Editor's Choice – Global Temporal Trends in the Incidence of Major Lower Limb Amputations: A Systematic Review and Meta-analysis

OBJECTIVE: Major lower limb amputations are most commonly performed for complications of diabetes, peripheral arterial disease (PAD), or trauma. Given the increasing rates of diabetes and PAD globally, this study aimed to understand the temporal trends in the incidence of major amputations in contemporary published literature. DATA SOURCES: Medline, Embase, Scopus, and African Journals Online. REVIEW METHODS: A systematic search was conducted for studies reporting the incidence of major amputations, regardless of cause or geography, published since 2008. Studies were included if they reported population level incidence over two or more consecutive or non-consecutive years. Incidence trends were estimated using average annual percentage change in numerator:denominator pairings (referred to as incidence estimates), using log linear or Poisson regression. Meta-analysis of average annual percentage change was performed. If consecutive temporal data were not provided, average annual percentage change was estimated based on annual compound change but was not included in meta-analysis. Average annual percentage change estimates were categorised based on the populations reported in included incidence studies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool was used for certainty assessment of meta-analysis. RESULTS: Seventy-six studies were included for data extraction, encompassing 88 incidence estimates, with falling incidence reported in 72 of 88 (82%). Three studies were from low and middle income countries, all three of which showed a rising incidence of major amputation. Meta-analysis demonstrated falling incidence of all cause major amputations in the general population (ten studies, average annual percentage change -3.44%, 95% CI -5.17 - -1.67; GRADE certainty analysis - high) and diabetes related major amputations in the diabetes population (19 studies, average annual percentage change -7.13, 95% CI -8.60 - -5.64; GRADE certainty analysis - high). CONCLUSION: Amputation rates are generally reported to be falling in high income countries. Conversely, rates appear to be rising in low and middle income countries. More data are required from low and middle income countries, whilst an understanding of changes resulting in reduced incidence in high income countries may inform practice to reduce major amputation rates in low and middle income countries.