Incidence Of Lower Limb Amputation Research Articles

Quantifying the incidence of lower limb amputation in people with and without diabetes in Wales between 2008–2018

BackgroundThere is variance in the incidence of lower extremity amputation across and within countries including within the UK. National data shows up to a fourfold variance in the amputation rate throughout the regions of England and differences in amputation incidence have been reported in Scotland and Ireland. Lower extremity amputation rate has yet to be documented within Wales. The aim of this cohort study was to examine trends in diabetes and non-diabetes related lower extremity amputation incidence within the Welsh population and to examine the influence of diabetes on the relative risk of amputation. Materials and MethodsAll first-time amputations between 2008-2018 were extracted from SAIL, a repository of all routine medical data of residents of Wales. People with diabetes were identified using an algorithm utilising data from several clinical and non-clinical sources. Crude and direct age and sex adjusted incidences were estimated over time. ResultsOver the period 3505 major amputations and 4335 minor amputations occurred. The diabetes population greater than 17 years of age increased by 29.4% from 143,595 in 2008 to 206,818 in 2018. There was a statistically significant rate reduction in major amputation in both populations. In the diabetes population the number of major amputations reduced from 6.9 [5.5–8.5]/10 000 person years (PY) in 2008 to 4.9 [5.4–6.2]/10 000 PY in 2018. However, for major amputation, the risk of incident amputation in people with diabetes was 7.3 fold higher [7.1–7.5] than those without diabetes. The relative risk of minor amputation for those with diabetes was higher at 11.9 [11.8 –1.01]. There was no reduction in this risk over the period. ConclusionThis study found that rates of major amputation decreased over the study period but the risk of amputation for persons with diabetes remained substantial. As the population with diabetes increases so do crude rates of amputation, providing a substantial financial and societal cost to the Welsh Population.

The relationship between physical activity and diabetes in middle-aged and elderly people.

To investigate the association between diabetes symptoms and physical activity (PA) levels among middle-aged and older Chinese adults. Data for this study were obtained from 2018 Charles data. Z test, logistic regression analysis, and linear hierarchical regression analysis were performed in 5352 individuals aged ≥50 years with complete information. In terms of diabetes, 6.8% of the middle-aged and elderly people with diabetes were detected, and 93.2% of the middle-aged and elderly people without diabetes symptoms. The proportion of middle-aged and elderly people with high PA levels was 50.5%, and the proportion of middle-aged and elderly people with low PA was 49.5%. There was a significant positive correlation between low PA and diabetes (P < .05). After adjusting demographic characteristics (gender, registered permanent residence type, education level, age, widowhood) and health status characteristics (poor mood, asthma, hyperlipidemia, disability, memory disease, self-assessment of health status, hypertension, smoking, stroke, depression), there was still a statistical significance between PA level and diabetes (P < .05). The risk of diabetes of middle-aged and elderly people in China increases with age, while the risk of diabetes of middle-aged and elderly people with low level of PA is higher. The risk of diabetes is high among middle-aged and elderly people who are old, have poor self-evaluation health, suffer from hyperlipidemia, memory disease, and asthma. The middle-aged and old people should increase their PA levels to prevent and improve diabetes.

Lower limb amputations among individuals living with diabetes mellitus in low- and middle-income countries: A systematic review protocol.

The burden of diabetes mellitus (DM) and its associated complications continue to burgeon, particularly in low- and middle-income countries (LMICs). Lower limb amputation (LLA) is one of the most life-altering complications of DM, associated with significant morbidity, mortality and socio-economic impacts. High-income countries have reported a decreasing incidence of DM-associated LLA, but the situation in many LMICs is unknown. We aim to conduct a systematic review to determine the incidence and prevalence of DM-associated LLA in LMICs to better inform appropriate interventions and health system response. A systematic search of the literature will be conducted on five databases: MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus and African Journal Online (AJOL). Only observational, quantitative studies reporting the incidence and/or prevalence of DM-related LLA will be considered. A validated study design-specific critical appraisal tool will be used to assess the risk of bias in individual studies. We will determine the incidence of LLA by examining the number of new cases of LLA among individuals with confirmed DM diagnosis during the specified period, while the prevalence will be based on the total number of all new and existing LLAs in a population. LLA will be considered as the resection of the lower limb from just above the knee to any point down to the toe. If heterogeneity is low to moderate, a random-effects meta-analysis will be conducted on extracted crude prevalence/incidence rates, with the median and interquartile range also reported. The systematic review will be performed in accordance with the JBI guideline for prevalence and incidence review. Study reporting will follow the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guideline. CRD42021238656.

Co-relation of functional mobility with anxiety in traumatic below knee amputees

Background: Amputation is defined as the surgical removal of one or more parts of the body. It causes great stress to the physical and mental wellbeing of an individual. The incidence of lower limb amputation is greater as compared to upper limb amputation. Also lower limb amputees experience more restricted mobility than upper limb amputee patients. Rehabilitation is an important to the recovery of an amputee. In cases of planned amputation, rehabilitation starts before the surgery. It involves physiotherapy, occupational therapy and recreational training. There is little to no studies on the co-relation of anxiety with functional mobility in amputees. This study focusses on the same. Context and purpose: Amputation causes restricted mobility and decreased quality of life. A study on the relation between anxiety and mobility will indicate a different outlook of a holistic approach while treating mobility issues in below knee amputees. Materials and methods: This is a one group co-relational study design. Study was conducted after taking approval from the institutional ethics committee and all the subjects gave their written informed consent. The study was conducted at Yashwantrao Chavan Memorial Hospital, Pune. Result: Statistical analysis of the data was done using the Pearson’s co-relation co-efficient and a co-relation was found between anxiety and functional mobility in below knee amputee patients. Conclusion: There is a co-relation between functional mobility and anxiety. Patients with anxiety showed a reduced performance on the functional mobility scale than the patients without anxiety. KEY WORDS: Amputation, Anxiety, below knee amputation, functional mobility, rehabilitation.

Incidence of lower limb amputation in people with and without diabetes: a nationwide 5-year cohort study in Japan

IntroductionThis study was conducted to investigate the incidence and time trend of lower limb amputation (LLA) among people with and without diabetes.Research design and methodsThis retrospective population-based cohort study was...

Incidence of lower limb amputation in Central Australia.

Objective The aims of this study were to review the demographic details of those who have undergone lower limb amputation (LLA) surgery in Central Australia and determine the region-specific age-adjusted incidence rate of LLA. Methods A retrospective audit of service users who underwent LLA in a Central Australian hospital from 2012 to 2017 was undertaken. Demographic, operative and postoperative outcomes data were collected. The age-adjusted incidence rate of LLA was determined using the direct method. Demographic data were analysed using descriptive parametric analysis. Results In the period 2012-17, 166 service users underwent a total of 291 amputations in 231 episodes of care (hospital admissions). The age-adjusted incidence rate of LLA was 87.4 per 100000 for females and 104.6 per 100000 for males in this region. In total, 84% (n=140) of those requiring amputation surgery identified as Aboriginal Australians (P<0.001), 54% (n=75) of whom were female. Aboriginal Australians who underwent LLA were, on average, 13 years younger and were more likely to have type 2 diabetes (P<0.001) and require renal dialysis (P<0.001) than the non-Aboriginal Australian cohort. Of the Aboriginal Australians who underwent LLA, 82% (n=103) lived very remotely (>100km from the central town's centre), compared with 23% of non-Aboriginal Australians (P<0.001). In addition, 46% (n=64) of Aboriginal Australians who underwent LLA required renal dialysis. Those requiring renal dialysis were more likely to require subsequent amputation (P=0.014) and had a higher mortality rate following amputation (P=0.031). Partial foot amputation was the most common level of amputation in Central Australia (38%). Conclusions Central Australia appears to have the highest incidence rate of LLA for any region in Australia, with Aboriginal Australians, particularly females and those undergoing renal dialysis, being disproportionately represented. Further studies should aim to determine targeted, culturally safe and successful methods of diabetic foot ulcer prevention, early detection and management with a view to reducing the high amputation rates for these cohorts. What is known about the topic? Large health inequalities between Aboriginal and non-Aboriginal Australians exist. Aboriginal Australians are currently fourfold as likely as non-Aboriginal Australians to have type 2 diabetes (T2D), increasing their risk of LLA. There is a geographical variance in the incidence of LLA in Australia; the Northern Territory is overrepresented, with rates two- to threefold higher than that of the national average. Regional incidence rates are not currently known. What does this paper add? This study showed that the age-adjusted incidence rate for LLA in Central Australia is significantly higher than in other regions in Australia. Most LLA surgeries undertaken in Central Australia were performed for Aboriginal Australians who have T2D, with a disproportionate representation of females and those requiring renal dialysis. What are the implications for practitioners? This study shows that there is a need for further research and preventative measures to address the high rates of LLA among Aboriginal Australians, particularly for females and those with renal impairment. These groups could benefit from targeted, culturally safe approaches to early identification, referral and management of lower limb ulceration by relevant service providers.

Amputation as an anticipated consequence of peripheral artery disease and ways to improve the prognosis of limb salvage

Peripheral artery disease is a common and acute social burden worldwide. The main method of treatment of PAD consists in open surgical or endovascular revascularization. However, despite steady growth of the number and quality of interventions, the incidence of lower-limb amputation still remains at a high level. Lower-limb amputation is a severe psychological blow for the patient and leads to significant deterioration of his or her quality of life, as well as has an extremely negative prognosis concerning the frequency of subsequent complications and survival. Consequences of amputations include not only severe disability but also an unfavourable prognosis of life, thus determining the necessity of adequate prevention of such events. Reconstructive and endovascular operations, as well as amputations are associated with a significant increase of the probability of the development of major adverse cardiovascular events, the frequency of repeat hospitalizations and, finally, the cost of treatment. Prescribing pathogenetically substantiated antithrombotic therapy is considered to be one of the methods to improve the results of surgical treatment and prognosis for the patient. Presented in the article is a literature review making it possible to assess the risks and consequences of amputations in patients with PAD, as well as to determine therapy capable of improving the prognosis.

220-OR: Plasma Adrenomedullin and Allelic Variation in the ADM Gene and Risk for Lower Extremity Amputation in People with Type 2 Diabetes

Patients with diabetes have an increased risk for lower limb amputation (LLA) but biomarker to assess risk of LLA is lacking. Adrenomedullin (ADM), a vasodilator peptide, has been shown to be associated with cardiovascular and renal risk in diabetes. The aim of this study is to assess the association between plasma MR-proADM (a surrogate of ADM), allelic variation in the ADM gene and the risk for LLA in cohorts of patients with type 2 diabetes. We studied 4532 participants of the DIABHYCAR and SURDIAGENE cohorts (men 70%, mean age 66, mean duration of diabetes 13 years, A1c 8,0%). MR-proADM was measured by immunofluorescence. Five SNPs were chosen in the haplotype block containing the ADM gene (chr11p15.4): rs4399321, rs11042725, rs7944706, rs2957692 and rs2957717. The mean follow-up was 5.3 years. Incidence of LLA by tertiles of MR-proADM (T1, T2, T3) was 1.0% (T1), 1.9% (T2) et 4.7% (T3) (p&amp;lt;0,001). In a Cox multivariable analysis model (adjusted for cohort, age, sex, diabetes duration, hypertension, A1c, cholesterol, history of peripheral arterial disease and glomerular filtration rate eGFR), HR for LLA was 4.21 (2.18-8.66; p&amp;lt;0.001) for T3 vs. T1, 2.46 (1.50-4.12; p=0.003) for T3 vs. T2 and 1.82 (1.25-2.67; p=0.002) for 1 unit of log [ADM]. All SNPs were significantly associated with baseline plasma ADM. Four were significantly associated with LLA: HR adjusted for sex, age, duration of diabetes, A1c, eGFR and cohort: 1.40 (1.046 - 1.84; p=0.02) for the G-allele of rs4399321 in a codominant model; 1.71 (1.13 - 2.54; p=0.01) for the AA vs. CX genotype of rs11042725; 1.61 (1.09 - 2.35; p=0.02, for the GG vs. AX genotype of rs7944706; 1.37 (1.06 - 1.77; p=0.04) for the G-allele of rs2957692 in a codominant model. We observed an association of plasma ADM with LLA and of allelic variations in the AMP locus with plasma ADM and with LLA in a large population of people with type 2 diabetes. This pattern of mendelian randomisation supports the causality of the association of plasma ADM with LLA. Disclosure L. Potier: Consultant; Self; Eli Lilly and Company, Novo Nordisk A/S, Sanofi. R. Roussel: Advisory Panel; Self; Abbott, AstraZeneca, Diabnext, Eli Lilly and Company, Merck &amp; Co., Inc., Mundipharma International, Novo Nordisk A/S, Sanofi-Aventis. P. Saulnier: None. F. Fumeron: None. K. Mohammedi: None. G. Velho: None.

Incidence of Lower Limb Amputation in Diabetic Patients in Osijek-Baranja County

Amputation of the lower limb (LLA) is one of the most feared adverse outcomes among diabetic patients. Our aim was to determine the incidence of amputation in diabetic patients in Osijek-Baranja County and to examine the possible correlation between clinical characteristics of the patients and the time elapsed before the first amputation. This was a tertiary-care-based retrospective study and included 925 diabetic patients who underwent non-traumatic lower limb amputation in the University Hospital Osijek from January 1st 2008 to December 31st 2018. Data on associated cardiovascular risk factors and clinical characteristics of the patients were collected from diabetic registry of the Department of diabetes and endocrinology. A total of 278 patients had all data for further analysis. There were 1551 LLAs over a ten year period. The incidence was 6.14 per 1,000 adults with diabetes. LLA rates per 1,000 adults with diabetes decreased by 29% between 2010 and 2013 and then increased by 76% between 2014 and 2018. In ten year period incidence of amputation in diabetic patients varied from 4 to 7.8 per 1000 persons-year. We observed the same pattern in both minor and major LLA but rates of amputation above knee steadily increased 2.7 times between 2010 and 2018 (from 0.69 to 1.83 per 1000 patients-year). The mean age of patients with LLA was 67.2 years, 66% were male, mean BMI was 29.6±4.8 kg/m2 and the mean duration of diabetes was 14.7±8.2 years. There was no association between smoking, arterial hypertension and hyperlipemia, ACE inhibitor use, statin use, antiplatelet use, CVD, neuropathy and duration of diabetes before first amputation. Only sulphonylurea and insulin therapy significantly prolonged the time before the first amputation (p = 0.00001, for each). In conclusion, our study confirmed high rate of lower limb amputation in diabetic patients in Osijek-Baranja County. Incidence rates of LLA in our population are important for further improvements in diabetes care and decisions in health care policy.

Quantitative compensation design for prosthetic socket based on eigenvector algorithm method

The incidence of lower limb amputation has increased in recent years. Prosthesis is the most important assistive device to compensate for limb defects in amputation patients and restore their abilities. The prosthetic socket is a key component connecting the residual limb and the prosthesis, with a direct effect on the function of the prosthesis and the patient’s comfort. As prosthetic socket design relies on the personal experience of prosthetists, this study explored an optimized prosthetic socket design method that combined the experiences of multiple prosthetists. The eigenvector algorithm was adopted to optimize the factors influencing prosthetic socket design and their quantitative compensations based on the design experience of prosthetists. Clinical assessments indicated that the proposed socket design method substantially improved fitting effects. This quantitative compensation design for prosthetic sockets will help overcome the limitations of traditional prosthetic socket design, which will be of great importance in improving the design accuracy and efficiency of prosthetic sockets.

Incidence of lower limb amputation in diabetic patients between 2010 and 2018 in Osijek-Baranja County

Incidence of lower limb amputation in diabetic patients between 2010 and 2018 in Osijek-Baranja County

A survey of lower limb amputation rate in patients with diabetes at Shahid Modarres Hospital, Tehran, Iran, during 5 years

Introduction: Lower limb amputation in patients with diabetes is one of its major complications. Therefor understanding the prevalence and causes of this problem has great importance. The aim of this study was to evaluate lower limb amputation in patients with diabetes. Methods: During this observational cross-sectional study, 350 patients with diabetes mellitus admitted to Shahid Modarres Hospital, Tehran, Iran, from March 2012 to March 2017 were studied and incidence of lower limb amputation was observed. Results: About 64% of patients suffered from some degree of amputation. Important factors in these patients were delay in referral to surgeon, ineffective debridement and longtime impaired distal blood flow. Conclusion: The frequency of lower limb amputation in patients with diabetes is high and therefore there is a great need to find and reduce its underlying problems.

Incidence of lower limb amputation in Canada.

To determine the Canadian age-adjusted incidence rates of lower limb amputation (LLA) by province, sex, level, and cause of amputation. Data on all hospital discharges associated with LLA from April 1, 2006, to March 31, 2012, were obtained from the Canadian Institute for Health Information's Discharge Abstract Database. National and provincial age-adjusted rates were calculated per 100 000 individuals by sex, level, and cause of LLA using the direct method of standardization. The relative risk of LLA in people with diabetes was calculated. There were a total of 44 430 LLAs performed in Canada over the study years. The number of LLAs increased from 7331 in 2006 to 7708 in 2011. Mean (SD) age was 65.7 (16.6) years, and 68.8% were males. Sixty-five percent of the LLA cases were due to diabetes. The average age-adjusted rate of LLA in Canada was 22.9 per 100 000 individuals. The age-adjusted rates declined over the study years. The relative risk of diabetes-related LLAs was 28.9. This study provided the first Canadian national and provincial age-adjusted incidence rates of LLA and a baseline for monitoring and evaluation in the future. Understanding the incidence of LLA is essential to managing preventive and rehabilitation services for this population. Although the age-adjusted LLA incidence rates have decreased, the number of new LLAs has increased. The increase in the number of LLAs has important implications for social and health care costs.

Trends in the incidence of lower limb amputation after implementation of a Multidisciplinary Diabetic Foot Unit

Backgrounds and objectiveIncidence of lower extremity amputations (LEA) in the population with and without diabetes mellitus (DM) was assessed after implementation of a Multidisciplinary Diabetic Foot Unit (MDFU) during 2008. Material and methodsNon-traumatic LEA were analyzed, and those performed before (2001–2007) and after (2008–2014) introduction of the MDFU were compared. LEA were grouped by age and sex. Their incidence was expressed as a rate per 100,000 population per year, adjusted to the standard European population. ResultsA total of 664 LEA were performed during the 2001–2014 period, 486 (73%) of them in patients with DM. Total LEA incidence was 11.2/105 population in DM versus 3.9/105 in the population without DM. Incidence of major LEA in patients with DM significantly decreased from 6.1/105 population in the 2001–2007 period to 4.5/105 in the 2008–2014 period (p=0.03). Joinpoint regression analysis also showed a reduction in the trend of incidence of major LEA in patients with DM, with an annual percentage change of −3.3% [95% CI, −6.2–0.3] (p=0.025). No significant differences were found for all other incidences and trends in the diabetic and non-diabetic populations. ConclusionsImplementation of a MDFU has been shown to be associated with a significant reduction in major amputation rate in the diabetic population, although the results are not optimal yet. Both results and work at the MDFU should be improved.

Provision of Prosthetic Services Following Lower Limb Amputation in Malaysia.

The incidence of lower limb amputation is high across the globe and continues to be a major threat to morbidity and mortality. Consequently, the provision of high quality and effective prosthetics services have been known as an essential component for a successful rehabilitation outcome. In Malaysia, amputation prevalence has been increasing in which several main components of service delivering aspects (such as service intervention, prosthetic personnel) should be anticipated to accommodate for the increasing demand. This article highlights the hurdles experienced in providing prosthetic services in Malaysia from multiple aspects such as financial burden to acquire the prosthesis and lack of expertise to produce quality prosthesis. This paramount issues consequently justify for the urgency to carry out national level survey on the current statistics of lower limb amputation and to ascertain the available workforce to provide a quality prosthetics services. Only with accurate and current information from the national survey, strategies and policies aimed at enhancing the outcome from prosthetics services can be achieved.

Limited evidence to assess the impact of primary health care system or service level attributes on health outcomes of Indigenous people with type 2 diabetes: a systematic review.

BackgroundTo describe reported studies of the impact on HbA1C levels, diabetes-related hospitalisations, and other primary care health endpoints of initiatives aimed at improving the management of diabetes in Indigenous adult populations of Australia, Canada, New Zealand and the United States.MethodSystematic literature review using data sources of MEDLINE, Embase, the Cochrane Library, CINHAL and PsycInfo from January 1985 to March 2012. Inclusion criteria were a clearly described primary care intervention, model of care or service, delivered to Indigenous adults with type 2 diabetes reporting a program impact on at least one quantitative diabetes-related health outcome, and where results were reported separately for Indigenous persons. Joanna Briggs Institute critical appraisal tools were used to assess the study quality. PRISMA guidelines were used for reporting.ResultsThe search strategy retrieved 2714 articles. Of these, 13 studies met the review inclusion criteria. Three levels of primary care initiatives were identified: 1) addition of a single service component to the existing service, 2) system-level improvement processes to enhance the quality of diabetes care, 3) change in primary health funding to support better access to care. Initiatives included in the review were diverse and included comprehensive multi-disciplinary diabetes care, specific workforce development, systematic foot care and intensive individual hypertension management. Twelve studies reported HbA1C, of those one also reported hospitalisations and one reported the incidence of lower limb amputation. The methodological quality of the four comparable cohort and seven observational studies was good, and moderate for the two randomised control trials.ConclusionsThe current literature provides an inadequate evidence base for making important policy and practice decisions in relation to primary care initiatives for Indigenous persons with type 2 diabetes. This reflects a very small number of published studies, the general reliance on intermediate health outcomes and the predominance of observational studies. Additional studies of the impacts of primary care need to consider carefully research design and the reporting of hospital outcomes or other primary end points. This is an important question for policy makers and further high quality research is needed to contribute to an evidence-base to inform decision making.

Incidence of lower limb amputation in Australian hospitals from 2000 to 2010

Contemporary literature reports that the incidence of lower limb amputation has declined in many countries. This impression may be misleading given that many publications only describe the incidence of lower limb amputations above the ankle and fail to include lower limb amputations below the ankle. To describe trends in the incidence of different levels of lower limb amputation in Australian hospitals over a 10-year period. Descriptive. Data describing the age-standardised incidence of lower limb amputation were calculated from the Australian National Hospital Morbidity database and analysed for trends over a 10-year period. The age-standardised incidence of lower limb amputation remained unchanged over time (p = 0.786). A significant increase in the incidence of partial foot amputations (p = 0.001) and a decline in the incidence of transfemoral (p = 0.00) and transtibial amputations (p = 0.00) were observed. There are now three lower limb amputations below the ankle for every lower limb amputation above the ankle. While the age-standardised incidence of all lower limb amputation has not changed, a shift in the proportion of lower limb amputations above the ankle and lower limb amputations below the ankle may be the result of improved management of precursor disease that makes partial foot amputation a more commonly utilised alternative to lower limb amputations above the ankle. Clinical relevance This article highlights that although the incidence of lower limb amputation has remained steady, the proportion of amputations above the ankle and below the ankle has changed dramatically over the last decade. This has implications for how we judge the success of efforts to reduce the incidence of lower limb amputation and the services required to meet the increasing proportion of persons with amputation below the ankle.

PS6 - 32. Unchanged incidence of lower limb amputation in Northern Netherlands

Understanding the incidence and population characteristics of people undergoing lower limb amputation (LLA) can help in planning and service delivery of preventative, rehabilitation and long-term care.

Recorded incidence of lower limb amputation varies across England

Recorded incidence of lower limb amputation varies across England

Variation in the recorded incidence of amputation of the lower limb in England

The study aimed to explore the variation in recorded incidence of lower limb amputation in England. The incidences of amputations in adults with and without diabetes were determined from hospital episode statistics over 3 years to 31 March 2010 and compared between the 151 Primary Care Trusts (PCTs) in England. There were 34,109 amputations, including 16,693 (48.9%) in people with diabetes. The incidence was 2.51 per 1,000 person-years in people with diabetes and 0.11 per 1,000 person-years in people without (relative diabetes risk 23.3). Incidence varied eightfold across PCTs in people both with diabetes (range 0.64-5.25 per 1,000 person-years) and without (0.03-0.24 per 1,000 person-years). Amputations in people with diabetes varied tenfold--both major (range 0.22-2.20 per 1,000 person-years) and minor (range 0.30-3.25 per 1,000 person-years). The incidences of minor and major amputations were positively correlated both in those with (r = 0.537, p < 0.0005) and without (r = 0.611, p < 0.0005) diabetes. Incidences of amputations were also correlated between people with and without diabetes (total amputations r = 0.433, p < 0.0005; major amputations r = 0.528, p < 0.0005). There was a negative correlation between the incidence of amputation and estimated prevalence of ethnic Asians. No association was found between the PCT incidence of either total amputations and general population prevalence of social deprivation (r = -0.138, p = 0.092) or smoking (r = 0.137, p = 0.096). Variation in amputation incidence occurs across England. Because of the similarity in amputation variation between people with and without diabetes the variation may reflect generic differences in local healthcare delivery, although racial factors may also contribute.