Factors Influencing Major Amputation and Death Following Limb Salvage Surgery in a Diabetic Population: Systematic Review and Real-World Comparison

Diabetic foot ulcers drive non-traumatic lower-limb amputation; limb salvage surgery is often pursued to preserve function and survival. Predictors of adverse outcomes remain incompletely defined, and evidence for multidisciplinary team (MDT) care is heterogeneous. We aimed to clarify risk factors for major amputation and death after diabetic limb salvage and evaluate MDT impact. We systematically reviewed 49 studies (2020–2025) reporting major amputation or mortality after limb salvage in diabetes (PROSPERO CRD420251044859). Risk factors spanned demographic, clinical, and surgical domains (e.g., older age, male sex, renal/cardiovascular disease, ischemia, osteomyelitis, advanced ulcer classification). MDT models generally showed lower amputation rates and improved wound healing, with occasional survival benefits; heterogeneity precluded meta-analysis. As a real-world comparator, the Mid Essex Diabetes Amputation Reduction Plan (MEDARP) treated 72 high-risk patients using a “toe and flow” MDT. Major amputation occurred in 6.9% and mortality in 12.5%, both at or below published ranges, with gains in patient-reported outcomes. Findings support MDT-based strategies, but conclusions should be interpreted cautiously given the predominantly observational evidence, and highlight the need for standardized outcome definitions and reporting.