|
| |
 |
|
| ORIGINAL ARTICLE |
|
| Year : 2021 | Volume
: 26
| Issue : 1 | Page : 64-69 |
|
Lower limb amputations in Nigeria: An appraisal of the indications and patterns from a premier teaching hospital
Okechukwu Onwuasoigwe1, Ikechukwu C Okwesili1, Leonard O Onyebulu1, Emmanuel C Nnadi1, Arinze D G Nwosu2
1 Department of Surgery, University of Nigeria Teaching Hospital, Ituku/Ozalla, Nigeria
2 Department of Anaesthesia, National Orthopaedic Hospital, Enugu, Nigeria
| Date of Submission | 13-Jul-2020 |
| Date of Decision | 24-Aug-2020 |
| Date of Acceptance | 14-Sep-2020 |
| Date of Web Publication | 21-Oct-2020 |
Correspondence Address:
Okechukwu Onwuasoigwe
Department of Surgery, Faculty of Medical Sciences, University of Nigeria, Ituku/Ozalla Campus, Enugu.
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ijmh.IJMH_47_20
Background: The most common indication for lower limb amputations in Nigeria is not known. Almost all studies on amputations in Nigeria considered lower and upper extremities together and report varying leading indications. Major lower limb amputation imposes a significant health burden on the patient and deserves effort at its prevention. The aim of the present study was to determine the predominant indication and patterns of lower limb amputations from a Nigerian premier teaching hospital to enable appropriate preventive recommendations. Materials and Methods: The operative records of patients who underwent lower limb amputation surgeries in the premier University of Nigeria Teaching Hospital, east of Nigeria, between January 2013 and December 2017 were retrospectively analyzed for the indications, levels of amputations, and patient characteristics. Results: Ninety-three unilateral lower limb amputations were performed within the 5-year period. There were 52 (55.9%) males with an M:F ratio of 1.3:1. The mean age of the patients was 52.23 years. Trans-tibial amputation was more commonly performed (51.6%), followed by trans-femoral (45.2%). Diabetic foot (DF) gangrene constituted the dominant indication (57%) and accounted for 54.8% of all the major amputations. The next common indication was tumors (19.3%). Foot gangrene from diabetes and from nondiabetic peripheral arterial diseases (10.8%) accounted for 67.8% of the indications. Conclusions: Major lower limb amputations predominate from this study, with peripheral vascular diseases (PVDs), especially due to diabetes mellitus, being the leading cause. Appropriate public health advocacy on DF complications and establishment of comprehensive multidisciplinary foot-care services, capable of prevention, diagnosis, and treatment of early DF lesions, will help reduce the incidence of DF gangrene. This measure will, no doubt, lower the high rate of major lower limb amputations. Keywords: Amputation, common indication, lower limb, Nigeria, prevention
How to cite this article:
Onwuasoigwe O, Okwesili IC, Onyebulu LO, Nnadi EC, Nwosu AD. Lower limb amputations in Nigeria: An appraisal of the indications and patterns from a premier teaching hospital. Int J Med Health Dev 2021;26:64-9 |
How to cite this URL:
Onwuasoigwe O, Okwesili IC, Onyebulu LO, Nnadi EC, Nwosu AD. Lower limb amputations in Nigeria: An appraisal of the indications and patterns from a premier teaching hospital. Int J Med Health Dev [serial online] 2021 [cited 2021 Jan 20];26:64-9. Available from: https://www.ijmhdev.com/text.asp?2021/26/1/64/298787 |
| Introduction | |  |
Surgical amputations date back to Hippocrates and were for many years one of the main functions of the surgeon.[1] Limbs were then amputated most frequently for life-threatening war injuries and accidents. However, similar to other aspects of medicine, amputation surgery has evolved over the years. The indications for the procedure have expanded to include removal of extremity that is injured beyond salvage, or severely diseased and pose a threat to life, or painful, functionless, and constitute a nuisance to the patient.[2] Nonetheless, both the prescription and consent to amputation of a limb are last-resort decisions for the surgeon and the patient, respectively, since limb loss, especially major amputation, inevitably increases the health burden of the amputee.[3],[4],[5]
Conventionally, extremity amputation is surgically classified into either major or minor. Major limb amputation, defined as severance of an extremity proximal to the wrist or the ankle with respect to the upper or lower limb, imposes significant functional, economic, and social limitations to the patient. These problems are more profound in the case of major lower limb amputations, especially in a resource-poor setting where there is limited availability, affordability, and acceptance of prosthetic rehabilitation.[6],[7],[8] Apart from the overt social stigma associated with lower limb loss, the ability to bear weight and relative equality of leg lengths, which are mandatory for maximal and satisfactory function in any individual, are compromised. The amputee’s quality of life becomes suboptimal, even with acceptable prosthetic rehabilitation.[9] In practices with clear knowledge of prevalent indications for lower limb amputations, clinicians have devised amputation prevention and incidence-lowering strategies such as revascularization surgeries, etc. with good outcomes.[10],[11]
Traditionally, the clinical indications for limb amputations fall under irredeemable peripheral vascular diseases (PVDs), trauma, tumors, infections, and congenital limb deficiencies.[2] However, PVD, infections, and some malignant tumors such as classic osteosarcoma and melanoma show a predilection for the lower extremity and rarely predispose to amputations of the upper limb.[7] On the other hand, congenital limb deformities are more prevalent on the upper limb. In the Western countries, PVD, consequent upon diabetes mellitus and nondiabetic arterial diseases, has been established as the most common indication for lower limb amputations.[12],[13],[14] In Nigeria, isolated lower limb amputation studies are sparse. Majority of the reports studied upper and lower limb amputations and present varying dominant indications across the nation. One systematic review of the Nigerian studies on amputations between 1991 and 2005 (15 years) highlighted limb gangrene arising from trauma, particularly from traditional bone setter (TBS) fracture treatments, as the national leading indication; >60% of cases, for amputations.[15] From that study, 14 publications, out the 19 included, analyzed amputations of upper and lower extremities. However, some recent publications from the southern parts of Nigeria point to a high prevalence of diabetic foot gangrene (DF gangrene)[16],[17] although figures from the northern and some eastern parts still oscillate between trauma and malignant tumors as the leading indications.[8],[18],[19] There is a need for reliable data on leading causes of lower limb amputations in Nigeria to streamline medical knowledge and to enable informed development of appropriate preventive strategies.
The Center for this study is the premier, tertiary teaching hospital in Eastern Nigeria with about four decades of variety of comprehensive patient-care services. We were unable to find published data on lower limb amputations from the hospital in the literature. This report presents a 5-year retrospective review of indications and patterns of LEA from this Center and we think the findings may help better definition of current Nigerian data on the topic.
| Materials and Methods | | |
This was a retrospective review of surgical records of lower limb amputations performed at the Teaching hospital from January 2013 to December 2017. The Institution is a multispecialty teaching hospital and receives patient referrals from across Eastern Nigeria and often beyond. Multidisciplinary evaluations and interventions, by specialties such as orthopedics/trauma, plastic and reconstructive surgery, vascular surgery, endocrine diseases, infectious diseases, oncology, among others, are often employed in the management of the patients according to needs. Decisions to amputate a limb are built on the consensus of all the relevant specialties and only when the extremity is adjudged unsalvageable. The Surgery Registry for all the operations in the hospital and the patient’s case files were the sources of data for this study. Data were collected on patient age and gender, level of amputation, and the diagnosed indication. Data were analyzed using IBM SPSS Statistics software, Version 23. Variables were expressed as means and standard deviations, median, and range. Results are presented with descriptive statistics, aided with tables and charts.
| Results | | |
Ninety-three lower limb amputations were performed in 93 patients within the 5-year period. They were 52 (55.9%) males and 41 (44.1%) females (M:F = 1.3:1).
The patients’ ages ranged between 8 and 82 years, with a mean of 52.23 (± 16.77) years. [Figure 1] presents the patients’ age distribution.
The distribution of amputation levels is shown in [Table 1]. Trans-tibial amputations accounted for most of the cases (51.6%), followed by trans-femoral (45.2%). All amputations were unilateral with a ratio of major to minor types of 30:1.
The most common indication for lower limb amputations from this study was DF gangrene (57%) followed by tumors (19.3%), and trauma (12.9%) as shown in [Table 2]. Altogether, the DF gangrenes (57%) and nondiabetic peripheral arterial diseases (PADs) (10.8%), components of PVD, account for 67.8% of the indications.
[Table 3] shows that there were 90 major amputations compared to 3 minors (ratio 30:1). DF gangrene accounted for 51 (54.8%) of the 90 major amputations in this series. However, trans-femoral amputation, compared to trans-tibial, occurs more frequently with indications of trauma, tumors, and PADs, than with DF gangrene.
| Discussion | | |
The finding from this report that PVD (57% from DF gangrene + 10.8% from PAD) accounts for 67.8% of indications for lower limb amputations in a Nigerian population is noteworthy [Table 2]. Vascular occlusive disease was diagnosed in the 53 DF gangrenes with routine Doppler ultrasound studies.
By consensus built from earlier reports, trauma, and complications to it, was seen as the most common indication for limb amputations in Nigeria.[8],[15],[19] This information does influence medical education on the topic. Medical trainees are often taught that this is the case in Nigeria, unlike in the Western countries where PVDs, from diabetes mellitus and nondiabetic atherosclerosis, constitute the dominant indication for lower limb amputations. While this disparity between the Nigerian and the Western data subsists, a few recent Nigerian studies drew attention to increasing importance of DF gangrene in their series and the authors wondered if there is a changing trend in the nation.[16],[17] The present study was conducted exclusively for lower limb amputations with the finding of PVD being the leading (67.8%) indication. These data not only support the observed relevance of DF gangrene as major indication, but also show implications for planning amputation prevention strategies and for revision of the medical teaching which states that PVD is not common while trauma is the dominant cause for limb amputations in Nigeria. However, this finding calls for more studies, particularly multicentre designed researches to conclusively resolve this question.
From our literature review, the Nigerian studies on limb amputations trend toward combining upper and lower limbs. Could this be the reason for the data disparities amongst the local reports and findings from developed countries? We believe that studies intended to establish common indications and patterns of limb amputations should segregate between upper and lower limbs. There are indications for amputation known to show predilection for either upper or lower limbs.[7] We suspect that these differences in disease predilections for upper or lower limbs could bias research outcomes when both extremities are recruited for causes of amputations. Secondly, the Nigerian reports emanated from single hospitals of varying capacities, and majority of the reports came from orthopedic/trauma only specialized centers. The study center for the present report is multidisciplinary with the capacity for specialists care to orthopedics/trauma, tumors, vascular and infectious diseases, endocrinology, etc., patients. We believe that the data from this report may reflect a microcosm of current Nigerian picture on lower limb amputations since the Center offers tertiary care to all causes of amputation [Table 4]. [Table 4] shows that traumatic conditions, hitherto regarded as the dominant indication for amputations in Nigeria, took a third stage with 12.9% of cases. Surprisingly too, TBS gangrene was seen in only one (1.08%) case in this series of lower limbs, even though earlier reports gave prominence to it as a major Nigerian cause for amputations.[8],[15],[19],[20],[21] TBS gangrene is most common with the upper limb and in children.[15],[21]
Another important concern from this study is the high ratio (30:1) of major to minor lower limb amputations [Tables 1] and [3]. Some other authors, both locally and from other developing countries, have reported a similar trend and attribute the pattern to the late presentation of cases.[8],[22] This reason, we also believe, explains the high ratio found in the present report. Late presentation of cases as a risk factor to major amputation is applicable to all causes of limb amputation. [Figure 2] represents the typical stages of disease for most of our cases that ended with major amputation. All the major amputations in this study were contributed by trans-tibial (51.6%) and trans-femoral (45.2%) levels in a ratio of 1.1:1. We did not encounter knee or hip disarticulations or hindquarter amputation in this study. While DF gangrene accounted for majority (54.8%) of the major amputations, 70.6% (36/51) of such cases ended with trans-tibial amputation unlike in other indications when trans-femoral levels were more likely [Table 3]. For major lower limb amputation, knee joint salvage is functionally most preferred because it enhances rehabilitative efforts and decreases the energy expenditure required for ambulation, compared to higher-level amputation.[23] Nevertheless, prevention of major amputation should be the goal whenever possible, given the associated significant social, functional, and financial losses to the affected amputee. The observed patterns of major amputations in this study, particularly in relation to the dysvascular (ischemic) diseases, tally with aetiopathogenesis of the different indications. Diabetic-induced vascular occlusive diseases (atherosclerosis) set in usually much earlier, in middle-aged individuals and the brunt is commonly infrageniculate (below the knee), unlike in nondiabetic PAD that manifests at more elderly patients, >60 years and the effect is often infrainguinal or even aortofemoral in extent.[24],[25],[26],[27] The mean age of our patients is 52.23 years [Figure 1] due to the preponderance of DF gangrene and it contrasts with the stated Nigerian mean age for amputations of about 35 years.[8],[15],[20] These presented data reflect notable demographic changes and may be pertinent to patient evaluation and treatment recommendations, for amputation cases in Nigeria.
Similar to what obtains in most developing countries, reports of poor prosthetic rehabilitation of amputees in Nigeria have been made.[6],[8],[9] Therefore, given the high proportion of major amputations observed from this study, preventive and incidence-lowering treatment strategies should be the top priority in managing amputation-prone cases in Nigeria. This underscores the importance of clear knowledge of common causes of lower limb amputations and their pathogenic pathways by the treating clinicians. Ischemic extremity, e.g., PVD, like in the present study, is increasingly becoming the most common risk factor for diseased lower limbs progressing to amputation. Following advances in surgical technology, many extremities with traumatic injuries and malignant tumors that historically would be amputated are increasingly being salvaged, thereby reducing the incidence of amputations from these causes.[28] Clinicians, therefore, should be wary of patient populations at risk for ischemic limbs, such as diabetics, hypertensive patients, smokers, the elderly and counsel them for regular checkups for prevention and treatment of early foot lesions to avoid their escalation.
Diabetes mellitus is an emerging global epidemic. Its common foot complications—peripheral arterial occlusive disease, neuropathy leading to trophic ulcers, and soft tissue and/or bone sepsis—are directly related to the observed rising incidence of lower extremity amputations (LEAs) worldwide, and in the USA where 82% of vascular-related LEA is stated to be due to diabetes.[12],[14],[29] The high prevalence of diabetics (57%) in this report also points to the existence of the threat locally and calls for extreme vigilance to curtail undue high proportion of major LEAs. In a recent meta-analysis, Wang et al. defined DF characteristics with a significant risk of major LEA such as ulcer reaching bone, hindfoot position, gangrene, lower ankle-brachial index, infection, and PAD.[30] In another study, the use of a high-intensity Statin regimen for PAD was found to significantly lower amputation rates compared to low-intensity Statin or antiplatelet therapy.[31] These are updates, complementary to the traditional methods that could benefit intentions to prevent or lower incidence of major LEAs. The management policy of prevention and aggressive healing of early DF lesions to forestall their progression to the critical stages would be ideal in lowering amputation rates.
| Conclusion | | |
Major lower limb amputations predominated and with DF gangrene being the leading cause in this series of Nigerian population. There is need for awareness creation on DF complications to the populace and institution of multidisciplinary foot-care centers to manage the foot lesions at the early stages. Public awareness creation may lead to early foot care and minor limb or no amputation.
Patient consent statement
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
None received for this work.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Hemigou P Amboise Pare`II: Pare’s contribution to amputation and ligature. Int Orthop 2013;34:769-72.  |
| 2. | Mihalko MJ, Amputations of the lower extremity. In: Azar FM, Beaty JH, Canale ST, editors. Campbell’s Operative Orthopaedics. E-Book, 13th ed. Philadeiphia PA, Elsevier Inc.; 2016. vol 1, Part VI, Chapt.16; pp. 647-85. |
| 3. | Eardley WG, Taylor DM, Parker PJ Amputation and the assessment of limb viability: Perceptions of two hundred and thirty two orthopaedic trainees. Ann R Coll Surg Engl 2010;92:411-6. |
| 4. | Higgins TF, Klatt JB, Beals TC Lower extremity assessment project (LEAP)–the best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am 2010;41:233-9. |
| 5. | Paudel B, Shrestha BK, Banskota AK Two faces of major lower limb amputations. Kathmandu Univ Med J (KUMJ) 2005;3:212-6. |
| 6. | Yinusa W, Ugbeye ME Problems of amputation surgery in a developing country. Int Orthop 2003;27:121-4. |
| 7. | Kim YC, Park CI, Kim DY, Kim TS, Shin JC Statistical analysis of amputations and trends in korea. Prosthet Orthot Int 1996;20:88-95. |
| 8. | Omoke NI, Nwigwe CG Limb amputations in Abakaliki, South East Nigeria. Afr J Med Sci 2016;15:30-5. http://www.ajmhs.org/text.asp?2016/15/1/30/183890 |
| 9. | Shaw J, Challa S, Conway D, Liu M, Haonga B, Eliezar E, et al. Quality of life and complications in lower limb amputees in Tanzania: Results from a pilot study. Lancet Global Health 2018;6:S18. |
| 10. | Goodney PP, Tarulli M, Faerber AE, Schanzer A, Zwolak RM Fifteen-year trends in lower limb amputation, revascularization, and preventive measures among medicare patients. JAMA Surg 2015;150:84-6. |
| 11. | Schweinberger MH Proven strategies to prevent lower extremity amputations. Diabetes Watch 2013;26:16-24. |
| 12. | Boyko EJ, Monteiro-Soares M, Wheeler SGB Peripheral arterial disease, foot ulcers, lower extremity amputations and diabetes. In: Cowie CC, Cassagrande SS, Menke A, et al; eds. Diabetes in America. 3rd ed. Bethesda MD: National Institute of Health, NIH Pub No. 17-1468; 2017. Chap 20. |
| 13. | Gabel J, Jabo B, Patel S, Kiang S, Bianchi C, Chiriano J, et al; Vascular Quality Initiative. Analysis of patients undergoing major lower extremity amputation in the vascular quality initiative. Ann Vasc Surg 2018;46:75-82. |
| 14. | Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, et al. Lower extremity amputations–a review of global variability in incidence. Diabet Med 2011;28:1144-53. |
| 15. | Thanni LOA, Tade AO Extremity amputations in Nigeria –a review of indications and mortality. The Surg -J R Coll Surg Ed and Ire 2007;5:213-7. |
| 16. | Dada AA, Awoyomi BO Is the trend of amputations in Nigeria changing? A review of 51 consecutive cases seen at Federal Medical Centre, Ebute Metta, Lagos, Nigeria. Nig Med J 2010;51:167-9. |
| 17. | Ndukwu CU, Muoneme CA Prevalence and pattern of major extremity amputations in a tertiary hospital in Nnewi, South East Nigeria. Trop J Med Res 2015;18:104-8. |
| 18. | Dabkana TM, Nyaku FT, Bwala ST Current indications for extremity amputations in Maiduguri, north-east Nigeria: A 6-year retrospective review. Ann Afr Med 2018;17:22-5. |
| 19. | Salawu ON, Babalola OM, Mejabi JO, Fadimu AA, Ahmed BA, Ibraheem GH, et al. Major extremity amputations: Indications and post surgery challenges in a Nigeria tertiary institution. Sahel Med J [serial online] 2019;22:8-12. http://www.smjonline.org/text.asp?2019/22/1/8/255172 |
| 20. | Olasinde AA, Oginni LM, Bankole JO, Adegbehingbe Oluwadiya KS Indications for amputations in Ile-Ife, Nigeria. Niger J Med 2002;11:118-21. |
| 21. | Onuminya JE, Onabowale BO, Obekpa PO, Ihezue CU Traditional bone setters gangrene. Int Orthop (SICOT) 1999;23:111-2. |
| 22. | Aljarrah Q, Allouh MZ, Bakkar S, Aleshawi A, Obeidat H, Hijazi E, et al. Major lower extremity amputation: A contemporary analysis from an academic tertiary referral centre in a developing community. BMC Surg 2019;19:170. |
| 23. | Waters RL, Perry J, Antonelli D, Hislop H Energy cost of walking of amputees: The influence of level of amputation. J Bone Joint Surg Am 1976;58:42-6. |
| 24. | Aiello A, Anichini R, Brocco E, Caravaggi C, Chiavetta A, Cioni R, et al; Italian Society of Diabetes; Italian Society of Radiology; Italian Society of Vascular Endovascular Surgery. Treatment of peripheral arterial disease in diabetes: A consensus of the Italian Societies of Diabetes (SID, AMD), radiology (SIRM) and vascular endovascular surgery (SICVE). Nutr Metab Cardiovasc Dis 2014;24:355-69. |
| 25. | Lowry D, Saeed M, Narendran P, Tiwari A A review of distribution of atherosclerosis in the lower limb arteries of patients with diabetes mellitus and peripheral vascular disease. Vasc Endovasc Surg 2018;52:535-42. |
| 26. | Hankey GJ, Norman PE, Eikelboom JW Medical treatment of peripheral arterial disease. JAMA 2006;295:547-53. |
| 27. | Yang W, Cei X, Han X, Ji L Clinical characteristics of young type 2 diabetes patients with atherosclerosis. PLoS One 2016;11:e0159055. |
| 28. | Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 2002;347:1924-31. |
| 29. | Beckman JA, Creager MA, Libby P Diabetes and atherosclerosis: Epidemiology, pathophysiology, and management. JAMA 2002;287:2570-81. |
| 30. | Wang N, Yang BH, Wang G, Gao Y, Cao X, Zhang XF, et al. A meta-analysis of the relationship between foot local characteristics and major lower extremity amputation in diabetic foot patients. J Cell Biochem 2019;120: 9091-6. |
| 31. | Arya S, Khakharia A, Binney ZO, DeMartino RR, Brewster LP, Goodney PP, et al. Association of statin dose with amputation and survival in patients with peripheral artery disease. Circulation 2018;137:1435-46. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
|
Search Pubmed for