A landmark study in England shows that even as below-knee amputations among people with diabetes decline, survival post-surgery remains critically poor, with over 80% dead within ten years and high short-term complications, highlighting the urgent need for improved post-amputation care.
A large national study in England has found that, even as the number of below-knee amputations among people with diabetes has eased over time, the outlook after surgery remains stark. Researchers led by Conor Hennessy of Oxford University Hospitals reported in Diabetes Care that 23.5% of patients died within a year of the procedure and 82.3% were dead within 10 years, with no meaningful improvement in survival since 2012.
The analysis covered 25,176 people with diabetes who underwent 28,232 transtibial amputations between 1998 and 2023. According to the paper, the rate of below-knee amputation in the general population fell from 2.5 per 100,000 people in 1998 to 1.9 in 2012, before settling at about 2.1 through 2022. The average hospital stay also shortened over the study period, dropping from 34 days in 1998 to 20 days in 2022.
Mortality rose sharply after surgery. The researchers found that 11.3% of patients had died within 90 days, 60.0% within five years and 82.3% within 10 years. Ischaemic heart disease, respiratory disease and sepsis related to the wound were among the leading causes of death. Women, older patients and those with a greater burden of other illness all faced a higher risk of dying after the operation.
The study also points to a heavy short-term burden after discharge. Within 90 days, about one in five patients was readmitted to hospital for any cause. Common complications included reoperation, heart attack, acute kidney injury and lower respiratory tract infection. In a separate analysis published on ScienceDirect, chronic kidney disease, low albumin, a raised white blood cell count and a higher Charlson Comorbidity Index were also linked with worse survival after below-knee amputation, reinforcing the importance of careful pre-operative assessment.
Taken together with earlier research showing that major amputations carry very high medium-term mortality, the new findings underline how severe the systemic illness is in many patients who reach this stage of diabetic foot disease. The authors said the next major opportunity to improve outcomes may lie in structured multidisciplinary post-amputation care pathways, a conclusion that echoes older UK and international studies calling for stronger team-based care to prevent amputations in the first place and to manage patients more aggressively afterwards.
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