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Short-term outcomes after major lower limb amputation: meta-analysis
Nick Moody1, Rhiannon Nielsen2, Megan Lyons3
1Department of Applied Health Sciences, College of Medicine and Health, University of Birmingham, Birmingham, UK.
Introduction:
Mortality after major lower limb amputation is a key factor in the decision to perform surgery. This review synthesizes the evidence on in-hospital and 30-day postoperative mortality after major amputation.
Methods:
Electronic databases Medline, Embase, Scopus and African Journals Online were searched using keywords and thesaurus terms in October 2024 and updated in November 2025. Studies published globally and reporting in-hospital or 30-day mortality after major lower limb amputation (defined as at- or above-ankle amputation, or transtibial amputation (TTA) and/or transfemoral amputation (TFA)) and published between 2008 and 2025 were included. Only population level studies were included. Meta-analysis was performed and prediction intervals used to report findings primarily. The Newcastle-Ottawa tool was used to assess the methodological quality of studies.
Results:
Fifty-two studies were included (1 067 616 patients). Only three studies were from low- and middle-income countries (two from Brazil, one from Togo). Most studies were either from North America (42%) or Europe and Central Asia (36%). Twenty-six studies reported in-hospital mortality and 26 reported 30-day mortality. Prediction intervals were 3.6-24.5% (point estimate 10.0%, 95% confidence interval 8.2% to 12.1%; 664 608), and 4.0-20.4% (point estimate 9.4%, 8.0% to 11.0%; 390 030) for in-hospital and 30-day mortality, respectively. In-hospital mortality prediction intervals were 2.9-12.7% (point estimate 6.2%, 5.1% to 7.7%; 77 204) for TTAs and 5.6-23.3% (point estimate: 11.8%, 9.6% to 14.4%; 78 632) for TFAs. Prediction intervals for 30-day mortality were 2.5-11.6% (point estimate 5.5%, 4.5% to 6.7%; 87 971) for TTAs and 4-26.6% (point estimate 10.9%, 8.3% to 14.2%; 42 145) for TFAs. Heterogeneity was high (> 75%) across all analyses.
Conclusion:
Most studies reporting short-term outcomes after major lower limb amputation are from high-income countries. Reported mortality is highly variable, but prediction intervals can be used to estimate mortality in future studies and inform shared decision-making.
