Review Article

Lower extremity amputations a review of global

variability in incidence
P. W. Moxey, P. Gogalniceanu, R. J. Hinchliffe, I. M. Loftus, K. J. Jones, M. M. Thompson
and P. J. Holt
St Georges Vascular Institute, St Georges Hospital NHS Trust, London, UK
Accepted 3 March 2011
Abstract
Aim To quantify global variation in the incidence of lower extremity amputations in light of the rising prevalence of diabetes
mellitus.
Methods An electronic search was performed using the EMBASE and MEDLINE databases from 1989 until 2010 for
incidence of lower extremity amputation. The literature reviewconformedtoPreferredReporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) statement standards.
Results Incidence of all forms of lower extremity amputationranges from46.1to9600per 10
5
inthe populationwithdiabetes
compared with 5.831 per 10
5
inthe total population. Major amputationranges from5.6to 600per 10
5
inthe populationwith
diabetes and from3.6 to 68.4 per 10
5
in the total population. Signicant reductions in incidence of lower extremity amputation
have been shown in specic at-risk populations after the introduction of specialist diabetic foot clinics.
Conclusion Signicant global variationexists inthe incidence of lower extremity amputation. Ethnicity andsocial deprivation
play a signicant role but it is the role of diabetes and its complications that is most profound. Lower extremity amputation
reporting methods demonstrate signicant variation with no single standard upon which to benchmark care. Effective
standardized reporting methods of major, minor and at-risk populations are needed in order to quantify and monitor the
growing multidisciplinary team effect on lower extremity amputation rates globally.
Diabet. Med. 28, 11441153 (2011)
Keywords amputation, diabetes, ethnicity, incidence, reporting
Introduction
The incidence of diabetes mellitus has reached pandemic status
and will drive an increase in future rates of peripheral arterial
occlusive disease(PAOD), neuropathyandsoft tissuesepsis [1,2].
This triad is responsible for the majority of lower extremity
amputations. Eighty-two per cent of all vascular-related lower
extremity amputations in the USA are associated with diabetes
[3] andpatients withdiabetes have a30times greater lifetime risk
of having an amputation than patients without diabetes [46].
This has signicant implications on global healthcare systems,
with annual costs of lower extremity amputations in the USA
reaching $4.3bn [7].
In 1990, the St Vincent Declaration identied the reduction of
lower extremity amputations as a principal healthcare target,
aiming to reduce the rate of amputation by half within 5 years
[5]. Attempts at quantifying the incidence of lower extremity
amputations have been made and a number of encouraging
studies have beenpublishedshowing signicant improvements in
the incidence of lower extremity amputations [813]. However,
in order to accurately assess the impact of new healthcare
measures and interventions, accurate data regarding the extent
and depth of the problem are needed to both direct service
provision and act as a baseline from which change can be
measured. We have sought to review the current literature for
contemporary data on the incidence of lower extremity
amputation and to examine variation in these parameters
worldwide.
Methods
A PubMed and Cochrane Library review was undertaken in
order toascertainincidence andmortality andchanging trends in
lower extremityamputationinthe UKandworldwide from1989
Correspondence to: P. W. Moxey, St Georges Vascular Institute, St Georges
Hospital NHS Trust, Tooting, London, SW17 0QT, UK. E-mail: paul.moxey@
nhs.net
DIABETICMedicine
DOI: 10.1111/j.1464-5491.2011.03279.x
2011 The Authors.
1144 Diabetic Medicine 2011 Diabetes UK
to the present. A search was performed for the terms
amputation and lower extremity amputation, with further
renements undertaken for the terms incidence and
prevalence. Inclusion criteria consisted of all single-centre,
regional or population-based studies with more than 50 patients
and lower extremity amputation at any anatomical level. Papers
describing bilateral primary lower extremity amputation or
contra-lateral lower extremity amputation following primary
lower extremity amputation were also included. Studies
describing lower extremity amputation secondary to trauma or
cancer were excluded.
Atotal of 2850 abstracts were identied, of which 57 fullled
the dened criteria. Figure 1 is a Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) ow chart
outlining the search and review process [14]. Because of the
retrospective nature of the data, no randomized controlled trials
were identied. Abstracts were screened for suitability and, if
appropriate, full-text articles were retrieved and reviewed by
PWM and PG.
Incidence, where possible, was expressed as numbers of lower
extremity amputations per 100 000 (10
5
) individuals. Incidence
in the at-risk population with diabetes was reported alongside
that of thegeneral population, wherepossible, andthepopulation
without diabetes (if data were available) for comparison. The
diabetic status of patients was ascertained if reported, with
differentiationbeing made betweenType 1andType 2diabetes,
as well as insulin-dependent and non-insulin-dependent status
for Type 2 diabetes. Amputation was dened as loss of part of a
lower limb in the transverse plane. Major lower extremity
amputation is dened as above, through or below knee loss of
a limb. Minor amputation refers to belowthe level of the ankle.
Results
From 48 manuscripts identied, the results were divided into
those papers reporting incidence of all lower extremity
amputations (major and minor combined) and those
differentiating between the two. Table 1 identies those studies
reporting incidence of all lower extremity amputations. No
differentiation was made between major or minor lower
extremity amputations in these studies. Four differentiate the
incidence of all lower extremity amputations between the
at-risk population with diabetes and those without diabetes
[4,1517]. Two data sources reported incidence rates with no
differentiation between types of amputation or patients diabetic
status [18,19].
Table 2 shows incidence rates for major lower extremity
amputation as reported in 28 papers.
Table 3 summarizes those papers reporting the incidence of
minor amputation. This is reported less frequently, with only
Records identified through
database searching
(n = 2850)
Additional records identified
through other sources
(n = 15)
Records after duplicates removed
(n = 2865)
Records screened
(n = 2865)
Records excluded
(n = 2773)
Full-text articles excluded
(n = 35)
Full-text articles assessed
for eligibility
(n = 92)
Studies included in review
(n = 57)
I
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u
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e
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FIGURE 1 PreferredReportingItems for Systematic Reviews andMeta-Analyses (PRISMA) owchart outliningtheprocess of searchandselectionof reviewed
articles [14]
DIABETICMedicine Review article
2011 The Authors.
Diabetic Medicine 2011 Diabetes UK 1145
seven studies reporting stand-alone incidence of minor
amputation.
Table 4 summarizes those studies that have reported a
signicant change in the incidence of major or minor
amputation over time. Other studies [2023] were identied
that report a reductioninincidence, but where excludedfromthe
table as no clear incidence gures were reported in the
manuscript but rather a percentage reduction given.
Discussion
This review of incidence rates for lower extremity amputation
aims to update readers with new data published since the last
major reviewby Jeffcoate and van Houtumin 2004 [13]. Lower
extremity amputation has become the focus of renewed interest
by the medical profession, and political bodies with new
initiatives such as Putting Feet First in the UK and
international meetings with a lower limb salvage focus being
launched in an attempt to raise awareness and reduce the
incidence of amputation [24].
The worldwide incidence of lower extremity amputation is
high and, although variations exist, it is often difcult to directly
compare rates as a result of heterogeneity in the populations
studied. Summarizing the large volume of published data
reporting incidence poses a signicant challenge because of the
variation in reporting methods used.
Studies that only report rates for all forms of lower extremity
amputations have questionable value in establishing trends and
informing practice. The clinical distinction and objectives of
performing a major and minor amputation are distinct. Minor
amputation may be performed as an adjunct to lower limb
revascularization in attempted limb salvage. Major amputation
represents failed limb salvage. The only meaningful use of all
lower extremity amputation incidence rates is to represent the
burden of amputation on the at-risk population with diabetes.
Van Houtum in 2008 and Jeffcoate in 2004 set out that, to
directly compare studies, one must look at the population
studied, the denition of numerator and denominator, specic
denitions used and the beliefs of the patients and investigators
[13,25]. The denominator is especiallyimportant as it canchange
the entire message of a study. Data from the Netherlands when
expressed per 100 000of the total populationshowednodecline
in lower extremity amputations, but when expressed as a
proportion of the rising population with diabetes there was a
clear trend downwards [26]. In the studies presented here, the
denominator is not constant but the message is clear: diabetes
mellitus greatly increases incidence and mortality of lower
extremity amputation.
Table 1 Global variation of incidence of all lower extremity amputations (LEA) by diabetic status
Reference
(by rst author)
Incidence
(per 10
5
) Year of study
Type of
amputation Population Study population
Calle-Pascual [4] 46.1 19941996 All LEA At risk Madrid, Spain
Chaturvedi [31]* 100 19771988 All LEA At risk East Asia
Leggetter [51] 147219 19921997 All LEA At risk London, UK
Morris [22] 248 19931994 All LEA At risk Tayside, Scotland, UK
van Houtum [26] 361 2000 All LEA At risk Netherlands
Lavery [58] 410 All LEA At risk non-Hispanic Whites Maryland, USA
Trautner [16] 428 2005 All LEA At risk Germany
Lavery [58] 590 All LEA At risk Texas, USA
Stiegler [17] 660 1995 All LEA At risk Germany
Birke [59] 720 1999 All LEA At risk Louisiana, USA
Lavery [58] 740 All LEA At riskMexicans Texas, USA
Adler [60] 1130 19901999 All LEA At-risk males Seattle, USA
Lee [61] 1800 19871991 All LEA At risk Oklahoma Indians, USA
Chaturvedi [31]* 3100 19771988 All LEA At risk American Indians, USA
Patout [23] 9600 19981999 All LEA At risk Louisiana
Payne [62] 14 19951998 All LEA At risk in total population Australia
Dangelser [63] 54 2000 All LEA At risk in total population Reunion Island
Fosse [15] 158 20022003 All LEA At risk in total population France
Vaccaro [49] 5.8 1996 All LEA Total population Campania, Italy
Deerochanawong [64] 5.7 19891991 Major LEA Total population Newcastle, UK
Chen [19] 18.1 1997 All LEA Total population Taiwan
CDC Monthly Report [18] 24 2005 All LEA Total population USA
Trautner [16] 31 2005 All LEA Total population Germany
Calle-Pascual [4] 1.5 19941996 All LEA No diabetes Madrid, Spain
Trautner [16] 12 2005 All LEA No diabetes Germany
Fosse [15] 13 20022003 All LEA No diabetes France
Stiegler [17] 20 1995 All LEA No diabetes Germany
*This study includes unoperated gangrene.
Centre for Disease Control and Prevention, Atlanta, USA.
DIABETICMedicine Lower extremity amputationsa global review P. W. Moxey et al.
2011 The Authors.
1146 Diabetic Medicine 2011 Diabetes UK
Diabetes, infection and peripheral vascular disease are known
to be the predominant causes of non-healing foot ulcers [27],
which in turn is the principal cause of lower extremity
amputation both in the UK and USA [28,29]. Discrepancies in
lower extremity amputation rates on a national level may be
caused by differences in vascular-diabetic service provision and
regional clinical practice [30]. Ethnicity, socio-economic status,
access to health care and the annual caseload of procedures
undertaken by individual surgeons or units are also likely to play
a role.
The Global Lower Extremity Amputation Study (GLEAS)
remains the largest retrospective registry study to use
standardized data in order to compare the international
epidemiology of major lower extremity amputation, but is now
11 years old [28]. Selected results have been reported in Table 2
at opposite ends of the range of variation. Chaturvedi et al. also
Table 2 Variation in incidence of major lower extremity amputation (LEA) by diabetic status
Reference
(by rst author)
Incidence
(per 10
5
) Year of study
Type of
amputation Diabetes status Study population
Calle-Pascual [67] 5.6 19971999 Major Women at risk Madrid, Spain
Calle-Pascual [67] 12 19971999 Major Men at risk Madrid, Spain
Rayman.[33] 162 19972000 Major At risk Ipswich, UK
Aragon-Sanchez [68] 176 2009 Major At risk Gran Canaria, Spain
Johannesson [69] 195 19972006 Major* At risk Sweden
Trautner [35] 230 19901991
19941998
Major At risk Germany
Morris [22] 248 19931994 Major At risk Scotland, UK
Wrobel [36] 383 19961997 Major At risk Medicare, USA
Winell [70] 387 2002 Major At risk Finland
Rith-Najarian [71] 600 19941996 Major At risk Chippewa Indians
Vamos [34] 0.7 2005 Major At risk in total population England
Holstein [65] 2.1 1995 Major At risk in total population Copenhagen, Denmark
Vamos [34] 2.7 2005 Major At risk in total population England
Vaccaro [49] 3.5 1996 Major At risk in total population Campania, Italy
Larsson [66] 3.6 19821993 Major At risk in total population Sweden
Holstein [65] 4.1 1995 Major At risk in total population Copenhagen, Denmark
Larsson [66] 9.4 19821993 Major At risk in total population Sweden
Eskelinen [41] 7.3 19992002 Major At risk in total population Helsinki
Canavan [8] 75 2000 Major At risk in total population Middlesbrough, UK
Larsson [66] 3.6 19821993 Major Total population Sweden
GLEAS Group [28] 3.8 19951997 Major Total population Tochigi, Japan
Witso [72] 4.4 19941997 Major Total population Trondheim, Norway
Ebskov [5] 4.5 19821993 Major Female total population Denmark
Ebskov [5] 4.7 19821993 Major Male total population Denmark
Trautner [35] 4.7 19901991
19941998
Major Total population Germany
Rayman [33] 4.5 19972000 Major Total population Ipswich, UK
Moxey [32] 5.1 20032008 Major Total population England, UK
Deerochanawong [64] 5.7 19891991 Major Total population Newcastle, UK
Holstein [65] 6.9 1995 Major Total population Copenhagen, Denmark
Chen [19] 8.8 1997 Major Total population Taiwan
Renzi [29] 15 2006 Major, female Total population USA
Pernot [73] 17.1 1994 Major Total population Limberg, Netherlands
Renzi [29] 23 2006 Major, male Total population USA
GLEAS Group [28] 58.7 19951997 Major Total population Navajo Indians
Remes [74] 24.1 19982002 Major Elderly total population Turku, Finland
Carmona [75] 34.7 19901999 Major Female total population Switzerland
Carmona [75] 68.4 19901999 Major Male total population Switzerland
Vamos [34] 4.9 2005 Major No diabetes England, UK
Eskelinen [41] 5.3 19992002 Major No diabetes Helsinki
Aragon-Sanchez [68] 11 2009 Major No diabetes Gran Canaria, Spain
Morris [22] 14 19931994 Major No diabetes Scotland, UK
Canavan [8] 15.3 2000 Major No diabetes Middlesbrough, UK
Johannesson [69] 23 19972006 Major* No diabetes Sweden
Wrobel [36] 38 19961997 Major No diabetes Medicare, USA
*Trans-metatarsal and above.
GLEAS, Global Lower Extremity Amputation Study.
DIABETICMedicine Review article
2011 The Authors.
Diabetic Medicine 2011 Diabetes UK 1147
publishedglobal results, but theycombinedunoperatedgangrene
and all forms of lower extremity amputation [31]. Although this
allows geographical comparison within their own data to be
made, it is difcult to compare it against other data where
gangrene is not included.
Global variation
National studies have been published that show variations in
incidence bothwithincontinental andnational borders. The UK,
for example, has age-adjusted incidence of rst lower extremity
amputation ranging between 5.1 and 176 per 10
5
population in
different centres [8,28,32]. In England, a 47%decrease in major
amputation rates has been reported between 1997 and 2000,
affecting both the populations with and without diabetes
[8,10,33]. Recent work based upon Hospital Episode Statistic
(HES) data has attempted to clarify the incidence of lower
extremity amputations in England. Moxey et al. reported no
change inthe rate of major amputation(diabetes andnodiabetes)
between 2003 and 2008 (of 5.1 per 10
5
) in England [32] and
Table 3 Variation in incidence of minor lower extremity amputation (LEA) by diabetic status
Reference
(by rst author) Incidence (per 10
5
) Year of study
Type of
amputation Diabetes status Study population
Calle-Pascual [67] 11.3 19971999 Minor At riskwomen Madrid, Spain
Calle-Pascual [67] 33.1 19971999 Minor At riskmen Madrid, Spain
Rayman [33] 123 19972000 Minor At risk Ipswich, UK
Morris [22] 144 19931994 Minor At risk Scotland, UK
Vamos [34] 1.2 2005 Minor At risk in total population England, UK
Vamos [34] 4.1 2005 Minor At risk in total population England, UK
Larsson [42] 6.5 19982001 Minor At risk in total population Sweden
Canavan [8] 100 2000 Minor At risk in total population Middlesbrough, UK
GLEAS Group [28] 0.6 19951997 Minor Total population Tochigi, Japan
Rayman [33] 3.3 19972000 Minor Total population Ipswich, UK
Moxey [32] 6.3 20032008 Minor Total population England, UK
GLEAS Group [28] 98.8 19951997 Minor Total population Navajo Indians
Vamos [34] 5.1 2005 Minor No diabetes England, UK
Morris [22] 9 19931994 Minor No diabetes Scotland, UK
GLEAS, Global Lower Extremity Amputation Study.
Table 4 Studies showing change in incidence of lower extremity amputations (LEA) over time in at-risk populations
Reference
(by rst author)
Baseline
Incidence (10
5
)
End Incidence
(10
5
) Years
Type of amputation and
population
Canavan [8] 310 75 19962000 Major, Middlesbrough, UK
Canavan [8] 253 100 19962000 Minor, Middlesbrough, UK
Krishnan [10] 414 67 19952005 Major, Ipswich, UK
Krishnan [10] 118 93 19952005 Minor, Ipswich, UK
Larsson [42] 16 6.8 19822001 Major, Sweden
Larsson [42] 4.7 6.5 19822001 Minor, Sweden
Calle-Pascual [67] 70.6 12.4 19891999 Major, Madrid, Spain
Calle-Pascual [67] 15.3 5.6 19891999 Major, Madrid, Spain
Calle-Pascual [67] 58.9 33.1 19891999 Minor, Madrid, Spain
Calle-Pascual [67] 11.9 11.3 19891999 Minor, Madrid, Spain
van Houtum [26] 550 360 19912000 All LEA, Netherlands
Trautner [16] 549 428 19902005 All LEA, Germany
Vamos [34] 1.5 1.2 19962005 Minor, England, UK
Vamos. [34] 2.4 4.1 19962005 Minor, England, UK
Vamos [34] 1.3 0.7 19962005 Major, England, UK
Vamos [34] 2 2.7 19962005 Major, England, UK
Stiegler [17] 610 660 19901995 All LEA, Germany
Rayman [33] 228 108 19982000 Major, Ipswich, UK
Winell [70] 924 387 19882002 All LEA, Finland
Patout [23] 9600 2200 1990s All LEA, Louisiana, USA
Birke [59] 1003 720 19981999 All LEA, Louisiana, USA
Ebskov [5] 4.5 2.7 19821993 Major, Denmark
DIABETICMedicine Lower extremity amputationsa global review P. W. Moxey et al.
2011 The Authors.
1148 Diabetic Medicine 2011 Diabetes UK
Vamos et al. report a reduction in the incidence of major
amputation in patients with Type 1 diabetes from 1.3 10
5
in
1996 to 0.7 10
5
in 2005 [34]. The most signicant nding was
the variation in incidence across the country, with rates ranging
from 3.9 to 7.2 per 10
5
(P < 0.0001) across different Strategic
Health Authorities (administrative areas). Diabetes mellitus was
identied as a risk factor in 39.4% of all patients undergoing
lower extremity amputation. Fosse et al. published a rst
national estimate of all lower extremity amputations in France,
withrates of 13per 10
5
inindividuals without diabetes compared
with 158 per 10
5
in individuals with diabetes [15]. Some
European studies document no signicant changes in the rates of
all lower extremity amputations between 1990 and 1998 in both
patients with and without diabetes [17,35], whereas others
suggest an increase in minor amputations subsequent to the
introduction of diabetic podiatry screening services (Table 4).
In the USA, Wrobel et al. report an incidence of major
amputation of 38 per 10
5
in the population of the USA without
diabetes in a national investigation of the Medicare admini-
strative database [36] incorporating all ages and ethnicity. The
USAhas seen a 5%per year drop in the rate of minor and major
amputation between 1989 and 1998, although diabetes-related
lower extremity amputation rates remained unchanged [37].
One study of 33 775 hospital discharges reported a drop in
major amputation rates from 24 to 17 per 10
5
(19962004).
Differences between ethnic groups remained unchanged, with
lower extremity amputation rates in African-American areas
being ve times larger than in non-African-American areas.
Furthermore, whilst major amputation rates in predominantly
white areas decreased from 14 to 12 per 10
5
, incidence in
predominantly African-American areas rose from 59 to 65 per
10
5
(19872004) [38]. Overall, major amputation rates are
higher in the USAcompared with the rest of the world at 23.6 vs.
14.2 per 10
5
males and 15.2 vs. 6.7 per 10
5
females [29].
Disparity in incidence also exists across Asia and Australasia.
In Australia, a fall in lower extremity amputations rates has been
recorded between 1980 and 1992 [39,40], similar to trends seen
inEurope. Japanhas one of the lowest rates overall at 3.8per 10
5
,
but Taiwan and East Asia are signicantly worse with rates of
18.1 and 100 per 10
5
, respectively [19,28,31].
Incidence over time
Table 4 summarizes the studies that reported a change in
incidence of lower extremity amputations over time. Often this
change in trend is the seminal message fromthe publication and
toreport only the nal incidence wouldbe tomiss the point of the
article. Almost all attribute the decline in incidence of lower
extremity amputation (major and all lower extremity
amputations) to the contribution of the multidisciplinary
diabetic foot team. Northern European countries have
produced encouraging results from recent years [5,41], where
the proportion of hospitals with diabetic foot services increased
from 32 to 72%, with a corresponding decrease in the rate of
diabetes-related lower extremity amputations from 55 to 36.3
per 10
5
persons, despite a rise in the prevalence of diabetes from
307 000 to 462 000 between 1991 and 2000 [26].
Trends in minor amputation are less clear. Canavan et al. [8]
reported a decrease in the incidence of minor amputation in an
at-risk population, Rayman et al. [33] reported no change and
Larsson et al. [42] reported a decrease in incidence over time.
Diabetes
Determining the extent of the impact of diabetes on amputation
rates is crucial in developing risk-reduction strategies and in
explaining variations in patterns of lower extremity amputation.
In the UK, almost one in three amputees has diabetes [22,43],
whilst almost half of all Australian amputees are affected [39].
Marked differences in the rates of lower extremity amputations
have been documented between individuals with diabetes and
thosewithout diabetes (248vs. 20per 10
5
) inthe UK, withpeople
with diabetes facing a 12.3-fold risk of amputation [22]. Similar
signicant differences are seen in Taiwan, where 6-year
cumulative event rates of lower extremity amputations were
higher in people with diabetes compared with the general
population (2.4% with diabetes vs. 0.28% without diabetes in
men; 1.87% with diabetes vs. 0.17% without diabetes in
women; P < 0.0001) [44]. The Global Lower Extremity
Amputation Study demonstrated high levels of association
between diabetes and lower extremity amputation worldwide,
but the wide regional and international variation of lower
extremity amputations could be not be wholly explained by
geographical differences in diabetes prevalence [28].
Diabetic-related risk factors for lower extremity amputation
include longer duration of disease, poor glycaemic control,
higher systolic bloodpressure andtreatment withinsulin[45,46].
The impact of diabetes on lower extremity amputation is
manifested as a younger age at rst amputation for patients
with diabetes, occurring up to 78 years earlier [5,7]. Patients
withdiabetes are more likelytobereadmittedandtoprogress toa
higher level of lower extremity amputation [7] [4749].
There is a substantial and growing body of work already
published, and summarized in Table 4, that supports the use of
dedicateddiabetic foot teams andthe multidisciplinaryapproach
to limb salvage in the at-risk population. Although the
relationship between diabetes and lower extremity amputation
is intimate andwell proven, strategies toreduce the incidence and
complications of diabetes have been in place for decades and,
unfortunately, a corresponding reduction in amputation rates
has not been seen. Investment in programmes that improve
screening, detection and a multidisciplinary approach to
treatment of the inevitable complications may be a more
efcient and productive use of limited resources.
Ethnicity and access to health care
Markedethnicdifferences inrates of lower extremityamputation
have beendocumented. In Leicestershire inthe UK, the incidence
of lower extremity amputation in Asians was signicantly lower
DIABETICMedicine Review article
2011 The Authors.
Diabetic Medicine 2011 Diabetes UK 1149
compared with White Caucasians, both in the population with
diabetes (3.4 vs. 14.2 per 10
4
) and without diabetes (0.4 vs. 1.5
per 10
4
) [50] despite a higher rate of other vascular
complications, such as coronary and renal disease. In English
Afro-Caribbean people with diabetes, the incidence of lower
extremity amputation is also lower than in the European
population (147 per 10
5
vs. 219 per 10
5
) [51]. Currently,
African-Americans continue to have higher rates of lower
extremity amputation than White Americans, but not White
Britons, exemplifying the complex confounding effects of
ethnicity on lower extremity amputation.
American studies suggest that lower extremity amputation is
morelikelytooccur inAfrican-Americans thaninCaucasians (45
vs. 20%) [52,53], with Afro-Caribbean and Hispanic ethnicity
beingindependent riskfactors for lower extremity amputationin
patients with peripheral arterial disease [54]. Although the
burden of diabetes and hypertension is higher in minority
patients, the impact of this burden does not account for the
increased risk for the outcome of lower extremity amputation in
these two populations, meaning ethnicity itself is a risk factor
[54].
Social, economic and geographical factors linked to ethnicity
may prevent certain individuals from accessing healthcare
resources and the benets of limb-salvaging interventions such
as revascularization [55]. Smoking, low education status, low
income, lack of commercial insurance and non-White ethnicity
have all been shown to be predictive of risk of lower extremity
amputation.
It is possible that some of these factors are inuenced by the
varying degrees of access to healthcare provision seen between
different ethnic and social groups, especially low-income, non-
insured patients in the USA [36,56]. Interestingly, Black
patients were more likely to have above knee amputation
compared with White patients (60 vs. 53%, P < 0.001), whilst
Afro-Caribbeans undergoing revascularization were less likely
to benet from endovascular interventions (46 vs. 51%, P <
0.001) [52].
Discrepancies in access to health care cannot solely be used to
explain these differences. Native and African Americans
suffering with diabetes in Veterans Health hospitals, where all
patients had similar access to health care, had higher relative risk
(RR) of lower extremityamputations (relative risk1.74and1.41,
respectively) comparedwithCaucasians, whilst AsianAmericans
appeared relatively protected (relative risk 0.31) [57].
Furthermore, recent data show that, whilst Afro-Caribbeans
were more likely to have lower extremity amputations in low-
volume hospitals performed by non-specialists, the odds of
amputationremained1.7times higher thaninWhites, evenwhen
adjustment was performed for co-morbidities, hospital and
surgeon performance [52]. Tertiary centres with adequate
revascularization facilities in the same study still featured
higher rates of lower extremity amputation amongst Afro-
Caribbeans than in the White population (7 vs. 4%, P < 0.001)
[52], suggesting that factors other thansocio-economic ones may
also contribute to the observed differences. Ethnic variations in
the incidence of lower extremity amputation undoubtedly exist,
but differ between the UK and North America. Further work is
needed to explain these ndings.
Data
Signicant limitations affect current lower extremity amputation
studies, many of which rely on data from single institutions,
which are often specialist vascular units whose encouraging
outcomes do not necessarily reect the true national situation.
Differences in population demographics and risk-factor prole,
as well as discrepancies in data collection, analysis and reporting
between different countries, do not allow an accurate
comparison to be made. Future research needs to employ
internationally agreed protocols similar those in the Global
Lower Extremity Amputation Study project, but must in
addition take into consideration access to health care and
hospital or surgeons work volume to outcome relationships in
order to elucidate regional variations in clinical practice [31].
Considering the crucial role of diabetes in lower extremity
amputation, better documentation of the type, disease duration,
pharmacological therapy and systemic complications is needed.
Conclusion
Although lower extremity amputation continues to be a major
source of morbidity and mortality worldwide, the extent of this
burden cannot be accurately quantied because of international
variation and a lack of standardized reporting measures.
Effective standardized reporting methods of major, minor and
at-risk populations are needed.
The rising incidence of diabetes mellitus, global average age,
ethnicity and social deprivation all inuence incidence of
amputation worldwide. Addressing the unrecognized and
poorly managed complications of diabetes has been shown to
drive down amputation rates and it is here that attention should
be focused.
Competing interests
Nothing to declare.
Acknowledgement
PWM is funded by a joint Dunhill Medical Foundation Royal
College of Surgeons of England Surgical Research Fellowship.
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