One year after a below-knee amputation, a quarter of patients are dead

Design

national population study using mortality-linked Hospital Episode Statistics, 25 years

Population

25,176 people with diabetes undergoing 28,232 below-knee amputations in England

Primary outcome

all-cause mortality (Kaplan-Meier)

Effect

23.5% at 1 year, 60.0% at 5 years, 82.3% at 10 years; no improvement since 2012

Mortality-linked Hospital Episode Statistics covering 25,176 people with diabetes and 28,232 below-knee amputation procedures in England give the clearest survival picture yet for advanced diabetic foot disease. All-cause mortality by Kaplan-Meier analysis was 23.5% at one year, 60.0% at five years and 82.3% at ten years. The study's own conclusion is the part that stings: no improvement since 2012.

Older age carried a hazard ratio of 1.62 (95% CI 1.56-1.69), rising Charlson Comorbidity Index 1.04 per point, and female sex 1.06 (95% CI 1.03-1.10). Within 90 days, 20.25% were readmitted, 6.24% went back to theatre and 3.74% had a myocardial infarction. The cumulative incidence of losing the other leg reached 6.43% (95% CI 6.14-6.73) at five years.

These numbers belong in two conversations. The first is consent: a major amputation is not a procedure a patient recovers from and moves on: it identifies a person whose ten-year survival is worse than many cancers. The second is escalation. If outcomes after amputation have been flat for over a decade, the gains available are upstream, in the weeks when a foot is still salvageable and a vascular opinion is still useful.

• Record the one- and five-year figures explicitly in the amputation consent discussion, not just the perioperative risk.
• Treat a completed below-knee amputation as a trigger for full cardiovascular risk review, not as the end of an episode.
• Check the contralateral foot at every post-amputation contact; roughly 1 in 15 lose it within five years.
• Flag high Charlson score and older age at referral, not after the operation, while limb salvage is still possible.
• In Indian practice, where presentation is frequently later and vascular services are further away, treat any ulcer with an absent pulse as an urgent referral rather than a dressing problem.

Why it matters

Amputation is still often framed as the treatment that ends the foot problem; these figures say it marks the start of the highest-risk period of the patient's life.

Don't overread it

This is observational registry data: it identifies who dies after amputation, not what would have happened had the limb been salvaged.

The statistics, in plain English

The hazard ratios for sex (1.06, CI 1.03-1.10) and comorbidity (1.04 per point) are statistically clear but small: sex is not what decides this patient's outlook. Age, at 1.62, is doing far more work. The confidence intervals are tight because the cohort is large, so precision here reflects sample size rather than a large effect, and a narrow interval around a small number is still a small number.

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