|Year : 2015 | Volume
| Issue : 2 | Page : 104-108
Prevalence and pattern of major extremity amputation in a tertiary Hospital in Nnewi, South East Nigeria
Chibuzo U Ndukwu, Chigozie A Muoneme
Department of Orthopaedic Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra, Nigeria
|Date of Web Publication||9-Jun-2015|
Dr. Chibuzo U Ndukwu
Department of Orthopaedic Surgery, Nnamdi Azikiwe University Teaching Hospital, PMB 5025, Nnewi, Anambra
Introduction: Amputation surgery is an orthopedic surgical procedure carried out as the last resort, when limb salvage is not feasible. It is usually associated with social, emotional and psychological disturbances to the patient and the family. Objectives: To determine the prevalence and pattern of amputation surgeries in the Orthopedic unit of the Nnamdi Azikiwe University teaching hospital (NAUTH) Nnewi. This will be compared with trends in similar studies. Patients and Methods: This was a 2 year retrospective analysis of major limb amputations in NAUTH Nnewi from January 2011 to December 2012. Information extracted from the case notes included the biodata, indication for amputation, levels of amputation, complications and prosthetic use. Result: A total of 90 patients had major extremity amputations. All the cases were unilateral amputations. The age range was 17 to 89 years with a mean of 58.3 ± 15.9 years. The male to female ratio was 1.5:1. The amputation prevalence amongst all orthopedic surgeries within the period was 21.8%. Diabetic foot gangrene was the most common indication for amputation in 65 (72.2%) patients. Below knee amputation was the most common level of amputation (64.4%). Wound dehiscence was the most common complication. Only 10 patients used prosthesis and the mortality rate was 34.1%. Conclusion: There is a high prevalence of limb amputation in this study with diabetic gangrene being a leading cause. The public should be enlightened to adopt a better health-seeking attitude which may help to drastically control the almost epidemic menace of diabetes and the complications.
Keywords: Amputation, extremity, Nnewi
|How to cite this article:|
Ndukwu CU, Muoneme CA. Prevalence and pattern of major extremity amputation in a tertiary Hospital in Nnewi, South East Nigeria. Trop J Med Res 2015;18:104-8
|How to cite this URL:|
Ndukwu CU, Muoneme CA. Prevalence and pattern of major extremity amputation in a tertiary Hospital in Nnewi, South East Nigeria. Trop J Med Res [serial online] 2015 [cited 2020 May 27];18:104-8. Available from: http://www.tjmrjournal.org/text.asp?2015/18/2/104/158405
| Introduction|| |
Amputation surgery is one of the oldest surgical procedures dating back to the days of HIPPOCRATES. , It is a common procedure in the practice of Orthopedics in Nigeria and is aimed at saving life and improving function in a diseased extremity.
Major limb amputation, defined as the severance of a limb proximal to the wrist or the ankle, is reported to be a major but preventable public health problem. It is associated with profound economic, social and psychological effect on the patient and family especially in developing countries where the knowledge and acceptance of prosthetic use is poor. ,,, Prostheses are equally not readily available and affordable by many of these patients.
Studies have documented a steady rise in the incidence of major limb amputations in Nigeria over the years and for differing indications including foot gangrene resulting as a complication of uncontrolled diabetes mellitus, trauma and traditional bone setters gangrene. ,,,,,, In developed countries, peripheral arterial disease, as a result of atherosclerosis is the most common reason for lower limb amputation.  Other indications for amputation have been noted to include infection, tumor, non-diabetic gangrene and congenital limb abnormalities. ,,, It is therefore important that center-specific prevalence, indications and patterns be determined as a prelude to setting up strategies to locally and globally reduce this menace. This study is therefore necessary to provide this essential information which will be compared with data from previous works done on this subject.
| Patients and Methods|| |
This was a 2 year retrospective analysis of patients who had major limb amputations in Nnamdi Azikiwe University Teaching Hospital (NAUTH) Nnewi, from January 2011 to December 2012.
NAUTH Nnewi has a department of Orthopedics and Trauma, with two functional units, and receives referrals from Anambra state and neighboring states of Imo, Delta, Enugu and Abia. Ethical approval for the study was obtained from the hospital's ethical committee.
Information was extracted from the case notes and theatre register using a structured proforma. Data obtained included the biodata, indication for amputation, levels of amputation, complications and prosthetic use.
Data entry and management was done with microsoft excel software and the Statistical Package for Social Sciences version 20 (SPSS 20). The level of statistical significance was taken as P value less than 0.05 (P < 0.05).
| Results|| |
A total of 91 out of 417 patients that underwent orthopedic surgical procedures had major limb amputation during the study period. All these patients had unilateral amputations. There were 54 males and 37 females giving a male to female ratio of 1.5:1. The age range was 17 to 89 years with a mean age of 58.3 ± 15.9 years. The peak age incidence was 51-70 years [Table 1] and [Figure 1]. The amputation prevalence amongst all orthopedic surgeries within the period was 21.8%.
[Table 2] shows the employment status of the patients: 52 (57.1%) employed, among which 35 (38.5%) were males while 17 (18.7%) were females. 27 (29.7%) and 7 (7.7%) were unemployed and retired, respectively.
[Figure 2] is a pie chart illustrating the indications for amputation. Diabetic gangrene was the most common indication accounting for 71.4% of all cases of amputation carried out within the period under review. Trauma which occupied the second position (10.9%) was far below diabetic gangrene. Other indications included non-diabetic gangrene (6.6%), tumor (6.6%), and infection (1.1%).
[Figure 3] shows that the most common level of amputation was below knee which was done in 58 (63.7%) of cases. Above knee amputation was done in 24 (26.4%), while above elbow amputation was the least 3 (3.3%). Thus, 92.3% of all the amputations done were in the lower limb. All the upper limb amputations were as a result of malignant bone tumors in the third decade of life. There was no below elbow amputation done during the study period.
There was no significant correlation between gender and indication for amputation from this study [Table 3].
The most common complication was wound dehiscence in seven (7.7%), followed by phantom limb in five (5.5%). Others include wound infection in three (3.3%), stump hemorrhage, septicemia and pressure sore in one (1.1%) each, respectively.
Mortality rate recorded from this study was 34.1% with 31 patients. Out of these, 24 (77.4%) was from diabetic foot gangrene. Tumor, trauma and infection accounted for two (1.8%) each. One patient was discharged against medical advice. Only 10 (9.1%) of patients used prosthesis.
| Discussion|| |
Limb amputation has been shown to be a common orthopedic surgical procedure in the index study, just as reported in several other studies. ,,,,,, A little more than one out of every five orthopedic surgeries in the index center being an amputation surgery (21.8%) is quite significant. Previous studies recorded a much lower prevalence of amputations though these were among all surgical procedures without isolating orthopedic surgeries.  Amputations are usually carried out as a last resort when limb salvage is impossible, when the limb is dead, viable but non-functional, or endangering the patient's life.  The high prevalence in the area studied is definitely a reflection of the health-seeking attitude of the populace. The center of study is a referral tertiary health center that attends to referred patients who may have been poorly managed peripherally, thus presenting with complications that may require amputations mostly as a life-saving intervention. Many of these patients in our environment usually seek traditional therapy as a first resort for almost every kind of ailment as has also been reported in several studies in Nigeria and Africa. ,,, There will thus be a consequent belated seeking of orthodox attention with the attendant complications. The propaganda that "seeking orthodox orthopedic care will ultimately result in amputation" may have a relationship to this kind of high amputation prevalence. The circulation of this propaganda with the actual reality on ground may ultimately result in a vicious cycle of continued late presentations for orthodox orthopedic care and subsequent high prevalence of amputations.
Diabetic gangrene was found to be the most common indication for amputation in the index center, accounting for 71.43% of all cases of amputations carried out within the study period. This differs from studies in developed countries where vascular insufficiency is reported to be the most common indication for amputations but is similar to evidence from recent studies in Africa and Nigeria showing that diabetic gangrene is becoming a leading cause of amputation. ,,,,,,, This suggests a changing trend as in the past, trauma and complications of traditional bone setting were the leading indications for amputations in Nigeria. ,, The high evolving incidence of diabetic complications may be as a result of increasing urbanization with adverse change in life style and diet, complicated by a low awareness of the disease and its complications with inappropriate patient education on foot care, and poor health-seeking attitude.  With majority of Nigerians living below the poverty line, many cannot fund transportation to a hospital nor pay for the necessary treatment, thus resulting in almost a fanatical dependence on traditional healers, fuelled by the erroneous belief in this part of the world that both ulcerative and gangrenous foot lesions arise from poison contacted by foot. Despite the need for foot lesions in diabetic patients to be given adequate early attention and treated aggressively where necessary to prevent complications, many people with diabetes foot ulceration seek medical attention late, when bone damage has already set in with amputation and premature death being common outcomes.  The lower percentage arising from trauma in our study may be due to a more efficient public enlightenment campaign on road safety measures together with prompt management of cases in our facility. The index pattern in terms of most common indications is similar to other findings in Nigeria and Africa. ,,,
The male preponderance found from this study agrees with findings in other studies. ,,, This may be explained by the fact that males are more active and thus more likely to sustain foot injuries.
Lower limb amputations constituted the vast majority of cases with the most common level from this study being below knee amputations in 63.7%. This agrees with a similar published study from this center by Ofiaeli in 2001 in which below knee amputation accounted for 48% of amputations.  Other local and global studies also report a similar trend. ,,,, However, Onyemaechi et al., in Northern Nigeria, reported a higher prevalence of above knee amputations.  It is generally observed that traumatic injuries occur more in the lower limbs and diabetic gangrene is also more common in the lower limb than anywhere else in the body, accounting for this observation.
Amputation was found to be most common in the age group 50-70 years. This agrees with report from other authors who documented peak age incidences of peripheral vascular disease and diabetes in the 6 th and 7 th decades of life. ,, This may be because the risk factors are more common in the aging populace.
The most common complication of amputation from this study which was stump wound dehiscence in 7.69% is at variance with other studies where wound infection was recorded as the most common complication. ,, The reason for this was not elicited from the study. The mortality rate of 34.06% from this study (out of which 77.4% were from diabetic foot gangrene) is higher than 8.9%, 16.0% and 21.6% found by Onyemaechi et al., Dada et al. and Naaeder et al., respectively. ,, This may still be attributed to late presentation of diabetic patients especially those with foot lesions to tertiary health facilities. The diabetic foot is reported to be the second leading cause of diabetes-related deaths in Nigeria, accounting for 24% of all diabetes mortalities.  Delayed consent for amputation may play a major role as wide family consultations are usually made before consenting to surgery. Those with cultural and religious beliefs in reincarnation may also delay consent as they would not want to come back to life maimed. Major extremity amputation is usually associated with several challenges, paramount among which is the psychosocial stigmatization which may lead to severe depression.  This probably explains why most patients find it difficult to give consent even in the face of life threatening conditions. Only 9.1% used prosthetic fitting. Onyemaechi et al. reported similar patterns (7.1%) in their study.  This relative low usage of prosthesis may be due to lack of availability, cost and deliberate refusal by some amputees who prefer to join destitute in the streets to beg for alms.
| Conclusion|| |
Limb amputation is highly prevalent among Orthopedic surgeries. This study is thus a wakeup call for a more radical approach to drastically control the menace which is almost assuming an epidemic proportion. Health education and public enlightenment on early presentation for orthodox medical care, compliance to medication, adequate foot care and aggressive management of foot lesions in diabetics will no doubt reduce the incidence of diabetic gangrene (presently the most common indication) with resultant decrease in amputation. Availability and subsidization of prosthetic fittings will definitely improve quality of care rendered to diabetics that will ultimately have a positive impact on their quality of life.
| References|| |
Van der Meij W. K N: No leg to stand on. Historical relation between amputations. Surgery Prostheseology 1995;1:1-256.
Paudel B, Shrestha BK, Banskota AK. Two faces of major lower limb amputations. Kathmandu Univ Med J (KUMJ) 2005;3:212-6.
Essoh JB, Bamba I, Dje Bi Dje V, Traore A, Lambin Y. Limb amputations in adults in an Ivorian teaching hospital. Niger J Ortho Trauma 2007;6:61-3.
Nwankwo OE, Katchy AU. Surgical limb amputations: A five year experience at Hiltop Orthopaedic Hospital Enugu, Nigeria. Nig J Orthop Trauma 2004;3:139-49.
Onuminya JE, Obekpa PO, Ihezue HC, Ukegbu ND, Onabowale BO. Major amputations in Nigeria: A plea to educate traditional bone setters. Trop Doct 2000;30:133-5.
Yinusa W, Ugbeye ME. Problems of amputation surgery in developing country. Int Orthop 2003;27:121-4.
Ogunlade SO, Alonge TO, Omololu AB, Gana JY, Salawu SA. Major limb amputation in Ibadan. Afr J Med Med Sci 2002;31:333-6.
Solagberu BA. The scope of amputations in a Nigerian teaching hospital. Afr J Med Med Sci 2001;30:225-7.
Ofiaeli RO. Indications, level and outcome of lower extremity amputations in Nnewi, Nigeria. J Med Invest Pract 2001;2:18-21.
Akiode O, Shonubi AM, Musa A, Sule G. Major limb amputations: An audit of indications in a suburban surgical practice. J Natl Med Assoc 2005;97:74-8.
Solagberu BA. Diabetic foot in Nigeria - A review article. Afr J Med Med Sci 2003;32:111-8.
Ahmad N, Thomas GN, Chan C, Gill P. Ethnic differences in lower limb revascularization and amputation rates. Implications for the aetiopathology of atherosclerosis? Atherosclerosis 2014;233:503-7.
Naaeder SB. Amputation of the lower limb in Korle-Bu teaching hospital, Accra. West Afr J Med 1993;12:21-6.
Ofiaeli RO. Complications of methods of fracture treatment used by traditional healers: A report of three cases necessitating amputation at Ihiala, Nigeria. Trop Doct 1991;21:182-3.
Ward FE. Amputations. In: Hardy JD, editor. Hard's Textbook of Surgery. Philadelphia: Lippincott; 1983. p. 1208-14.
Ebskov LB. Level of lower amputations in relation to aetiology and epidemiological study. Prosthet Orthot Int 1992;16:163-7.
Dada AA, Awoyomi BO. Is the trend of amputation in Nigeria changing? A review of 51 consecutive cases seen at Federal medical centre Ebute Metta, Lagos, Nigeria. Niger Med J 2010;51:167-9.
Onyemaechi NO, Oche IJ, Popoola SO, Ahaotu FN, Elachi IC. Aetiological factors in limb amputation: The changing pattern! Nig J Orthop Trauma 2012;11:79-83.
Obalum DC, Okeke GC. Lower limb amputations at a Nigerian private tertiary hospital. West Afr J Med 2009;28:314-17.
Esan O, Adeyemi TO, Orimolade EA, Esan OT. Primary and revision amputation surgery in a tertary institution in South West Nigeria. East Cent Afr J Surg 2012;17:102-6.
Chalya PL, Mabula JB, Dass RM, Ngayomela IH, Chandika AB, Mbelenge N, et al
. Major limb amputations: A tertiary hospital experience in northwestern Tanzania. J Orth Surg Res 2012;7:18.
Murwanashyaka E, Ssebuufu R, Kyamanywa P. Prevalence, indications, levels and outcome Limb amputations at university teaching hospital-Butare in Rwanda. East Cent Afr J Surg 2013;18:103-7.
Ogbera A, Fasanmade O, Ohwovoriole A. High costs, low awareness, and a lack of care- the diabetic foot in Nigeria. Diabetes Voice 2006;51:30-2.
Gregory-Dean A. Amputations: Statistics and trends. Ann R Coll Surg Engl 1991;73:137-42.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]
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