Lower Extremity Amputation-incidence and Review of Diabetic and Non-diabetic Patients in Central Slovenia Population from 2001 to 2019

  • Igor Frangež, * Department for Surgical Infections, University Medical Center Ljubljana, & Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia https://orcid.org/0000-0001-9963-8810
  • Tea Nizič-Kos Institute of Oncology Ljubljana, Department of Surgery, Ljubljana, Slovenia
  • Nadja Alikadic Department for Surgical Infections, University Medical Center Ljubljana, Ljubljana, Slovenia
Keywords: Lower Extremity, Amputation, Diabetes Mellitus, Peripheral Vascular Disease


Introduction: This retrospective study aimed to determine the trends in the incidence of non-traumatic lower extremity amputations in diabetic and non-diabetic patients.
Methods: A retrospective, population-based cohort study was conducted at the University Medical Center Ljubljana which is representative of Slovenia. By defined inclusion criteria, we gathered information on patients treated for lower extremity amputations over 19 years (2001 - 2019). Patients were divided into two groups, diabetics and non-diabetics. Linear regression analysis was used to analyze amputation trends over the studied years.
Results: A total of 2,341 patients were included in our study, the majority were diabetics (1412/2341; 60.32%). Our results revealed an increased incidence of lower extremity amputations in diabetic and non-diabetic patients alike. The age- and gender-adjusted relative increase in amputation rates were 45% in all amputations and 35% in major amputations (P < 0.001). Non-diabetics were slightly older (2 years on average; P < 0.05), with a higher mortality rate (6.1% vs. 1.8%; P < 0.05).
Conclusions: Despite efforts to reduce lower extremity amputations in diabetics, their incidence in Slovenia is increasing. Higher amputation rates can only partially be justified by an aging population and an increasing number of diabetics. Preventive measures for amputation amply described in the literature are available and implemented also in our country, but considering our results, they need to be re-evaluated.

Author Biography

Igor Frangež, *, Department for Surgical Infections, University Medical Center Ljubljana, & Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia

E-mail: igor.frangez@kclj.si, Tel: +386 1 522 23 19


Lin C, Liu J, Sun H. Risk factors for lower extremity amputation in patients with diabetic foot ulcers: A meta-analysis. PLoS One. 2020;15(9):e0239236. http://dx.doi.org/10.1371/journal.pone.0239236 https://www.ncbi.nlm.nih.gov/pubmed/32936828

Preece RA, Dilaver N, Waldron CA, Pallmann P, Thomas-Jones E, Gwilym BL, et al. A Systematic Review and Narrative Synthesis of Risk Prediction Tools Used to Estimate Mortality, Morbidity, and Other Outcomes Following Major Lower Limb Amputation. Eur J Vasc Endovasc Surg. 2021;62(1):127-35. http://dx.doi.org/10.1016/j.ejvs.2021.02.038 https://www.ncbi.nlm.nih.gov/pubmed/33903018

Wrobel JS, Mayfield JA, Reiber GE. Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population. Diabetes Care. 2001;24(5):860-4. http://dx.doi.org/10.2337/diacare.24.5.860 https://www.ncbi.nlm.nih.gov/pubmed/11347744

Resnick HE, Carter EA, Lindsay R, Henly SJ, Ness FK, Welty TK, et al. Relation of lower-extremity amputation to all-cause and cardiovascular disease mortality in American Indians: the Strong Heart Study. Diabetes Care. 2004;27(6):1286-93. http://dx.doi.org/10.2337/diacare.27.6.1286 https://www.ncbi.nlm.nih.gov/pubmed/15161777

Teraa M, Conte MS, Moll FL, Verhaar MC. Critical Limb Ischemia: Current Trends and Future Directions. J Am Heart Assoc. 2016;5(2). http://dx.doi.org/10.1161/JAHA.115.002938 https://www.ncbi.nlm.nih.gov/pubmed/26908409

Geiss LS, Li Y, Hora I, Albright A, Rolka D, Gregg EW. Resurgence of Diabetes-Related Nontraumatic Lower-Extremity Amputation in the Young and Middle-Aged Adult U.S. Population. Diabetes Care. 2019;42(1):50-4. http://dx.doi.org/10.2337/dc18-1380 https://www.ncbi.nlm.nih.gov/pubmed/30409811

Albayati MA, Shearman CP. Peripheral arterial disease and bypass surgery in the diabetic lower limb. Med Clin North Am. 2013;97(5):821-34. http://dx.doi.org/10.1016/j.mcna.2013.03.009 https://www.ncbi.nlm.nih.gov/pubmed/23992894

Malyar NM, Freisinger E, Meyborg M, Luders F, Gebauer K, Reinecke H, et al. Amputations and mortality in in-hospital treated patients with peripheral artery disease and diabetic foot syndrome. J Diabetes Complications. 2016;30(6):1117-22. http://dx.doi.org/10.1016/j.jdiacomp.2016.03.033 https://www.ncbi.nlm.nih.gov/pubmed/27118161

Gregg EW, Sorlie P, Paulose-Ram R, Gu Q, Eberhardt MS, Wolz M, et al. Prevalence of lower-extremity disease in the US adult population >=40 years of age with and without diabetes: 1999-2000 national health and nutrition examination survey. Diabetes Care. 2004;27(7):1591-7. http://dx.doi.org/10.2337/diacare.27.7.1591 https://www.ncbi.nlm.nih.gov/pubmed/15220233

Mills JL. Lower limb ischaemia in patients with diabetic foot ulcers and gangrene: recognition, anatomic patterns and revascularization strategies. Diabetes Metab Res Rev. 2016;32 Suppl 1:239-45. http://dx.doi.org/10.1002/dmrr.2753 https://www.ncbi.nlm.nih.gov/pubmed/26455728

The Saint Vincent Declaration on diabetes care and research in Europe. . Acta Diabetologica. 1989;10:143-4.

Felton A-M, Hall MS. Diabetes — from St Vincent to Glasgow. Have we progressed in 20 years? The British Journal of Diabetes & Vascular Disease. 2009;9(4):142-4. http://dx.doi.org/10.1177/1474651409341318

Lombardo FL, Maggini M, De Bellis A, Seghieri G, Anichini R. Lower extremity amputations in persons with and without diabetes in Italy: 2001-2010. PLoS One. 2014;9(1):e86405. http://dx.doi.org/10.1371/journal.pone.0086405 https://www.ncbi.nlm.nih.gov/pubmed/24489723

Kröger K, Berg C, Santosa F, Malyar N, Reinecke H. Lower Limb Amputation in Germany. Deutsches Aerzteblatt Online. 2017. http://dx.doi.org/10.3238/arztebl.2017.0130

Monteiro-Soares M, Vale-Lima J, Martiniano J, Pinheiro-Torres S, Dias V, Boyko EJ. A systematic review with meta-analysis of the impact of access and quality of diabetic foot care delivery in preventing lower extremity amputation. J Diabetes Complications. 2021;35(4):107837. http://dx.doi.org/10.1016/j.jdiacomp.2020.107837 https://www.ncbi.nlm.nih.gov/pubmed/33423910

Diabetes Prevention and Care Development Programme 2010 - 2020 Based on the National Diabetes Prevention and Care Development Programme Development Strategy 2010 - 2020 Ljubljana2010 [cited 2020 December 20th]. Available from: http://www.mz.gov.si/fileadmin/mz.gov.si/pageuploads/mz_dokumenti/delovna_podrocja/javno_zdravje/diabetes/National_Diabetes_Prevention_and_Care_Development_Programme.pdf.

Vamos EP, Bottle A, Edmonds ME, Valabhji J, Majeed A, Millett C. Changes in the incidence of lower extremity amputations in individuals with and without diabetes in England between 2004 and 2008. Diabetes Care. 2010;33(12):2592-7. http://dx.doi.org/10.2337/dc10-0989 https://www.ncbi.nlm.nih.gov/pubmed/20833865

Diabetes in Slovenia, data from Slovenian National Institute of Public Health. 2020 [cited 2020 December 20th]. Available from: http://www.nijz.si/en/report-on-national-conference-on-diabetes-management-2020.

Dangelser G, Besson S, Gatina JH, Blicklé JF. Amputations among diabetics in Reunion Island. Diabetes & Metabolism. 2003;29(6):628-34. http://dx.doi.org/10.1016/s1262-3636(07)70079-4

Long CA, Mulder H, Fowkes FGR, Baumgartner I, Berger JS, Katona BG, et al. Incidence and Factors Associated With Major Amputation in Patients With Peripheral Artery Disease: Insights From the EUCLID Trial. Circ Cardiovasc Qual Outcomes. 2020;13(7):e006399. http://dx.doi.org/10.1161/CIRCOUTCOMES.119.006399 https://www.ncbi.nlm.nih.gov/pubmed/32615798

Faglia E, Clerici G, Clerissi J, Gabrielli L, Losa S, Mantero M, et al. Early and five-year amputation and survival rate of diabetic patients with critical limb ischemia: data of a cohort study of 564 patients. Eur J Vasc Endovasc Surg. 2006;32(5):484-90. http://dx.doi.org/10.1016/j.ejvs.2006.03.006 https://www.ncbi.nlm.nih.gov/pubmed/16730466

Johannesson A, Larsson GU, Ramstrand N, Turkiewicz A, Wirehn AB, Atroshi I. Incidence of lower-limb amputation in the diabetic and nondiabetic general population: a 10-year population-based cohort study of initial unilateral and contralateral amputations and reamputations. Diabetes Care. 2009;32(2):275-80. http://dx.doi.org/10.2337/dc08-1639 https://www.ncbi.nlm.nih.gov/pubmed/19001192

Papazafiropoulou A, Tentolouris N, Soldatos RP, Liapis CD, Dounis E, Kostakis AG, et al. Mortality in diabetic and nondiabetic patients after amputations performed from 1996 to 2005 in a tertiary hospital population: a 3-year follow-up study. J Diabetes Complications. 2009;23(1):7-11. http://dx.doi.org/10.1016/j.jdiacomp.2007.11.008 https://www.ncbi.nlm.nih.gov/pubmed/18413176

Malyar NM, Freisinger E, Meyborg M, Luders F, Furstenberg T, Kroger K, et al. Low Rates of Revascularization and High In-Hospital Mortality in Patients With Ischemic Lower Limb Amputation: Morbidity and Mortality of Ischemic Amputation. Angiology. 2016;67(9):860-9. http://dx.doi.org/10.1177/0003319715626849 https://www.ncbi.nlm.nih.gov/pubmed/26764367

Lopez-de-Andres A, Jimenez-Garcia R, Aragon-Sanchez J, Jimenez-Trujillo I, Hernandez-Barrera V, Mendez-Bailon M, et al. National trends in incidence and outcomes in lower extremity amputations in people with and without diabetes in Spain, 2001-2012. Diabetes Res Clin Pract. 2015;108(3):499-507. http://dx.doi.org/10.1016/j.diabres.2015.01.010 https://www.ncbi.nlm.nih.gov/pubmed/25866357

Buckley CM, O'Farrell A, Canavan RJ, Lynch AD, De La Harpe DV, Bradley CP, et al. Trends in the incidence of lower extremity amputations in people with and without diabetes over a five-year period in the Republic of Ireland. PLoS One. 2012;7(7):e41492. http://dx.doi.org/10.1371/journal.pone.0041492 https://www.ncbi.nlm.nih.gov/pubmed/22859991

Schaper NC, Van Netten JJ, Apelqvist J, Lipsky BA, Bakker K, International Working Group on the Diabetic F. Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance Documents. Diabetes Metab Res Rev. 2016;32 Suppl 1:7-15. http://dx.doi.org/10.1002/dmrr.2695 https://www.ncbi.nlm.nih.gov/pubmed/26335366

Meza-Torres B, Carinci F, Heiss C, Joy M, de Lusignan S. Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis. Acta Diabetol. 2021;58(6):735-47. http://dx.doi.org/10.1007/s00592-020-01662-x https://www.ncbi.nlm.nih.gov/pubmed/33547497

Rossboth S, Lechleitner M, Oberaigner W. Risk factors for diabetic foot complications in type 2 diabetes-A systematic review. Endocrinol Diabetes Metab. 2021;4(1):e00175. http://dx.doi.org/10.1002/edm2.175 https://www.ncbi.nlm.nih.gov/pubmed/33532615

Alvarsson A, Sandgren B, Wendel C, Alvarsson M, Brismar K. A retrospective analysis of amputation rates in diabetic patients: can lower extremity amputations be further prevented? Cardiovasc Diabetol. 2012;11:18. http://dx.doi.org/10.1186/1475-2840-11-18 https://www.ncbi.nlm.nih.gov/pubmed/22385577

Original Article