Estimating the Prevalence of Limb Loss in the United States: 2005 to 2050


      Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050.


      To estimate the current prevalence of limb loss in the United States and project the future prevalence to the year 2050.


      Estimates were constructed using age-, sex-, and race-specific incidence rates for amputation combined with age-, sex-, and race-specific assumptions about mortality. Incidence rates were derived from the 1988 to 1999 Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project, corrected for the likelihood of reamputation among those undergoing amputation for vascular disease. Incidence rates were assumed to remain constant over time and applied to historic mortality and population data along with the best available estimates of relative risk, future mortality, and future population projections. To investigate the sensitivity of our projections to increasing or decreasing incidence, we developed alternative sets of estimates of limb loss related to dysvascular conditions based on assumptions of a 10% or 25% increase or decrease in incidence of amputations for these conditions.


      Community, nonfederal, short-term hospitals in the United States.


      Persons who were discharged from a hospital with a procedure code for upper-limb or lower-limb amputation or diagnosis code of traumatic amputation.


      Not applicable.

      Main Outcome Measures

      Prevalence of limb loss by age, sex, race, etiology, and level in 2005 and projections to the year 2050.


      In the year 2005, 1.6 million persons were living with the loss of a limb. Of these subjects, 42% were nonwhite and 38% had an amputation secondary to dysvascular disease with a comorbid diagnosis of diabetes mellitus. It is projected that the number of people living with the loss of a limb will more than double by the year 2050 to 3.6 million. If incidence rates secondary to dysvascular disease can be reduced by 10%, this number would be lowered by 225,000.


      One in 190 Americans is currently living with the loss of a limb. Unchecked, this number may double by the year 2050.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Owings M.
        • Kozak L.
        Ambulatory and inpatient procedures in the United States, 1996.
        Vital Health Stat 13. 1998; 139: 1-119
        • Dillingham T.
        • Pezzin L.
        • MacKenzie E.
        Limb amputation and limb deficiencies: epidemiology and recent trends in the United States.
        South Med J. 2002; 95: 875-883
        • Wrobel J.
        • Mayfield J.
        • Reiber G.
        Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population.
        Diabetes Care. 2001; 24: 860-864
        • Lavery L.
        • Ashry H.
        • van Houtum W.
        • Pugh J.
        • Harkless L.
        • Basu S.
        Variation in the incidence and proportion of diabetes-related amputations in minorities.
        Diabetes Care. 1996; 19: 48-52
        • Lavery L.
        • van Houtum W.
        • Ashry H.
        • Armstrong D.
        • Pugh J.
        Diabetes-related lower-extremity amputations disproportionately affect Blacks and Mexican Americans.
        South Med J. 1999; 92: 593-599
        • van Houtum W.
        • Lavery L.
        Regional variation in the incidence of diabetes-related amputations in The Netherlands.
        Diabetes Res Clin Pract. 1996; 31: 125-132
        • van Houtum W.
        • Lavery L.
        • Harkless L.
        The impact of diabetes-related lower-extremity amputations in The Netherlands.
        J Diabetes Complications. 1996; 10: 325-330
        • van Houtum W.
        • Lavery L.
        Outcomes associated with diabetes-related amputations in The Netherlands and in the state of California, USA.
        J Intern Med. 1996; 240: 227-231
        • van Houtum W.
        • Lavery L.
        Methodological issues affect variability in reported incidence of lower extremity amputations due to diabetes.
        Diabetes Res Clin Pract. 1997; 38: 177-183
        • Van Buskirk A.
        • Barta P.
        • Schlossbach N.
        Lower extremity amputations in New Jersey.
        N J Med. 1994; 91: 260-263
        • Valway S.
        • Linkins R.
        • Gohdes D.
        Epidemiology of lower-extremity amputations in the Indian Health Service, 1982-1987.
        Diabetes Care. 1993; 16: 349-353
        • Wetterhall S.
        • Olson D.
        • DeStefano F.
        • et al.
        Trends in diabetes and diabetic complications, 1980-1987.
        Diabetes Care. 1992; 15: 960-967
        • Centers for Disease Control (CDC)
        Lower extremity amputations among persons with diabetes mellitus—Washington, 1988.
        MMWR Morb Mort Wkly Rep. 1991; 40: 737-739
        • Miller A.
        • Van Buskirk A.
        • Verhoek-Oftedahl W.
        • Miller E.
        Diabetes-related lower extremity amputations in New Jersey, 1979 to 1981.
        J Med Soc N J. 1985; 82: 723-726
        • Most R.
        • Sinnock P.
        The epidemiology of lower extremity amputations in diabetic individuals.
        Diabetes Care. 1983; 6: 87-91
        • Dillingham T.
        • Pezzin L.
        • MacKenzie E.
        Racial differences in the incidence of limb loss secondary to peripheral vascular disease: a population-based study.
        Arch Phys Med Rehabil. 2002; 83: 1252-1257
        • Feinglass J.
        • Brown J.
        • LoSasso A.
        • et al.
        Rates of lower-extremity amputation and arterial reconstruction in the United States, 1979 to 1996.
        Am J Public Health. 1999; 89: 1222-1227
        • Feinglass J.
        • Kaushik S.
        • Handel D.
        • Kosifas A.
        • Martin G.
        • Pearce W.
        Peripheral bypass surgery and amputation: northern Illinois demographics, 1993 to 1997.
        Arch Surg. 2000; 135: 75-80
        • Huber T.
        • Wang J.
        • Wheeler K.
        • et al.
        Impact of race on the treatment for peripheral arterial occlusive disease.
        J Vasc Surg. 1999; 30: 417-425
        • Tunis S.
        • Bass E.
        • Steinberg E.
        The use of angioplasty, bypass surgery, and amputation in the management of peripheral vascular disease.
        N Engl J Med. 1991; 325: 556-562
        • Tunis S.
        • Bass E.
        • Klag M.
        • Steinberg E.
        Variation in utilization of procedures for treatment of peripheral arterial disease.
        Arch Intern Med. 1993; 153: 991-998
        • Dillingham T.
        • Pezzin L.
        • MacKenzie E.
        Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study.
        Arch Phys Med Rehabil. 1998; 79: 279-287
        • Boyle D.
        • Parker D.
        • Larson C.
        • Pessoa-Brandao L.
        Nature, incidence, and cause of work-related amputations in Minnesota.
        Am J Ind Med. 2000; 37: 551-557
        • Sorock G.
        • Smith E.
        • Hall N.
        Hospitalized occupational finger amputations, New Jersey, 1985-1986.
        Am J Ind Med. 1993; 23: 439-447
        • Ebskov L.
        Major amputation for malignant melanoma: an epidemiological study.
        J Surg Oncol. 1993; 52: 89-91
        • Adams P.
        • Hendershot G.
        • Marano M.
        • Centers for Disease Control and Prevention/National Center for Health Statistics
        Current estimates from the National Health Interview Survey, 1996.
        Vital Health Stat 10. 1999; 200: 1-203
        • Brookmeyer R.
        • Gray S.
        Methods for projecting the incidence and prevalence of chronic diseases in ageing populations: application to Alzheimer’s disease.
        Stat Med. 2000; 19: 1481-1493
        • Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health
        Forecasting the global burden of Alzheimer’s disease.
        (Accessed July 20, 2007)
        • Dillingham T.
        • Pezzin L.
        • MacKenzie E.
        Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study.
        Arch Phys Med Rehabil. 1998; 79: 279-287
        • Izumi Y.
        • Satterfield K.
        • Lee S.
        • Harkless L.B.
        Risk of reamputation in diabetic patients stratified by limb and level of amputation.
        Diabetes Care. 2006; 29: 566-570
        • Sambamoorthi U.
        • Tseng C.L.
        • Rajan M.
        • Anjali T.
        • Findley P.A.
        • Pogach L.
        Initial nontraumatic lower-extremity amputations among veterans with diabetes.
        Med Care. 2006; 44: 779-787
        • Dillingham T.R.
        • Pezzin L.E.
        • Shore A.D.
        Reamputation, mortality and health care costs among persons with dysvascular lower-limb amputations.
        Arch Phys Med Rehabil. 2005; 86: 480-486
        • U.S. Census Bureau
        Population estimates.
        (Accessed Oct 30, 2007)
        • Hastie T.J.
        • Tibshirani R.J.
        Generalized additive models.
        in: Chapman & Hall, London1990: 15
        • U.S. Census Bureau
        Population projections.
        (Accessed Oct 30, 2007)
        • National Center for Health Statistics
        Vital statistics of the United States, 1955-1958.
        (Vol 1) U.S. Department of Health, Education, and Welfare, Public Health Service, Washington (DC)1957-1960
        • National Center for Health Statistics
        Vital statistics of the United States, 1959.
        (Vol I) U.S. Department of Health, Education, and Welfare, Public Health Service, Washington (DC)1962
        • National Center for Health Statistics
        Vital statistics of the United States, 1960-1998.
        (Vol 1) U.S. Department of Health, Education, and Welfare, Public Health Service, Washington (DC)1963-2001
        • U.S. Census Bureau
        Historical statistics for the United States, colonial times to 1970.
        (Pt 1) Population Div, U.S. Census Bureau, Washington (DC)1975
        • Hoyert D.
        • Arias E.
        • Smith B.
        • Murphy S.
        • Kochanek K.D.
        Deaths: final data for 1999.
        Natl Vital Stat Rep. 2001; 49: 1-113
      1. Surveillance, Epidemiology, and End Results (SEER) Program public-use data (1992-2002). National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch, Rockville2004 (Available at: Accessed Oct 30, 2007)
        • Criqui M.
        Peripheral arterial disease—epidemiological aspects.
        Vasc Med. 2001; 6: 3-7
        • Gu K.
        • Cowie C.
        • Harris M.
        Mortality in adults with and without diabetes in a national cohort of the U.S. population, 1971-1993.
        Diabetes Care. 1998; 21: 1138-1145
        • Wild S.
        • Roglic G.
        • Green A.
        • Sicree R.
        • King H.
        Global prevalence of diabetes.
        Diabetes Care. 2004; 27: 1047-1053
        • Flegal K.
        • Carroll M.
        • Ogden C.
        • Johnson C.
        Prevalence and trends in obesity among US adults, 1999-2000.
        JAMA. 2002; 288: 1723-1727
        • Mokdad A.
        • Bowman B.
        • Ford E.
        • Vinicor F.
        • Marks J.
        • Koplan J.
        The continuing epidemics of obesity and diabetes in the United States.
        JAMA. 2001; 286: 1195-1200
        • Gregg E.
        • Cadwell B.
        • Cheng Y.
        • et al.
        Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the U.S.
        Diabetes Care. 2004; 27: 2806-2812
        • Manson J.
        • Nathan D.
        • Krolewski A.
        • Stampfer M.
        • Willett W.
        • Hennedkens C.
        A prospective study of exercise and incidence of diabetes among US male physicians.
        JAMA. 1992; 268: 63-67
        • Hu F.
        • Manson J.
        • Stampfer M.
        • et al.
        Diet, lifestyle, and the risk of type 2 diabetes mellitus in women.
        N Engl J Med. 2001; 345: 790-797
        • Gujral J.
        • McNally P.
        • O’Malley B.
        • Burden A.
        Ethnic differences in the incidence of lower extremity amputation secondary to diabetes mellitus.
        Diabet Med. 1993; 10: 271-274
        • Wachtel M.
        Family poverty accounts for difference in lower-extremity amputation rates of minorities 50 years old or more with diabetes.
        J Natl Med Assoc. 2005; 97: 334-338
        • Rucker-Whitaker C.
        • Feinglass J.
        • Pearce W.
        Explaining racial variation in lower extremity amputation: a 5-year retrospective claims data and medical record review at an urban teaching hospital.
        Arch Surg. 2003; 138: 1347-1351
        • Feinglass J.
        • Rucker-Whitaker C.
        • Lindquist L.
        • McCarthy W.
        • Pearce W.
        Racial differences in primary and repeat lower extremity amputation: results from a multihospital study.
        J Vasc Surg. 2005; 41: 823-829
        • U.S. Department of Health and Human Services
        Healthy people 2010: understanding and improving health.
        2nd ed. U.S. Government Printing Office, Washington (DC)2000
        • Mayfield J.
        • Reiber G.
        • Nelson R.
        • Greene T.
        Do foot examinations reduce the risk of diabetic amputation?.
        J Fam Pract. 2000; 49: 499-504
        • Larsson J.
        • Apelqvist J.
        • Agardh C.
        • Stenstrom A.
        Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach?.
        Diabet Med. 1995; 12: 770-776
        • Rith-Najarian S.
        • Reiber G.
        Prevention of foot problems in persons with diabetes.
        J Fam Pract. 2000; 49: S30-S39
        • Strine T.
        • Okoro C.
        • Chapman D.
        • Beckles G.
        • Balluz L.
        • Mokdad A.
        The impact of formal diabetes education on the preventive health practices and behaviors of persons with type 2 diabetes.
        Prev Med. 2005; 41: 79-84
        • Reiber G.
        • Boyko E.
        • Smith D.
        Lower extremity foot ulcers and amputations in diabetes.
        in: Harris M. Cowie C. Stern M. Boyko E. Reiber G. Bennett P. Diabetes in America. 2nd ed. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda1995: 409-428 (NIH Publication No. 95-1468)
        • Armstrong D.
        • Lavery L.
        • Harkless L.
        • van Houtum W.
        Amputation and reamputation of the diabetic foot.
        J Am Podiatr Med Assoc. 1997; 87: 255-259
        • Larsson J.
        • Agardh C.
        • Apelqvist J.
        • Stenstrom A.
        Long term prognosis after healed amputations in patients with diabetes.
        Clin Orthop Relat Res. 1998; 350 (May): 149-158
        • Pecoraro R.
        • Reiber G.
        • Burgess E.
        Pathways to diabetic limb amputation: basis for prevention.
        Diabetes Care. 1990; 13: 513-521
        • Mayfield J.A.
        • Reiber G.E.
        • Maynard C.
        • Czerniecki J.M.
        • Caps M.T.
        • Sangeorzan B.J.
        Trends in lower limb amputation in the Veterans Health Administration, 1989-1998.
        J Rehabil Res Dev. 2000; 37: 23-30
        • Fischer H.
        CRS report to Congress. U.S. military casualty statistics: Operation Iraqi Freedom and Operation Enduring Freedom.
        (Accessed July 26, 2007)
        • Blustein J.
        The reliability of racial classifications in hospital discharge abstract data.
        Am J Public Health. 1994; 84: 1018-1021
        • Boehmer U.
        • Kressin N.
        • Berlowitz D.
        • Christiansen C.
        • Kazis L.
        • Jones J.
        Self-reported vs administrative race/ethnicity data and study results.
        Am J Public Health. 2002; 92: 1471-1472
        • Kressin N.
        • Chang B.
        • Hendricks A.
        • Kazis L.
        Agreement between administrative data and patients’ self-reports of race/ethnicity.
        Am J Public Health. 2003; 93: 1734-1739