Major lower-limb amputation, performed either below the knee (transtibial) or above the knee (transfemoral), remains one of the most serious outcomes of diabetic foot disease and peripheral artery disease (PAD). Much of the diabetic foot literature focuses on preventing amputation, but understanding what happens after one is equally important. Survival, the ability to walk again, and the likelihood of returning home all vary considerably, and the level at which an amputation is performed is among the strongest influences on each. This article summarizes what recent systematic reviews and cohort studies report about life after a major amputation in people with diabetes and vascular disease.
Survival After Major Amputation
Mortality after major amputation is high, reflecting the burden of cardiovascular and kidney disease that usually accompanies it. A 2021 systematic review and meta-analysis by Meshkin and colleagues, published in the Journal of Foot and Ankle Surgery, pooled 61 studies including 36,037 patients who underwent nontraumatic major amputation. Pooled mortality was 33.7% at one year, 51.5% at two years, 53% at three years, 64.4% at five years, and 80% at ten years. In the subgroup of 8,184 patients with type 1 or type 2 diabetes, mortality was 27.3% at one year and 63.2% at five years.
An earlier meta-analysis by Stern and colleagues in the Annals of Vascular Surgery (2017), which included 16 observational studies published between 2005 and 2015, reported similarly sobering figures and identified factors associated with at least a two-fold increase in mortality: coronary artery disease, cerebrovascular disease, renal dysfunction, an American Society of Anesthesiologists class of 4 or higher, dementia, and being nonambulatory before surgery. A higher amputation level and staged procedures beginning with a guillotine amputation were also associated with worse survival.
Below-Knee Versus Above-Knee
Amputation level matters. In a 2023 literature review of 45 studies and more than 400,000 patients, Qaarie reported that average one-year mortality was approximately 28% after below-knee amputation compared with approximately 49.5% after above-knee amputation. These are unweighted averages across heterogeneous studies, and part of the difference reflects the fact that people who need an above-knee amputation are often older and more medically fragile. Even so, the pattern is consistent across the literature: preserving the knee is associated with better survival.
Walking Again: Prosthetic Mobility
For many patients, the most meaningful question after amputation is whether they will walk again. Forsyth and colleagues (2023) analyzed 2,055 patients in the Vascular Quality Initiative registry who were walking before a major amputation and who had one-year follow-up. At one year, 67% of patients with a below-knee amputation were ambulatory, independently or with assistance, compared with 50% of those with an above-knee amputation. Overall, 62% of previously ambulatory patients were still walking at one year. A prior amputation of the opposite leg was the strongest predictor of being unable to walk.
The energy cost of walking explains part of this gap. Walking with a transfemoral prosthesis requires considerably more effort than walking with a transtibial prosthesis, and that added demand can exceed what an older person with heart disease, lung disease, or deconditioning can sustain.
An updated systematic review by Kahle and colleagues (2016), covering more than 12,000 participants, found moderate to strong support for several predictors of successful prosthetic use: the cause of amputation, physical fitness, living situation before amputation, amputation level, age, and comorbidities. People whose amputations are due to vascular disease, as in most diabetic amputations, generally have lower rates of prosthetic success than those whose amputations are due to trauma.
Returning Home and Rehabilitation
Discharge destination is another important outcome. In a multicentre Dutch study of 382 people who underwent dysvascular major amputation, Fard, Geertzen, and Dijkstra (2020) found that only 21% of patients admitted from home who survived the hospital stay were discharged directly home. Among those discharged to a care facility who survived the first year, 77% eventually returned home within that year. Living with a partner was associated with nearly three times the odds of returning home, while inpatient rehabilitation was associated with more than ten times the odds. Roughly one-third of the cohort did not survive to one year.
These findings suggest that structured rehabilitation, whether in a dedicated inpatient unit or a geriatric rehabilitation setting, is closely linked to regaining independence, although observational data cannot fully separate the effect of rehabilitation from the selection of healthier patients into these programs.
Conclusion
Major amputation in people with diabetes and PAD carries a mortality rate of roughly one in three at one year and close to two in three at five years. Below-knee amputation is consistently associated with better survival and a higher likelihood of walking again than above-knee amputation. Prior contralateral amputation, older age, and significant cardiac, cerebrovascular, and renal disease predict poorer outcomes, while inpatient rehabilitation and social support are associated with returning home. These outcomes underline why preserving limb length, and above all preventing the foot ulcers and infections that lead to amputation, remains central to diabetic foot care.
References
- Meshkin DH, Zolper EG, Chang K, et al. Long-term mortality after nontraumatic major lower extremity amputation: a systematic review and meta-analysis. Journal of Foot and Ankle Surgery. 2021;60:567-576.
- Stern JR, Wong CK, Yerovinkina M, et al. A meta-analysis of long-term mortality and associated risk factors following lower extremity amputation. Annals of Vascular Surgery. 2017;42:322-327.
- Qaarie MY. Life expectancy and mortality after lower extremity amputation: overview and analysis of literature. Cureus. 2023;15(5):e38944.
- Forsyth A, Diamond K, Judelson D, Aiello F, Schanzer A, Simons J. Predictors of ambulatory status at 1 year following major lower extremity amputation. Journal of Foot and Ankle Surgery. 2023;62(6):943-950.
- Kahle JT, Highsmith MJ, Schaepper H, Johannesson A, Orendurff MS, Kaufman K. Predicting walking ability following lower limb amputation: an updated systematic literature review. Technology and Innovation. 2016;18(2-3).
- Fard B, Geertzen JHB, Dijkstra PU. Return home after dysvascular major amputation of the lower limb: a multicentre observational study in the Netherlands. Journal of Rehabilitation Medicine. 2020;52(1).
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