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Lower extremity amputations – a review of global variation in incidence

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DOI: 10.1111/j.1464-5491.2011.03279.x · Source: PubMed

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DIABETICMedicine

DOI: 10.1111/j.1464-5491.2011.03279.x

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 George’s Vascular Institute, St George’s 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 review conformed to Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) statement standards.
Results Incidence of all forms of lower extremity amputation ranges from 46.1 to 9600 per 105 in the population with diabetes
compared with 5.8–31 per 105 in the total population. Major amputation ranges from 5.6 to 600 per 105 in the population with
diabetes and from 3.6 to 68.4 per 105 in the total population. Significant reductions in incidence of lower extremity amputation
have been shown in specific at-risk populations after the introduction of specialist diabetic foot clinics.
Conclusion Significant global variation exists in the incidence of lower extremity amputation. Ethnicity and social deprivation
play a significant role but it is the role of diabetes and its complications that is most profound. Lower extremity amputation
reporting methods demonstrate significant 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, 1144–1153 (2011)
Keywords amputation, diabetes, ethnicity, incidence, reporting

aiming to reduce the rate of amputation by half within 5 years

Introduction
[5]. Attempts at quantifying the incidence of lower extremity
The incidence of diabetes mellitus has reached pandemic status amputations have been made and a number of encouraging
and will drive an increase in future rates of peripheral arterial studies have been published showing significant improvements in
occlusive disease (PAOD), neuropathy and soft tissue sepsis [1,2]. the incidence of lower extremity amputations [8–13]. However,
This triad is responsible for the majority of lower extremity in order to accurately assess the impact of new healthcare
amputations. Eighty-two per cent of all vascular-related lower measures and interventions, accurate data regarding the extent
extremity amputations in the USA are associated with diabetes and depth of the problem are needed to both direct service
[3] and patients with diabetes have a 30 times greater lifetime risk provision and act as a baseline from which change can be
of having an amputation than patients without diabetes [4–6]. measured. We have sought to review the current literature for
This has significant implications on global healthcare systems, contemporary data on the incidence of lower extremity
with annual costs of lower extremity amputations in the USA amputation and to examine variation in these parameters
reaching $4.3bn [7]. worldwide.
In 1990, the St Vincent Declaration identified the reduction of
lower extremity amputations as a principal healthcare target,
Methods
A PubMed and Cochrane Library review was undertaken in
Correspondence to: P. W. Moxey, St George’s Vascular Institute, St George’s
Hospital NHS Trust, Tooting, London, SW17 0QT, UK. E-mail: paul.moxey@
order to ascertain incidence and mortality and changing trends in
nhs.net lower extremity amputation in the UK and worldwide from 1989

ª 2011 The Authors.

1144 Diabetic Medicine ª 2011 Diabetes UK
 Review article DIABETICMedicine

to the present. A search was performed for the terms differentiation being made between Type 1 and Type 2 diabetes,
‘amputation’ and ‘lower extremity amputation’, with further as well as insulin-dependent and non-insulin-dependent status
refinements undertaken for the terms ‘incidence’ and for Type 2 diabetes. Amputation was defined as loss of part of a
‘prevalence’. Inclusion criteria consisted of all single-centre, lower limb in the transverse plane. Major lower extremity
regional or population-based studies with more than 50 patients amputation is defined as above, through or below knee loss of
and lower extremity amputation at any anatomical level. Papers a limb. Minor amputation refers to below the level of the ankle.
describing bilateral primary lower extremity amputation or
contra-lateral lower extremity amputation following primary
Results
lower extremity amputation were also included. Studies
describing lower extremity amputation secondary to trauma or From 48 manuscripts identified, the results were divided into
cancer were excluded. those papers reporting incidence of all lower extremity
A total of 2850 abstracts were identified, of which 57 fulfilled amputations (major and minor combined) and those
the defined criteria. Figure 1 is a Preferred Reporting Items for differentiating between the two. Table 1 identifies those studies
Systematic Reviews and Meta-Analyses (PRISMA) flow chart reporting incidence of all lower extremity amputations. No
outlining the search and review process [14]. Because of the differentiation was made between major or minor lower
retrospective nature of the data, no randomized controlled trials extremity amputations in these studies. Four differentiate the
were identified. Abstracts were screened for suitability and, if incidence of all lower extremity amputations between the
appropriate, full-text articles were retrieved and reviewed by ‘at-risk’ population with diabetes and those without diabetes
PWM and PG. [4,15–17]. Two data sources reported incidence rates with no
Incidence, where possible, was expressed as numbers of lower differentiation between types of amputation or patient’s diabetic
extremity amputations per 100 000 (105) individuals. Incidence status [18,19].
in the ‘at-risk population’ with diabetes was reported alongside Table 2 shows incidence rates for major lower extremity
that of the generalpopulation, where possible, and the population amputation as reported in 28 papers.
without diabetes (if data were available) for comparison. The Table 3 summarizes those papers reporting the incidence of
diabetic status of patients was ascertained if reported, with minor amputation. This is reported less frequently, with only
Identification

Records identified through Additional records identified

database searching through other sources
(n = 2850) (n = 15)

Records after duplicates removed

(n = 2865)
Screening

Records screened Records excluded

(n = 2865) (n = 2773)

Full-text articles assessed

Full-text articles excluded
for eligibility
Eligibility

(n = 35)
(n = 92)

Studies included in review

(n = 57)
Included

FIGURE 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart outlining the process of search and selection of reviewed
articles [14]

ª 2011 The Authors.

Diabetic Medicine ª 2011 Diabetes UK 1145
DIABETICMedicine Lower extremity amputations—a global review • P. W. Moxey et al.

Table 1 Global variation of incidence of all lower extremity amputations (LEA) by diabetic status

Reference Incidence Type of

(by first author) (per 105) Year of study amputation Population Study population

Calle-Pascual [4] 46.1 1994–1996 All LEA At risk Madrid, Spain

Chaturvedi [31]* 100 1977–1988 All LEA At risk East Asia
Leggetter [51] 147–219 1992–1997 All LEA At risk London, UK
Morris [22] 248 1993–1994 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 risk—Mexicans Texas, USA
Adler [60] 1130 1990–1999 All LEA At-risk males Seattle, USA
Lee [61] 1800 1987–1991 All LEA At risk Oklahoma Indians, USA
Chaturvedi [31]* 3100 1977–1988 All LEA At risk American Indians, USA
Patout [23] 9600 1998–1999 All LEA At risk Louisiana
Payne [62] 14 1995–1998 All LEA At risk in total population Australia
Dangelser [63] 54 2000 All LEA At risk in total population Reunion Island
Fosse [15] 158 2002–2003 All LEA At risk in total population France
Vaccaro [49] 5.8 1996 All LEA Total population Campania, Italy
Deerochanawong [64] 5.7 1989–1991 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 1994–1996 All LEA No diabetes Madrid, Spain
Trautner [16] 12 2005 All LEA No diabetes Germany
Fosse [15] 13 2002–2003 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.

seven studies reporting stand-alone incidence of minor reporting incidence poses a significant challenge because of the
amputation. variation in reporting methods used.
Table 4 summarizes those studies that have reported a Studies that only report rates for all forms of lower extremity
significant change in the incidence of major or minor amputations have questionable value in establishing trends and
amputation over time. Other studies [20–23] were identified informing practice. The clinical distinction and objectives of
that report a reduction in incidence, but where excluded from the performing a major and minor amputation are distinct. Minor
table as no clear incidence figures were reported in the amputation may be performed as an adjunct to lower limb
manuscript but rather a percentage reduction given. 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
Discussion
burden of amputation on the at-risk population with diabetes.
This review of incidence rates for lower extremity amputation Van Houtum in 2008 and Jeffcoate in 2004 set out that, to
aims to update readers with new data published since the last directly compare studies, one must look at the population
major review by Jeffcoate and van Houtum in 2004 [13]. Lower studied, the definition of numerator and denominator, specific
extremity amputation has become the focus of renewed interest definitions used and the beliefs of the patients and investigators
by the medical profession, and political bodies with new [13,25]. The denominator is especially important as it can change
initiatives such as ‘Putting Feet First’ in the UK and the entire message of a study. Data from the Netherlands when
international meetings with a lower limb salvage focus being expressed per 100 000 of the total population showed no decline
launched in an attempt to raise awareness and reduce the in lower extremity amputations, but when expressed as a
incidence of amputation [24]. proportion of the rising population with diabetes there was a
The worldwide incidence of lower extremity amputation is clear trend downwards [26]. In the studies presented here, the
high and, although variations exist, it is often difficult to directly denominator is not constant but the message is clear: diabetes
compare rates as a result of heterogeneity in the populations mellitus greatly increases incidence and mortality of lower
studied. Summarizing the large volume of published data extremity amputation.

ª 2011 The Authors.

1146 Diabetic Medicine ª 2011 Diabetes UK
 Review article DIABETICMedicine

Table 2 Variation in incidence of major lower extremity amputation (LEA) by diabetic status

Reference Incidence Type of

(by first author) (per 105) Year of study amputation Diabetes status Study population

Calle-Pascual [67] 5.6 1997–1999 Major Women at risk Madrid, Spain

Calle-Pascual [67] 12 1997–1999 Major Men at risk Madrid, Spain
Rayman.[33] 162 1997–2000 Major At risk Ipswich, UK
Aragon-Sanchez [68] 176 2009 Major At risk Gran Canaria, Spain
Johannesson [69] 195 1997–2006 Major* At risk Sweden
Trautner [35] 230 1990–1991 Major At risk Germany
1994–1998
Morris [22] 248 1993–1994 Major At risk Scotland, UK
Wrobel [36] 383 1996–1997 Major At risk Medicare, USA
Winell [70] 387 2002 Major At risk Finland
Rith-Najarian [71] 600 1994–1996 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 1982–1993 Major At risk in total population Sweden
Holstein [65] 4.1 1995 Major At risk in total population Copenhagen, Denmark
Larsson [66] 9.4 1982–1993 Major At risk in total population Sweden
Eskelinen [41] 7.3 1999–2002 Major At risk in total population Helsinki
Canavan [8] 75 2000 Major At risk in total population Middlesbrough, UK
Larsson [66] 3.6 1982–1993 Major Total population Sweden
GLEAS Group [28] 3.8 1995–1997 Major Total population Tochigi, Japan
Witso [72] 4.4 1994–1997 Major Total population Trondheim, Norway
Ebskov [5] 4.5 1982–1993 Major Female total population Denmark
Ebskov [5] 4.7 1982–1993 Major Male total population Denmark
Trautner [35] 4.7 1990–1991 Major Total population Germany
1994–1998
Rayman [33] 4.5 1997–2000 Major Total population Ipswich, UK
Moxey [32] 5.1 2003–2008 Major Total population England, UK
Deerochanawong [64] 5.7 1989–1991 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 1995–1997 Major Total population Navajo Indians
Remes [74] 24.1 1998–2002 Major Elderly total population Turku, Finland
Carmona [75] 34.7 1990–1999 Major Female total population Switzerland
Carmona [75] 68.4 1990–1999 Major Male total population Switzerland
Vamos [34] 4.9 2005 Major No diabetes England, UK
Eskelinen [41] 5.3 1999–2002 Major No diabetes Helsinki
Aragon-Sanchez [68] 11 2009 Major No diabetes Gran Canaria, Spain
Morris [22] 14 1993–1994 Major No diabetes Scotland, UK
Canavan [8] 15.3 2000 Major No diabetes Middlesbrough, UK
Johannesson [69] 23 1997–2006 Major* No diabetes Sweden
Wrobel [36] 38 1996–1997 Major No diabetes Medicare, USA

*Trans-metatarsal and above.

GLEAS, Global Lower Extremity Amputation Study.

Diabetes, infection and peripheral vascular disease are known undertaken by individual surgeons or units are also likely to play
to be the predominant causes of non-healing foot ulcers [27], a role.
which in turn is the principal cause of lower extremity The Global Lower Extremity Amputation Study (GLEAS)
amputation both in the UK and USA [28,29]. Discrepancies in remains the largest retrospective registry study to use
lower extremity amputation rates on a national level may be standardized data in order to compare the international
caused by differences in vascular-diabetic service provision and epidemiology of major lower extremity amputation, but is now
regional clinical practice [30]. Ethnicity, socio-economic status, 11 years old [28]. Selected results have been reported in Table 2
access to health care and the annual caseload of procedures at opposite ends of the range of variation. Chaturvedi et al. also

ª 2011 The Authors.

Diabetic Medicine ª 2011 Diabetes UK 1147
DIABETICMedicine Lower extremity amputations—a global review • P. W. Moxey et al.

Table 3 Variation in incidence of minor lower extremity amputation (LEA) by diabetic status

Reference Type of
(by first author) Incidence (per 105) Year of study amputation Diabetes status Study population

Calle-Pascual [67] 11.3 1997–1999 Minor At risk—women Madrid, Spain

Calle-Pascual [67] 33.1 1997–1999 Minor At risk—men Madrid, Spain
Rayman [33] 123 1997–2000 Minor At risk Ipswich, UK
Morris [22] 144 1993–1994 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 1998–2001 Minor At risk in total population Sweden
Canavan [8] 100 2000 Minor At risk in total population Middlesbrough, UK
GLEAS Group [28] 0.6 1995–1997 Minor Total population Tochigi, Japan
Rayman [33] 3.3 1997–2000 Minor Total population Ipswich, UK
Moxey [32] 6.3 2003–2008 Minor Total population England, UK
GLEAS Group [28] 98.8 1995–1997 Minor Total population Navajo Indians
Vamos [34] 5.1 2005 Minor No diabetes England, UK
Morris [22] 9 1993–1994 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 Baseline End Incidence Type of amputation and

(by first author) Incidence (105) (105) Years population

Canavan [8] 310 75 1996–2000 Major, Middlesbrough, UK

Canavan [8] 253 100 1996–2000 Minor, Middlesbrough, UK
Krishnan [10] 414 67 1995–2005 Major, Ipswich, UK
Krishnan [10] 118 93 1995–2005 Minor, Ipswich, UK
Larsson [42] 16 6.8 1982–2001 Major, Sweden
Larsson [42] 4.7 6.5 1982–2001 Minor, Sweden
Calle-Pascual [67] 70.6 12.4 1989–1999 Major, Madrid, Spain
Calle-Pascual [67] 15.3 5.6 1989–1999 Major, Madrid, Spain
Calle-Pascual [67] 58.9 33.1 1989–1999 Minor, Madrid, Spain
Calle-Pascual [67] 11.9 11.3 1989–1999 Minor, Madrid, Spain
van Houtum [26] 550 360 1991–2000 All LEA, Netherlands
Trautner [16] 549 428 1990–2005 All LEA, Germany
Vamos [34] 1.5 1.2 1996–2005 Minor, England, UK
Vamos. [34] 2.4 4.1 1996–2005 Minor, England, UK
Vamos [34] 1.3 0.7 1996–2005 Major, England, UK
Vamos [34] 2 2.7 1996–2005 Major, England, UK
Stiegler [17] 610 660 1990–1995 All LEA, Germany
Rayman [33] 228 108 1998–2000 Major, Ipswich, UK
Winell [70] 924 387 1988–2002 All LEA, Finland
Patout [23] 9600 2200 1990s All LEA, Louisiana, USA
Birke [59] 1003 720 1998–1999 All LEA, Louisiana, USA
Ebskov [5] 4.5 2.7 1982–1993 Major, Denmark

published global results, but they combined unoperated gangrene for example, has age-adjusted incidence of first lower extremity
and all forms of lower extremity amputation [31]. Although this amputation ranging between 5.1 and 176 per 105 population in
allows geographical comparison within their own data to be different centres [8,28,32]. In England, a 47% decrease in major
made, it is difficult to compare it against other data where amputation rates has been reported between 1997 and 2000,
gangrene is not included. 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
Global variation
extremity amputations in England. Moxey et al. reported no
National studies have been published that show variations in change in the rate of major amputation (diabetes and no diabetes)
incidence both within continental and national borders. The UK, between 2003 and 2008 (of 5.1 per 105) in England [32] and

ª 2011 The Authors.

1148 Diabetic Medicine ª 2011 Diabetes UK
 Review article DIABETICMedicine

Vamos et al. report a reduction in the incidence of major per 105 persons, despite a rise in the prevalence of diabetes from
amputation in patients with Type 1 diabetes from 1.3 · 105 in 307 000 to 462 000 between 1991 and 2000 [26].
1996 to 0.7 · 105 in 2005 [34]. The most significant finding was Trends in minor amputation are less clear. Canavan et al. [8]
the variation in incidence across the country, with rates ranging reported a decrease in the incidence of minor amputation in an
from 3.9 to 7.2 per 105 (P < 0.0001) across different Strategic at-risk population, Rayman et al. [33] reported no change and
Health Authorities (administrative areas). Diabetes mellitus was Larsson et al. [42] reported a decrease in incidence over time.
identified as a risk factor in 39.4% of all patients undergoing
lower extremity amputation. Fosse et al. published a first
Diabetes
national estimate of all lower extremity amputations in France,
with rates of 13 per 105 in individuals without diabetes compared Determining the extent of the impact of diabetes on amputation
with 158 per 105 in individuals with diabetes [15]. Some rates is crucial in developing risk-reduction strategies and in
European studies document no significant changes in the rates of explaining variations in patterns of lower extremity amputation.
all lower extremity amputations between 1990 and 1998 in both In the UK, almost one in three amputees has diabetes [22,43],
patients with and without diabetes [17,35], whereas others whilst almost half of all Australian amputees are affected [39].
suggest an increase in minor amputations subsequent to the Marked differences in the rates of lower extremity amputations
introduction of diabetic podiatry screening services (Table 4). have been documented between individuals with diabetes and
In the USA, Wrobel et al. report an incidence of major those without diabetes (248 vs. 20 per 105) in the UK, with people
amputation of 38 per 105 in the population of the USA without with diabetes facing a 12.3-fold risk of amputation [22]. Similar
diabetes in a national investigation of the Medicare admini- significant differences are seen in Taiwan, where 6-year
strative database [36] incorporating all ages and ethnicity. The cumulative event rates of lower extremity amputations were
USA has seen a 5% per year drop in the rate of minor and major higher in people with diabetes compared with the general
amputation between 1989 and 1998, although diabetes-related population (2.4% with diabetes vs. 0.28% without diabetes in
lower extremity amputation rates remained unchanged [37]. men; 1.87% with diabetes vs. 0.17% without diabetes in
One study of 33 775 hospital discharges reported a drop in women; P < 0.0001) [44]. The Global Lower Extremity
major amputation rates from 24 to 17 per 105 (1996–2004). Amputation Study demonstrated high levels of association
Differences between ethnic groups remained unchanged, with between diabetes and lower extremity amputation worldwide,
lower extremity amputation rates in African-American areas but the wide regional and international variation of lower
being five times larger than in non-African-American areas. extremity amputations could be not be wholly explained by
Furthermore, whilst major amputation rates in predominantly geographical differences in diabetes prevalence [28].
white areas decreased from 14 to 12 per 105, incidence in Diabetic-related risk factors for lower extremity amputation
predominantly African-American areas rose from 59 to 65 per include longer duration of disease, poor glycaemic control,
105 (1987–2004) [38]. Overall, major amputation rates are higher systolic blood pressure and treatment with insulin [45,46].
higher in the USA compared with the rest of the world at 23.6 vs. The impact of diabetes on lower extremity amputation is
14.2 per 105 males and 15.2 vs. 6.7 per 105 females [29]. manifested as a younger age at first amputation for patients
Disparity in incidence also exists across Asia and Australasia. with diabetes, occurring up to 7–8 years earlier [5,7]. Patients
In Australia, a fall in lower extremity amputations rates has been with diabetes are more likely to be readmitted and to progress to a
recorded between 1980 and 1992 [39,40], similar to trends seen higher level of lower extremity amputation [7] [47–49].
in Europe. Japan has one of the lowest rates overall at 3.8 per 105, There is a substantial and growing body of work already
but Taiwan and East Asia are significantly worse with rates of published, and summarized in Table 4, that supports the use of
18.1 and 100 per 105, respectively [19,28,31]. dedicated diabetic foot teams and the multidisciplinary approach
to limb salvage in the at-risk population. Although the
relationship between diabetes and lower extremity amputation
Incidence over time
is intimate and well proven, strategies to reduce the incidence and
Table 4 summarizes the studies that reported a change in complications of diabetes have been in place for decades and,
incidence of lower extremity amputations over time. Often this unfortunately, a corresponding reduction in amputation rates
change in trend is the seminal message from the publication and has not been seen. Investment in programmes that improve
to report only the final incidence would be to miss the point of the screening, detection and a multidisciplinary approach to
article. Almost all attribute the decline in incidence of lower treatment of the inevitable complications may be a more
extremity amputation (major and all lower extremity efficient and productive use of limited resources.
amputations) to the contribution of the multidisciplinary
diabetic foot team. Northern European countries have
Ethnicity and access to health care
produced encouraging results from recent years [5,41], where
the proportion of hospitals with diabetic foot services increased Marked ethnic differences in rates of lower extremity amputation
from 32 to 72%, with a corresponding decrease in the rate of have been documented. In Leicestershire in the UK, the incidence
diabetes-related lower extremity amputations from 55 to 36.3 of lower extremity amputation in Asians was significantly lower

ª 2011 The Authors.

Diabetic Medicine ª 2011 Diabetes UK 1149
DIABETICMedicine Lower extremity amputations—a global review • P. W. Moxey et al.

compared with White Caucasians, both in the population with the incidence of lower extremity amputation undoubtedly exist,
diabetes (3.4 vs. 14.2 per 104) and without diabetes (0.4 vs. 1.5 but differ between the UK and North America. Further work is
per 104) [50] despite a higher rate of other vascular needed to explain these findings.
complications, such as coronary and renal disease. In English
Afro-Caribbean people with diabetes, the incidence of lower
Data
extremity amputation is also lower than in the European
population (147 per 105 vs. 219 per 105) [51]. Currently, Significant limitations affect current lower extremity amputation
African-Americans continue to have higher rates of lower studies, many of which rely on data from single institutions,
extremity amputation than White Americans, but not White which are often specialist vascular units whose encouraging
Britons, exemplifying the complex confounding effects of outcomes do not necessarily reflect the true national situation.
ethnicity on lower extremity amputation. Differences in population demographics and risk-factor profile,
American studies suggest that lower extremity amputation is as well as discrepancies in data collection, analysis and reporting
more likely to occur in African-Americans than in Caucasians (45 between different countries, do not allow an accurate
vs. 20%) [52,53], with Afro-Caribbean and Hispanic ethnicity comparison to be made. Future research needs to employ
being independent risk factors for lower extremity amputation in internationally agreed protocols similar those in the Global
patients with peripheral arterial disease [54]. Although the Lower Extremity Amputation Study project, but must in
burden of diabetes and hypertension is higher in minority addition take into consideration access to health care and
patients, the impact of this burden does not account for the hospital or surgeon’s work volume to outcome relationships in
increased risk for the outcome of lower extremity amputation in order to elucidate regional variations in clinical practice [31].
these two populations, meaning ethnicity itself is a risk factor Considering the crucial role of diabetes in lower extremity
[54]. amputation, better documentation of the type, disease duration,
Social, economic and geographical factors linked to ethnicity pharmacological therapy and systemic complications is needed.
may prevent certain individuals from accessing healthcare
resources and the benefits of limb-salvaging interventions such
Conclusion
as revascularization [55]. Smoking, low education status, low
income, lack of commercial insurance and non-White ethnicity Although lower extremity amputation continues to be a major
have all been shown to be predictive of risk of lower extremity source of morbidity and mortality worldwide, the extent of this
amputation. burden cannot be accurately quantified because of international
It is possible that some of these factors are influenced by the variation and a lack of standardized reporting measures.
varying degrees of access to healthcare provision seen between Effective standardized reporting methods of major, minor and
different ethnic and social groups, especially low-income, non- at-risk populations are needed.
insured patients in the USA [36,56]. Interestingly, Black The rising incidence of diabetes mellitus, global average age,
patients were more likely to have above knee amputation ethnicity and social deprivation all influence incidence of
compared with White patients (60 vs. 53%, P < 0.001), whilst amputation worldwide. Addressing the unrecognized and
Afro-Caribbean’s undergoing revascularization were less likely poorly managed complications of diabetes has been shown to
to benefit from endovascular interventions (46 vs. 51%, P < drive down amputation rates and it is here that attention should
0.001) [52]. be focused.
Discrepancies in access to health care cannot solely be used to
explain these differences. Native and African Americans
Competing interests
suffering with diabetes in Veterans’ Health hospitals, where all
patients had similar access to health care, had higher relative risk Nothing to declare.
(RR) of lower extremity amputations (relative risk 1.74 and 1.41,
respectively) compared with Caucasians, whilst Asian Americans
Acknowledgement
appeared relatively protected (relative risk 0.31) [57].
Furthermore, recent data show that, whilst Afro-Caribbean’s PWM is funded by a joint Dunhill Medical Foundation ⁄ Royal
were more likely to have lower extremity amputations in low- College of Surgeons of England Surgical Research Fellowship.
volume hospitals performed by non-specialists, the odds of
amputation remained 1.7 times higher than in Whites, even when
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1150 Diabetic Medicine ª 2011 Diabetes UK
 Review article DIABETICMedicine

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1152 Diabetic Medicine ª 2011 Diabetes UK
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