Below-knee amputation in diabetes: mortality has not improved since 2012

Design

National population cohort, linked hospital and mortality records, 25 years

Population

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

Primary outcome

All-cause mortality (Kaplan-Meier)

Effect

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

Investigators linked Hospital Episode Statistics to death records for every person with diabetes in England who had a below-knee amputation over 25 years: 25,176 people and 28,232 procedures.

Mortality was 23.5% at one year, 60.0% at five years and 82.3% at ten, and the curve has not shifted since 2012. Older age (HR 1.62), female sex (HR 1.06) and each extra point on the Charlson Comorbidity Index (HR 1.04) were independently associated with death. Within 90 days, 20.25% were readmitted, 6.24% returned to theatre and 3.74% had a myocardial infarction. By five years, 6.43% had lost the other leg.

These figures sit alongside many cancers, and they should shape both the conversation before surgery and the cardiovascular and contralateral foot care afterwards. The amputation is not the end of the foot problem; it marks a patient at very high risk on every front.

• Use the one-year figure of about one in four deaths when counselling a patient and family before below-knee amputation.
• Review statin, antiplatelet and blood pressure treatment after amputation — about 1 in 27 had a heart attack within 90 days.
• Put the remaining foot under high-risk surveillance from discharge; about 1 in 16 lose it within five years.
• Plan for readmission: one in five returned to hospital within 90 days.
• Older patients, women and those with several comorbidities carried the highest risk of death.

Why it matters

Ten years of better diabetes drugs have not moved survival after amputation, so the gain has to come from what happens around it.

Don't overread it

This is routinely coded hospital data — it shows who died, not which care would have prevented it.

The statistics, in plain English

A hazard ratio of 1.62 for older age means the risk of death at any point was about 62% higher in the older group after adjusting for the other factors. The female-sex ratio of 1.06 is statistically clear in a cohort this size but small in absolute terms; comorbidity and age matter far more for an individual patient.

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