MAJOR LIMB AMPUTATION IN KUMASI, GHANA

Dr Michael Ohene-Yeboah, Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana (surgksi@ghana.com)

ABSTRACT

It is widely accepted that infections and the complications are responsible for most amputations in developing countries. It is also believed that diabetes mellitus and other so-called "diseases of affluence" are uncommon in our environment. Recent studies however suggest a changing trend. The purpose of this study is to evaluate the changing pattern of major limb amputations in our environment

One hundred and fourteen consecutive patients requiring a major limb amputation were included in a prospective study over a four-year period. The details of these patients and the indications for amputations were recorded and analysed.

There were a total of 116 major limb amputations, 102 in the lower and 14 in the upper limbs. The indications for the lower limb amputation included diabetic gangrene 47 (46.1%), injuries 30 (29.4%) non-diabetic vascular insufficiency 12 (11.8%) cancers 9 (8.8%) and others 4 (3.9%). Injuries and complications of fracture treatment accounted for 13(92.0%) and diabetic complications 11 (7.1%) of the upper limb amputations. There were 84 (82.2%) and 10 (9.8%) above and below amputations respectively. The over all mortality was 13.0%. Stump revision was required in 5 patients (4.3%) and hypoglycaemic coma occurred in 15% of diabetic patients.

Complications of diabetes mellitus and injuries have become the leading causes of major limb amputations in our environment.

INTRODUCTION

The loss of a limb often has profound economic, social and psychological effects on the victim and the family. In many situations however, amputating a limb is the only effective option to save the life of the patient.

In developing countries such as Ghana, infective and herbal treatment related gangrene often lead to amputations. With limited resources to provide adequate limb replacement services, many amputees become economic and social dependents. Though complications of limb infections continue to require many amputations in our environment, personal workload experience and clinical observations suggest that there has been a significant alteration in these patterns. Complications of diabetes requiring amputations have become common. Furthermore, motor-traffic related injuries have increased the numbers of limb requiring amputations. In the light of these new trends, this study was undertaken to determine if these changes are real or apparent and thus evaluate the pattern of major limb amputations in Kumasi, Ghana.

PATIENTS AND METHODS

For a four-year period, January 1988 to February 2002 inclusive, all adult patients admitted to the emergency ward of Komfo Anokye Teaching Hospital and requiring major amputations by both trauma and general surgeons were included in the study.

A simple pro forma was designed to record the name, age, sex of patients as well as the clinical diagnosis, indication and level of amputation, post-operative complications and number of postoperative deaths.

Surgical Details

Standard techniques were used with equal anterior and posterior and long posterior myofascial flaps for the above and below-knee amputations respectively. All wounds were drained for 48 hours. Skin sutures were removed in 14 days, primary healing being defined as clean, dry wound at 14 days. Wound infection was referred to as a discharging wound requiring removal of sutures before 14 days to allow drainage.

Badly infected or contaminated traumatic amputations were left open after securing haemostasis. The appropriate stump was fashioned over after 3 - 5 days. Wound failure was defined as complete breakdown requiring re-amputation. The level of amputation was determined by clinical considerations.

RESULTS

Indications

One hundred patients underwent 102 lower limb amputations. There were 14 upper limb amputations making a total of 116 major limb amputations. The indications for 102 lower and 14 upper limb amputations are outlined in tables II and III respectively. Diabetic gangrene 46.1 percent, injuries 29.4 percent and non-diabetic vascular insufficiency 11.8 percent accounted for most of the lower limb amputations (table II).

The trauma group included 25 car crushes, 2 gunshot wounds, 2 crushed legs at timber felling and one patient with herbal treatment complications of an open tibial fracture following a fall from a coconut tree.

The indications for the upper limb amputations are outlined in table III. Injuries or their complications accounted for 13 amputations including a young male narcotic drug abuser who injected into his right brachial artery resulting in eventual amputation after several days. One rare case of diabetic gangrene of the forearm in a woman required an above elbow amputation.

Squamous Cell Carcinoma SCC (7 patients) and soft tissue sarcomas (4) accounted for the 11 cancers treated by above-knee amputations to achieve adequate clearance.

Two cases of neglected lower leg cellulitis treated with herbal preparations resulted in one elbow knee and one above knee amputations.

There were two unusual cases of acute popliteal artery emboli in two males aged 45 and 52 years. Arteriotomy to relieve the ischaemia failed resulting in two above knee amputations.

Level Of Amputation:

The proximal extent of gangrene and the anatomical distribution of crush and devitalized tissues determined the level of amputation. Late presentation and extensive tissue damage led to more proximal operations as 82.4 percent (84/102) of above knee and 92 percent (13/14) of above-elbow amputations respectively (Table IV).

Ten percent of lower limb amputations were below knee. There was one below elbow amputation in a 16-year-old man.

Mortality

There were 16 deaths, 6 males and 10 females; all aged between 59 - 90 years. Eleven deaths occurred in diabetic, 3 in non-diabetic vascular insufficiency, and 2 in the trauma patients. Fourteen (87.5 percent) of those who died had above-knee amputations. The other two mortalities were one below-knee and one above elbow amputees. The over-all mortality was 14.0 percent (16/114). The mortality among diabetic patients was 23.4 percent (11/471).

Complications:

Table V shows the three main postoperative morbid conditions. Delayed wound healing occurred if the wounds did not heal within 14 days. Insulin (hypoglycaemic) shock was seen in diabetics whose insulin dose was not reduced after operations.

DISCUSSION

We undertook this study to evaluate the changing pattern of amputations in our environment. The findings that diabetic gangrene, road traffic accidents, and gangrene due to non-diabetic vascular insufficiency lead to most amputations pose a challenge to the health and social systems of our country. Similar diabetic dominated pattern of amputations have been reported elsewhere3, 5, 6

The relatively younger age of incidence of, the trauma amputees (20-39 years) as compared to the much older diabetic and non-diabetic vascular insufficiency amputees (60-79 years, figure 1) highlight the economic, social and health impact of major amputations in Ghana and elsewhere.2, 3

Young economically active men (20-39 years) may become dependent following an amputation. They are no longer able to support the older (60-79 years) diabetics who may need even more social and economic support following a major amputation.

The need to halt this trend is self-evident as the resources to support dependent citizens are not available.

Large-scale health education programmes are needed in three main areas:

(i) To improve diabetic control and foot care and thus reduce infection and its progression to gangrene7.

(ii) To reduce the numbers and severity of road traffic accidents and car crashes that lead to severe limb injuries.

(iii) To encourage healthy lifestyle as we discourage cigarette smoking thereby protecting our people against the risk of non-diabetic vascular insufficiencies.

Cancers are relatively uncommon cause of amputations2, 3. The present series with 11 patients or 8.8 percent cancer, confirms the low incidence of amputations due to malignant lesions of the limbs.

However, a study from Zaria Northern Nigeria reported that squamous cell carcinoma complicating long-standing leg ulcers was a common indication for lower limb amputations8.

In this series the 1.9 percent amputations due to infections confirms the changing trends.

The success of arterial surgery is related to exposure and experience, as the incidence of vascular related gangrene increases, better results are expected.

Mortality

This study identified the main risk factors for mortality following amputations as female sex, increasing age (above 59 years), diabetic gangrene and above-knee amputations.3,9

Early presentation, at least for diabetics, may allow a more distal amputation and thus reduce the over-all mortality which at 14.1 percent is lower than most other series,1,2,3,8,9,10 presumably because of the relatively large proportion of young otherwise healthy traumatic male amputees. The diabetic disease specific mortality of 24.0 percent compares favourably with other series1,3,8, but can be reduced by better pre and post operative diabetes control 2, 3. Improvements in amputation surgery results can be expected if more facilities such as Doppler Pressure studies11, skin oxygen transport measurements12 and fluorescein angiography13 are available to better assess optimal level for amputations thereby reducing stump sepsis, necrosis and wound revision that complicate below-knee amputations.

CONCLUSION

In conclusion this study has shown that surgical infections have been replaced by complications of diabetes and traffic related injuries as the most common indications for major limb amputations in our environment.

The incidence and complications of diabetes and trauma can be reduced by health educational programmes, that stress behaviour change. This could be an inexpensive way of prevention amputations in our environment.

Acknowledgement

I am grateful to Professor Charles Mock, Seattle, USA for reading the manuscript and also would like to thank residents and house officers for completing some of the information charts.

Miss Juliana Boahene typed the script, accept my gratitude.

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