A.M. Eligh1,2 MD, I. Seinen2, V. Shestalova2, N. Boers1 MD MSc, M. Castro Cabezas3,4 MD PhD, J.H. Coert1 MD PhD, W.D. Rinkel5 MD PhD
1 Department of Plastic, Reconstructive, and Hand Surgery, Utrecht University Medical Center, Utrecht, the Netherlands
2 Department of Economic and Medical Affairs, Dutch Healthcare Authority, Utrecht, the Netherlands
3 Department of Internal Medicine, Franciscus Gasthuis Rotterdam, Rotterdam, the Netherlands
4 Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
5 Department of Plastic, Reconstructive, and Hand Surgery, Ziekenhuisgroep Twente, Twente, the Netherlands
Background: Diabetic foot ulcers (DFUs) and lower extremity amputations (LEAs) are severe complications of diabetes mellitus, associated with substantial morbidity and mortality. Despite advances in diabetes care, survival following foot complications remains poor, and national-level data are limited. This study aims to examine (re)amputation-free survival and all-cause mortality following DFUs and LEAs in the Netherlands to better understand long-term outcomes.
Methods: A retrospective cohort study was conducted using nationwide health insurance claims data (2012-2023) from 1,751,403 individuals with diabetes mellitus. One- and five-year survival rates following a first DFU, minor LEA, or major LEA were estimated using Kaplan-Meier analyses and Cox proportional hazards models. Each case was matched 1:1 by age, sex, and diabetes type to a reference individual with diabetes but without DFUs or LEAs. Outcomes included overall survival, amputation-free survival after a first DFU, and reamputation-free survival after a first LEA.
Results: Between 2012 and 2023, 100,839 individuals developed a DFU and 41,792 underwent a LEA (29,205 minor; 12,587 major). Men were at higher risk for developing diabetic foot complications. One- and five-year survival following DFU was 88% and 56%, respectively. After minor LEA, survival was 80% at one year and 45% at five years. Following major LEA, survival dropped to 67% and 32%, respectively. In comparison, survival among individuals with diabetes without DFU or LEA was 96% at one year and 78% at five years. Amputation-free survival after a first DFU was 76% at one year and 46% at five years. Reamputation-free survival after a first LEA was 51% and 22%, respectively.
Conclusion: Patients with diabetic foot complications face a significantly worse prognosis than those with diabetes alone, particularly following major amputations. These findings highlight the ongoing burden of limb loss and premature mortality in this population and emphasize the need for earlier detection and preventive care to improve long-term outcomes.