Outcomes and predictors of prosthetic use, mobility, and survival after below-knee amputation: a literature review
DOI:
https://doi.org/10.48750/acv.662Keywords:
Major lower limb amputation, Below-knee amputation, Prosthetic useAbstract
INTRODUCTION: Despite advances in prevention and revascularization, a significant number of patients still require major lower-limb amputation. Below-knee amputation (BKA) is generally associated with better functional outcomes and prosthetic use than more proximal amputations. In recent years, increased access to healthcare has led to a shift in the patient profile undergoing BKA: individuals now tend to undergo amputation later in the disease course and often present with more severe comorbidities and advanced limb ischemia. This literature review aims to re-evaluate the prognostic advantages of BKA and understand how factors such as pre-existing comorbidities and prior surgical interventions affect outcomes after BKA.
METHODS: A search of the PubMed database was conducted using the following query: ("below-knee amputation" OR "transtibial amputation") AND ("prosthetic use" OR "prosthesis" OR "mobility" OR "survival" OR "mortality") AND ("predictors" OR "outcomes").
RESULTS: A total of 230 articles were analyzed, and 10 were included. One-year mortality after BKA ranged from 25% to over 40%, with dementia, dialysis dependence, cerebrovascular disease, and female sex identified as significant predictors of poor survival and prosthetic use. Prosthetic fitting success was reported in 38%–44.5% of patients. Functional outcomes were inversely related to preoperative frailty, comorbidities, and poor limb perfusion (TcPO2 < 40 mmHg). Reintervention rates—including conversion to above-knee amputation (AKA)—reached up to 20%. Delays in prosthetic fitting and limited actual use further impaired mobility outcomes. Composite success—defined as wound healing, ambulation, and survival—was achieved in just over half of patients in some studies.
CONCLUSION: The emerging patient profile undergoing BKA—older, more comorbid, and further along in disease progression—requires rethinking how success is defined and achieved. Tailored patient selection, frailty assessment, and early involvement of rehabilitation teams may help optimize BKA outcomes.
Downloads
References
Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, Skillman JJ, et al. Major lower extremity amputation: outcome of a modern series. Arch Surg. 2004;139:395-9.
Chung J, Modrall JG, Ahn C, Lavery LA, Valentine RJ. Multidisciplinary care improves amputation-free survival in patients with chronic critical limb ischemia. J Vasc Surg. 2015;61:162-9.
World Health Organization. Guidelines for training personnel in developing countries for prosthetics and orthotics services. Geneva: WHO; [n.d.].
Pell JP, Donnan PT, Fowkes FGR, Ruckley CV. Quality of life following lower limb amputation for peripheral arterial disease. Eur J Vasc Surg. 1993;7:448-51.
Crane H, Boam G, Carradice D, Vanicek N, Twiddy M, Smith GE. Through-knee versus above-knee amputation for vascular and non-vascular major lower limb amputations. Cochrane Database Syst Rev. 2021;12:CD013839.
Davie-Smith F, Coulter E, Kennon B, Wyke S, Paul L. Factors influencing quality of life following lower limb amputation for peripheral arterial occlusive disease: a systematic review. Prosthet Orthop Int. 2017;41:537-47.
Murakami T, Murray K. Outcomes of knee disarticulation and the influence of surgical techniques in dysvascular patients: a systematic review. Prosthet Orthop Int. 2016;40:423-35.
Tisi PV, Than MM. Type of incision for below knee amputation. Cochrane Database Syst Rev. 2014;(1):CD003749.
Goodney PP, Beck AW, Nagle J, Welch HG, Zwolak RM. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg. 2009;50:54-60.
Garcia ML, Torres EM, Velescu A, Duran CD, Pehart ML, Velasco AC. Natural history after below-knee amputation: analysis of survival and prosthetic fitting over two decades. Cir Esp (Engl Ed). 2020;98:403-8.
Columbo JA, Nolan BW, Stucke RS, Rzucidlo EM, Walker KL, Powell RJ, et al. Below-knee amputation failure and poor functional outcomes are higher than predicted in contemporary practice. Vasc Endovascular Surg. 2016;50:554-8.
Alavi T, Jalali M, Farahmand B, Babaee T. Prosthesis and health-related factors of mobility in people with nontraumatic unilateral transtibial amputation. Prosthet Orthop Int. 2025;49:548-554.
Beyaz S, Guler UO, Bagir GS. Factors affecting lifespan following below-knee amputation in diabetic patients. Acta Orthop Traumatol Turc. 2017;51:393-7.
Sambandam S, Bokhari SMMA, Tsai S, Nathan VS, Senthil T, Lanier H, et al. Morbidity and mortality in non-obese compared to different classes of obesity in patients undergoing transtibial amputations. J Clin Med. 2023;12:1-10.
Ciufo DJ, Thirukumaran CP, Marchese R, Oh I. Risk factors for reoperation, readmission, and early complications after below knee amputation. Injury. 2019;50:462-6.
Taylor SM, Kalbaugh CA, Cass AL, Buzzell NM, Daly CA, Cull DL, et al. "Successful outcome" after below-knee amputation: an objective definition and influence of clinical variables. J Am Coll Surg. 2008;207:292-302.
Wu JT, Wong M, Lo ZJ, Wong WE, Narayanan S, Tan GWL, et al. A series of 210 peripheral arterial disease below-knee amputations and predictors for subsequent above-knee amputations. Ann Vasc Dis. 2017;10:217-22.
Andersen JC, Gabel JA, Mannoia KA, Kiang SC, Patel ST, Teruya TH, et al. Five-item modified frailty index predicts outcomes after below-knee amputation in the Vascular Quality Initiative Amputation Registry. Am Surg. 2020;86:1225-9.
Kamrad I, Soderberg B, Örneholm H, Hagberg K. SwedeAmp—the Swedish Amputation and Prosthetics Registry: eight-year data on 5762 patients with lower limb amputation show sex differences in amputation level and patient-reported outcomes. Acta Orthop. 2020;91:464-70.
Davenport DL, Xenos ES, Hosokawa P, Radford J, Henderson WG, Endean ED. The influence of body mass index obesity status on vascular surgery 30-day morbidity and mortality. J Vasc Surg. 2009;49:140-7.
