TOPLINE

Among patients with diabetes in England, even as rates of below-knee amputation have declined, those who underwent the procedure continued to face substantial mortality — 23.5% at 1 year and 82.3% at 10 years — a risk that has shown no improvement since 2012. Female sex, older age, and greater comorbidity burden were independently associated with a higher risk for mortality.

METHODOLOGY

• Researchers conducted a nationwide cohort study to assess mortality, causes of death, and postoperative complications after below-knee amputation among patients with diabetes in England and to track whether outcomes have changed over time.
• They included 25,176 patients with diabetes (23.31% female individuals) representing 28,232 below-knee amputation procedures performed over a 25-year period spanning from 1998 to 2023.
• The procedure was limited to transtibial amputations; cases involving amputations through or above the knee, at the ankle, or of the foot were not included.
• The primary outcome was all-cause mortality; secondary outcomes included causes of death, complications and readmissions within 90 days, the need for repeat surgery, and any further amputation.
• The mean follow-up duration among survivors was 6.15 years after their procedure.

TAKEAWAY

• The incidence of below-knee amputation per 100,000 people in the general population fell from 2.5 (95% CI, 2.4-2.7) in 1998 to 1.9 (95% CI, 1.8-2.1) in 2012 and then remained steady at roughly 2.1 (95% CI, 2.0-2.2) through 2022.
• The risk for mortality after below-knee amputation was 11.32% by 90 days, increasing to 23.53% by 1 year, 60.04% by 5 years, and 82.28% by 10 years; ischaemic heart disease, respiratory illness, and sepsis linked to the surgical wound accounted for most deaths.
• In adjusted analysis, female vs male sex was linked to higher mortality (hazard ratio [HR], 1.06 at 1 year and 1.04 at 5 years); older age also significantly increased the risk for mortality (60-79 years: 1-year HR, 1.62; 80 years or older: 1-year HR, 2.66).
• A heavier burden of coexisting illness — measured using the Charlson Comorbidity Index score — raised the 1-year risk for mortality by 4% for every additional point on the score. The median length of stay in the hospital was 24 days, declining from 34 days in 1998 to 20 days in 2022.
• The 90-day readmission rate for any cause was 20.25% (95% CI, 19.78%-20.72%); common complications in that window included reoperation, myocardial infarction, acute kidney injury, and lower respiratory tract infection.

IN PRACTICE

"[The study] findings suggest that the next major opportunity to improve outcomes lies in developing and evaluating structured multidisciplinary postamputation care pathways for people who ultimately require BKA [below-knee amputation]," the authors wrote.

SOURCE

The study was led by Conor Hennessy, Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, England. It was published online on September 14, 2026, in Diabetes Care.

LIMITATIONS

Because the study's conclusions relied on how accurately procedures and diagnoses were coded in the records, some cases may have been misclassified or missed altogether. Moreover, the researchers also could not separate outcomes by diabetes type or the reasons behind each amputation.

DISCLOSURES

This study was funded by the Royal College of Surgeons, England, and the British Orthopaedic Foot and Ankle Society. The authors reported having no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.