All-Cause Mortality, Morbidity, and Reamputation Rates Following Below-Knee Amputation in 25,176 People With Diabetes: A 25-Year England Population Study

OBJECTIVE Below-knee amputation (BKA) is the most common major amputation for advanced diabetic foot disease. Understanding the associated mortality, cause of death, and postoperative risks is important for patient counseling and improving care. This national population study described mortality and causes of death following BKA in people with diabetes, identifying those at greatest risk and whether mortality has improved. It investigated perioperative complications, readmission, reoperation, and further limb amputation. RESEARCH DESIGN AND METHODS An England population study of people with diabetes undergoing BKA was performed using mortality-linked Hospital Episode Statistics. The primary outcome was Kaplan-Meier analysis of all-cause mortality. Cox proportional hazards modeling identified variables associated with high mortality. Secondary outcomes included causes of death, 90-day complications, readmission, and further amputation rates. RESULTS A total of 25,176 people with diabetes underwent 28,232 BKA procedures. Mortality was 23.5% at 1 year, 60.0% at 5 years, and 82.3% at 10 years, with no improvement since 2012. Female sex (hazard ratio [HR] 1.06 [95% CI 1.03–1.10]), older age (HR 1.62 [95% CI 1.56–1.69]), and increasing Charlson Comorbidity Index (HR 1.04 per point) were independently associated with increased mortality. Ninety-day complications included reoperation (6.24%), myocardial infarction (3.74%), and readmission (20.25%). The cumulative incidence of contralateral amputation was 6.43% (95% CI 6.14–6.73%) at 5 years. CONCLUSIONS The associated mortality of BKA in people with diabetes has not improved since 2012. One-year mortality was 23.5%, increasing to 82.3% at 10 years. Older age, female sex, and greater comorbidity burden identified people at greatest risk of death.