The Changing Rates of Lower-Limb Amputations in Germany

An analysis of data from the Federal Statistical Office, 2005–2023

Due to the fact that an amputation registry is still lacking, little is known about the number of amputations in Germany. At present, prevalence and incidence rates can only be estimated based on health insurance data and regional studies. For the frequency of amputations performed, on the other hand, diagnosis-related group statistics (DRG statistics) are more suitable (1). This is one of the few sources of statistics that can be used to describe and analyze changes over time. The aim of this work was to provide an up-to-date overview of trends in the number of amputations in Germany.

Methods

DRG statistics are maintained by the German Federal Statistical Office (Statistisches Bundesamt) and include data from all hospitals that fall within the scope of Section 1 of the Hospital Remuneration Act (Krankenhausentgeltgesetz) and bill their services according to the DRG remuneration system. For this evaluation, the Federal Statistical Office provided a detailed table of the German “Operations and Procedures Code” (Operationen- und Prozedurenschlüssel, OPS) covering the period from 2005 to 2023. Changes in amputation rates and levels over the observation period, as well as differences by age-group and sex, were analyzed. Amputation rates were calculated on an age-standardized basis per 100 000 inhabitants for 10-year age groups from 0 to 90 years, as well as for individuals aged over 90 years. The German population as of 31.12.2022 served as the standard population.

Definition

A distinction is made in the DRG system between major (OPS 5–864) and minor amputations (OPS 5–865). We adhere to this distinction, even though Syme’s amputation (OPS 5–865.0), which is in actual fact a distal lower-leg amputation, is somewhat arbitrarily classified here as a minor amputation. Since only 0.25% of all amputations performed in 2023 were Syme amputations, this classification affects the amputation rates only at the decimal level.

Results

Amputation rates

In 2023, a total of 69 534 lower-limb amputations were performed in Germany, of which 16 943 were major and 52 591 were minor amputations.

The rate of major amputations declined between 2005 and 2023 from 38.7 to 20.2 (− 47.7%). Parallel to this, the rate of minor amputations rose from 55.6 to 62.8 (+ 12.9%).

The stump revision rate for the hip as well as the upper and lower leg decreased slightly during the same period (−12.0%), whereas it rose sharply for the foot region (including toes) from 2.8 to 8.1 (+ 185.4 %) (Figure).

Figure

Age-standardized amputation and revision rates per 100 000 inhabitants in Germany

In 2023, an increase in the age-standardized amputation rate was seen in relation to three amputation levels compared to 2003: This increase relates to forefoot amputations (Chopart) (+ 19.1%), toe amputations (+ 8.7%), and in particular, toe ray resections (+ 95.0%). Rates declined for all other amputation levels.

Age group differences

In 2023, the average age at the time of major amputation was 70.6 years (SD: 12.8), while for minor amputations, it was 72.4 years (SD: 12.5). In total, 94.8% of major and 96.3% of minor amputations were performed on individuals aged 50 years or older. The age-standardized rate of major and minor amputations in the 50- to 59-year-old age group increased four-fold in 2023 compared to the 40- to 49-year-old age group. In the 60- to 69-year-old age group, the number of amputations doubled compared to the previous decade of life.

The over-90s age group showed not only the sharpest decline in major amputation rates (− 78.9%) but also the strongest rise in minor amputation rates (+ 25.24%).

Sex differences

In 2023, 69.7% of major amputations and 76.9% of minor amputations were performed on males. Females were, on average, 4 years older than males for both for major and minor amputations. Compared to 2005, major amputation rates among males (− 40.9%) have not declined as sharply as those among females (− 60.4%), while minor amputation rates have risen by 22.9% among males but declined by 18.8% among females over the same period.

Reasons for amputation

The most frequently reported primary diagnoses for major amputations in 2023 were vascular disease with or without diabetes mellitus (DM) (70.3%) and surgical complications (11.5%), while for minor amputations, vascular disease with or without DM was most commonly reported (82.9%). In 2005, major amputations were coded with an average of 11.6 secondary diagnoses per primary diagnosis, whereas the number of secondary diagnoses in 2023 was 20.8 (+ 79.1%). For minor amputations, the average number of secondary diagnoses per primary diagnosis increased from 9.0 to 15.2 (+ 69.1%). This may point to a change in coding practice.

Discussion

Given that a national amputation registry is currently still in the process of being set up in Germany (2), one can only speculate about the reasons for the decline in some amputation rates and the rise in others; it is also not possible to make any statements regarding the further course of diseases or treatment. Data on prevalence and incidence are not yet available.

Even DRG statistics are not able to provide a precise picture of incidence rates—partly due to the fact that not all hospitals are subject to the DRG system, and partly since there are inaccuracies in DRG statistics: Multiple procedures can be given per hospital case as well as per operating session, for example, bilateral arm amputation, multiple amputation procedures during one operation, or multiple amputations during one hospital stay (3). Furthermore, the quality of the data depends on the respective coding practices and other documentation effects. Minor amputations in diabetic foot syndrome are also often performed in the outpatient setting and are not included in DRG statistics.

Differences compared to the figures reported by Kröger et al. (1) are explained by differences in data retrieval from the German Federal Statistical Office as well as a different approach to age-standardization. Also, no cases were excluded from the present analysis on the basis of specific reasons for amputation.

In addition to research into causes, both incidence and prevalence rates are of considerable importance for healthcare provision. Valid figures form an essential basis for needs-oriented rehabilitative care structures and planning. Germany has some catching-up to do in this regard.

Christoph Egen, Andrea Bökel, Anika Großhennig, Jennifer Ernst, Christian Sturm, Jörg Schiller

Department of Rehabilitation and Sports Medicine, Hannover Medical School, Hannover, Germany (Egen, Bökel, Sturm, Schiller) [e-mail]

Institute of Biostatistics, Hannover Medical School, Hannover, Germany (Großhennig)

Department of Trauma Surgery, Hannover Medical School, Hannover, Germany (Ernst)

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 4 February 2025, revised version accepted on 4 June 2025.

Translated from the original German by Christine Rye.

Cite this as:
Egen C, Bökel A, Großhennig A, Ernst J, Sturm C, Schiller J: The changing rates of lower-limb amputations in Germany: An analysis of data from the Federal Statistical Office, 2005–2023. Dtsch Arztebl Int 2025; 122: 449–50. DOI: 10.3238/arztebl.m2025.0104

References

1. Kröger K, Berg C, Santosa F, Malyar N, Reinecke H: Lower limb ­amputation in Germany—an analysis of data from the German Federal Statistical Office between 2005 and 2014. Dtsch Arztebl Int 2017; 114: 130–6

2. Alimusaj M, Michel K, Block J, et al.: Update Amputationsregister Deutschland (AMP-Register). Unfallchirurgie 2025; 128: 240–7

3. Heller G, Günster C, Swart E: Über die Häufigkeit von Amputationen unterer Extremitäten in Deutschland. Dtsch Med Wochenschr 2005; 130: 1689–90