility in the oldest group, which may limit the repetitive mechanical trauma that drives skin breakdown even as structural risk rises. Similarly, although men carried higher at-risk status, active ulcers were actually more frequent in women, 3.7% versus 2.0%, a discrepancy that could reflect differences in healthcare utilization, footwear, mobility, or wound healing rather than biology. With so few ulcer events, the statistical models had limited precision, and the authors emphasize that their age–sex–HbA1c models were never intended as comprehensive risk-prediction tools.

The study’s strengths lie in its design discipline. The census approach avoided discretionary subsampling, the standardized IWGDF framework allowed comparison with international benchmarks, and reporting followed the STROBE guidelines for observational research. Its limitations are equally clear: the single tertiary center limits generalizability to primary care and community settings, the cross-sectional design forbids any causal inference, and the absence of the total number of diabetic patients seen at the center means the completeness of screening coverage could not be determined. A history of lower-extremity amputation was documented in only four patients and was deliberately excluded from the models, partly because amputation history is itself a defining criterion of IWGDF category 3, which would make its inclusion circular.

The practical message for clinicians and health systems is nonetheless concrete. With more than half of specialist-attending patients already in an at-risk category, the authors argue that foot screening and preventive care should be tailored to demographic profiles, with intensified surveillance for older patients and men, and delivered through multidisciplinary teams spanning podiatry, vascular assessment, endocrinology, and patient education. Glycemic optimization remains a cornerstone of diabetic foot prevention, but the study suggests that blood sugar control alone cannot identify who is in danger. What is needed next, the researchers conclude, are prospective, multicenter, longitudinal studies that capture the full spectrum of clinical, laboratory, and behavioral variables, so that risk-prediction models can be built and validated for Saudi Arabia and the wider Middle East and North Africa region, where the diabetes epidemic is still gathering force.

Subject of Research: Associations of glycemic control, age, and sex with diabetic foot risk and active foot ulceration in patients with diabetes in Saudi Arabia

Article Title: Associations of Glycemic Control, Age, and Sex with Diabetic Foot Risk and Active Foot Ulceration among Patients with Diabetes in Saudi Arabia: A Cross-Sectional Study

Article References: Alenazi, F. Z., Alslamah, T., Alharbi, B., Alotaibi, W. I., Fawaz, M., Algeffari, M., Alsalamah, Y. S., & Raposo, A. (2026). Associations of Glycemic Control, Age, and Sex with Diabetic Foot Risk and Active Foot Ulceration among Patients with Diabetes in Saudi Arabia: A Cross-Sectional Study. Diabetes Therapy. https://doi.org/10.1007/s13300-026-01923-y

Image Credits: AI Generated

DOI: 10.1007/s13300-026-01923-y

Keywords: diabetic foot, foot ulceration, HbA1c, glycemic control, IWGDF risk stratification, type 2 diabetes, peripheral neuropathy, peripheral arterial disease, Saudi Arabia, cross-sectional study, logistic regression, diabetes complications

Osteomyelitis of the foot is a familiar adversary in medicine, particularly among patients with diabetes and peripheral neuropathy, where loss of protective sensation allows small wounds to deepen unnoticed until bacteria reach bone. The standard playbook combines targeted antibiotics with surgical removal of infected bone, an approach widely accepted as effective for most cases of diabetic foot osteomyelitis. But the operation itself is only the opening act. Wound care after amputation remains one of the most deceptively difficult phases of treatment, because the surgeon is working with tissue that is already infected, poorly perfused, and dependent on a patient’s long-term cooperation. In this case, the toe was amputated at a secondary hospital, yet the story took a turn that clinicians see all too often: after seven days of hospitalization, dissatisfied with the service and the wound dressing care he was receiving, the patient discharged himself against medical advice.

Several days later he arrived at an outpatient clinic with an oozing wound at the amputation stump. Examination revealed loss of the cutaneous layer, with swollen subcutaneous tissue exposed to the air. Encouragingly, his white blood cell count and C-reactive protein levels were within normal limits, no microbial growth was identified in cultures, and no peripheral necrosis or vascular disease was detected. The wound was not systemically infected. But it refused to dry. The volume of exudate did not decrease, and a transparent yellow discharge, suspicious for synovial fluid leaking from the disrupted joint, persisted day after day. That detail mattered enormously. A dehisced stump with no protective skin barrier, sitting over a joint capsule that might be leaking synovial fluid, is an open invitation for bacteria to colonize the wound and seed the deeper structures. The treating team concluded that flap reconstruction was indispensable, not merely to close a hole but to rebuild the biological wall separating the outside world from the joint.

The operation they chose was the Limberg flap, also known as a rhomboid flap, a workhorse of reconstructive surgery first described decades ago and still prized for its elegant geometry. The technique recruits a diamond-shaped segment of adjacent healthy skin and subcutaneous tissue, transposes it across a pivot point, and uses the laxity of surrounding skin to fill the defect while distributing mechanical tension along the closure lines. Here, the surgeons first performed a rhomboid-shaped debridement, excising necrotic and swollen tissue to leave a clean 3.5 by 3.5 centimeter defect, then raised the Limberg flap with its pivot point at the medial side of the proximal phalanx stump. The geometry was constrained by the previous surgery and the scarcity of healthy adjacent tissue, meaning that mechanical tension on the flap was unavoidable, a compromise the team accepted because no better local option existed.

Perioperative care was built to protect the fragile reconstruction. The patient received a prophylactic first-generation cephalosporin to guard against infection, a prostaglandin E1 analogue to promote vasodilation, and antiplatelet therapy to enhance blood supply to the flap, a rational combination given that microvascular perfusion determines whether transferred skin lives or dies. In the immediate aftermath, the strategy appeared to work. Exudate dropped markedly, and the suspicious synovial fluid leakage stopped entirely, confirming that the flap had successfully sealed the joint. One week after surgery, however, mild edematous changes appeared in the flap, and the tissue eventually became necrotic. The reconstruction had partially failed, a consequence of the tension under which it was placed and the compromised local conditions.

What happened next is arguably the most instructive part of the case. Rather than rushing back to the operating room for another flap or a skin graft, the team pivoted to conservative management: daily dressing changes with intermittent debridement of the necrotic material. Although the skin flap did not fully survive, it continued to serve as a physical barrier and provided structural support to the adjacent tissue, promoting recovery and the formation of healthy granulation tissue beneath it. Over the following two months, healthy tissue gradually covered the lesion, and the wound healed by secondary intention. The authors point out that this outcome echoes a concept recognized in the literature, in which even a failed flap can function as a biological dressing, reducing contamination and inflammation and facilitating the development of healthy tissue before any subsequent grafting. In other words, a partially necrotic flap is not always a wasted operation; sometimes it is scaffolding.

The case also shines a light on how often amputation wounds go wrong in broader populations. Stump-related complications are dominated by wound infection and poor healing, which account for roughly 70 percent of problems, followed by poorly fashioned stumps at 20 percent and phantom pain at 10 percent. Research has linked smoking to both immediate and late complications, preoperative infection to immediate and intermediate complications, and amputations performed for peripheral vascular disease or trauma to late complications. One study of 739 patients who underwent lower-limb amputation found that 8.3 percent were readmitted within 30 days because of stump-related complications, and 61 percent of those complications required surgical intervention, with readmission rates of 35.9 percent after above-knee amputation and 68.7 percent after below-knee amputation. In the present patient, the authors suggest that both his smoking history and the underlying osteomyelitis likely contributed to the wound breakdown, and they note that pre-emptive vascular examinations to identify peripheral vascular disorders would have aided wound care planning from the start.

The report also engages with a genuine technical controversy in modern wound care: the use of topical negative pressure therapy, or TNP, in which vacuum sealing drainage systems actively draw fluid from a wound to promote granulation. While TNP has advanced the management of soft-tissue defects and amputation wounds, its application over open joints remains contested, with variable reported outcomes. In this case, the authors argue that applying negative pressure directly to the wound could have caused excessive drainage of synovial fluid and potential joint disruption. Their proposed sequence for similar situations is therefore deliberate: flap reconstruction first, to close the joint and reestablish the skin barrier, followed by TNP dressing only afterward, once the joint is protected. This ordering, they suggest, captures the benefits of vacuum therapy without exposing a leaking joint to its risks.

Perhaps the most sobering threads running through the case are the ones that have nothing to do with surgical technique. The patient’s poor sanitary conditions, his ingrown toenails, his self-discharge against medical advice, and his refusal to return to the hospital where the amputation was performed all shaped the clinical course as powerfully as any incision. The authors emphasize that understanding patient needs and providing clear explanations of wound status at every visit are essential for building trust, and that consistent wound care until complete recovery is non-negotiable, yet the high cost of treatment often limits access to appropriate care. This patient was a type I medical aid recipient in South Korea, with his basic wound care almost fully covered by government support, a fact the authors credit with making the prolonged dressing regimen feasible. They call for greater coordination among healthcare systems, insurance providers, and government assistance programs to reduce the burden of medical poverty, arguing that patient compliance, trust in clinicians, and financial support together determine whether complicated wounds heal. The case, prepared in accordance with the SCARE reporting criteria, ultimately delivers a double lesson: a well-executed Limberg flap can rescue a failing amputation stump even when the flap itself partially dies, but surgery is only one pillar of recovery, and the quieter work of daily dressings, repeated debridement, and sustained patient engagement is what carries the wound across the finish line.

Subject of Research: Management of a complicated post-amputation stump wound using Limberg flap reconstruction and persistent wound care following toe osteomyelitis

Article Title: Complicated post-amputation stump wound managed with a Limberg flap and persistent wound care: a case report

Article References: Complicated post-amputation stump wound managed with a Limberg flap and persistent wound care: a case report. (n.d.). https://doi.org/10.1186/s44452-026-00028-6

Image Credits: AI Generated

DOI: 10.1186/s44452-026-00028-6

Keywords: osteomyelitis, amputation, Limberg flap, wound care, flap reconstruction, debridement, stump complications, topical negative pressure, patient compliance, diabetic foot, reconstructive surgery, synovial fluid leakage