Clinical Outcomes of Below-Knee Amputation (BKA) in Diabetic Patients: Predictive Factors for Wound Healing — A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Primary Studies
Keywords:
below-knee amputation, transtibial amputation, diabetes mellitus, diabetic foot, wound healing, re-amputation, hypoalbuminaemiaAbstract
Introduction: Below-knee (transtibial) amputation is the most frequently performed major limb ablation in diabetes, with lower wound healing rates and higher re-amputation rates than above-knee amputation. Predictive factors for stump healing remain fragmented across the literature.
Methods: PRISMA 2020 systematic review and DerSimonian-Laird random-effects meta-analysis of primary studies reporting adjusted associations between preoperative predictors and wound healing/re-amputation outcomes. Heterogeneity assessed by I² and τ², leave-one-out sensitivity analysis, and GRADE certainty.
Results: Renal failure/dialysis increased risk (HR 2.00; 95% CI 1.45-2.77; p<0.001). CRP/albumin or BUN/albumin ratio had the largest effect (HR 3.00; 95% CI 2.04-4.42; p<0.001; I²=0%). Glycaemic dysregulation: HR 2.52 (95% CI 1.69-3.75; p<0.001). Abnormal ABI: HR 2.00 (95% CI 1.29-3.12; p=0.002). Hypoalbuminaemia predicted healing (HR 1.59; p=0.020) and mortality (HR 2.27; I²=0%). Other factors: non-ambulatory status (HR 1.65), anatomical ischaemia (HR 1.60), diabetes (HR 1.53), infection (HR 1.37), and smoking (HR 1.31). Adjunctive advanced wound therapy vs standard care was not significant (HR 1.36; 95% CI 0.76-2.43; p=0.298; I²=70%).
Discussion: Below-knee amputation wound healing failure in diabetes arises from four convergent pathophysiological axes: macro/microvascular insufficiency, protein-energy wasting with systemic inflammation, uraemic tissue dysfunction, and persistent infective burden. Inexpensive laboratory biomarkers carry prognostic weight comparable to advanced perfusion measurement.
Conclusion: Wound healing failure after below-knee amputation in diabetes is predicted by renal failure, hypoalbuminaemia, glycaemic dysregulation, abnormal ABI, and inflammatory-nutritional ratios. These variables should inform amputation-level decisions and preoperative optimisation.
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