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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 1  |  Page : 8-12

Major extremity amputations: Indications and post surgery challenges in a Nigeria tertiary institution


Department of Surgery, Federal Medical Centre, Birnin Kebbi, Nigeria

Date of Submission08-Jul-2017
Date of Acceptance16-Mar-2018
Date of Web Publication28-Mar-2019

Correspondence Address:
Dr. Oni Nasiru Salawu
Department of Surgery, Federal Medical Centre, Birnin Kebbi, Kebbi
Nigeria
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DOI: 10.4103/smj.smj_49_17

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  Abstract 


Background: Amputation is an ancient procedure which has been practiced for centuries for a variety of indications. The goal of the procedure is to eliminate potential threat to the patient while producing a viable stump for easy rehabilitation.
Objective: To identify the indications, postoperative complications and peculiarities of patients with amputation in a native African population.
Materials and Methods: This was a prospective study carried out on all consenting patients who had extremity amputation at Federal Medical Centre, Birnin Kebbi, from June 2015 to May 2016.
Results: During the study period, there were 47 amputations in 47 patients (34 males and 13 females). The mean age of the patients was 35.73 ± 19.43 years. The most common indication for amputation was traditional bone setter's (TBS) gangrene accounting for 44.7% of cases, followed by diabetic foot syndrome at 25.5%. Camel bites accounted for 6.4% of the amputations. The most common type of amputation was below-knee amputation (46.8%), followed by above-knee amputation (25.5%). Five (10.7%) patients had surgical site infection and only 2.1% of the patients developed phantom limb sensation. None of these patients was fitted with a prosthesis due to the high cost or nonavailability of the prosthesis.
Conclusion: Complications of TBS intervention were the leading cause of amputation in this study. Gangrene following camel bites was also found to be a peculiar cause for amputation in this environment. Appropriate public health interventions are necessary to reduce the incidence of preventable gangrene. Provision of prosthesis with adequate technical support is essential to proper rehabilitation of the amputees.

Keywords: Amputation, camel bite, traditional bone setter's gangrene


How to cite this article:
Salawu ON, Babalola O M, Mejabi J O, Fadimu A A, Ahmed B A, Ibraheem G H, Kadir D M. Major extremity amputations: Indications and post surgery challenges in a Nigeria tertiary institution. Sahel Med J 2019;22:8-12

How to cite this URL:
Salawu ON, Babalola O M, Mejabi J O, Fadimu A A, Ahmed B A, Ibraheem G H, Kadir D M. Major extremity amputations: Indications and post surgery challenges in a Nigeria tertiary institution. Sahel Med J [serial online] 2019 [cited 2019 Jun 19];22:8-12. Available from: http://www.smjonline.org/text.asp?2019/22/1/8/255172




  Introduction Top


Limb amputation is the removal of part of the limb through bone while disarticulation is the removal of the limb through a joint. Limb amputation is performed when limb salvage has failed or is not possible due to dead or dying limb, a limb that constitutes a nuisance to the patient or one that constitutes a danger to the continuous existence of the patient.[1]

Amputation is one of the oldest surgical procedures known and was performed as far back as 1700 BC during the regimen of the king Babylon for both punitive and therapeutic means.[2] There are no national data for amputation in Nigeria. Thanni and Tade estimated the prevalence of amputation in Nigeria as 1.6/100,000.[3]

In developed countries, peripheral vascular disease is the most common indication for amputation.[4] In Nigeria, various studies have identified different indications as the most common, including trauma,[3],[5],[6],[7],[8] diabetic foot gangrene,[9],[10],[11] and traditional bone setter's (TBS) gangrene.[12] The relative frequencies of these indications differ with environment and time of record.

The stigma confronted by amputees in our society makes it difficult for patients to accept the therapeutic value of the procedure.[13] Rehabilitation of an amputee is a major problem in Nigeria because majority do not have access to or cannot afford the cost of the prosthesis, so they move around with crutches and become beggars on the streets.[13] With or without prostheses, amputation carries a high morbidity burden with the loss of a limb being associated with severe psychological and physical problems.[14],[15]

The most commonly reported complication of amputations was wound infection, and the postoperative mortality following amputation in Nigeria has been reported to be 10.9%.[3],[6],[7],[8]

The aims of this study were to identify various indications for amputation as well as the postoperative complications and other problems faced by the patients after surgery, in a tertiary health center in North West Nigeria.


  Materials and Methods Top


This was a prospective descriptive hospital-based study which spanned a period of 1 year from June 2015 to May 2016 conducted at Federal Medical Centre, Birnin Kebbi, in the north-west geographic region of Nigeria. Ethical approval (FMC/BK/ADM/345/P/319) dated 6th July 2015 was obtained from the institutional ethics committee of the hospital. All the procedures have been carried out as per the guidelines given in Declaration of Helsinski 2013. All consecutive patients who required limb amputation and gave consent for the procedure to be carried out were recruited into the study.

The patients were counseled preoperatively based on a clinical assessment of the best site for amputation; however, the final decision on the site of election was determined intraoperatively for all the patients. Doppler ultrasound was not available to assess blood supply to the limb.

To perform the surgical procedure, regional or general anesthesia was used depending on the age of the patient and location of the pathology, with intravenous broad-spectrum antibiotic given at induction of anesthesia. A tourniquet was applied except in cases with arterial insufficiency. Skin flaps of equal anterior and posterior length were raised for above-knee and upper-limb amputations while long posterior flaps were raised for below-knee amputations. The combined length of the flaps was equal to 1.5 times the width of the limb at the site of amputation to ensure adequate soft-tissue coverage.

The muscle flaps were divided distal to the planned level of bone osteotomy. The main blood vessels were doubled ligated individually. The nerves were pulled out and sharply cut, to ensure adequate retraction into the soft tissue. The larger nerves with their blood supply were ligated first before dividing them. There are standard sites of election (osteotomy) for each bone of the limb. This is to ensure proper fitting of the stump into prosthesis and efficient use of the limb postamputation. Sites of amputation may, however, be determined by the presence or absence of viable soft tissues in situations where the standard site is involved in the disease process. These standard sites of election are 12 cm above the knee joint or 25–30 cm below the greater trochanter for above-knee amputation and 8–14 cm below the knee joint for a below-knee amputation. The anterior surface of the tibia should be beveled, and the fibular should be osteotomized 2–3 cm above the level of tibial cut in below-knee amputations. For above-elbow amputations, the site of election is 20 cm from the acromion, while the site of election is 18 cm distal to the olecranon for a below-elbow amputation.

After raising all these flaps and cutting the bone, edges of the bone were smoothened with bone rasp and deep wound drains were inserted. Agonist muscles were sutured to the antagonist muscles in the stump (myoplasty), and the subcutaneous layer and the skin were closed without tension.

The research instrument was a structured pro forma which contained the biodata, educational status of patients, indications for amputations, types or level of amputation, and complications of amputation. The pro forma was filled by the researcher before the surgery and was updated as the management of the patients progressed. The results were analyzed using SPSS version 17 (Inc., Chicago, IL, USA). Descriptive data analysis was employed.


  Results Top


During the study period, there were 47 amputations in 47 patients. There were 34 males and 13 females with a male-to-female ratio of 2.6:1. Their ages ranged from 6 years to 70 years with a mean age of 35.73 ± 19.43 years.

Thirty-six (76.6%) of the patients had no formal education, 7 (14.9%) of them had only Islamic education, 3 (6.4%) had primary education alone, while 1 (2.1%) of the patients had education up to secondary school level.

The most common indication for amputation was TBS gangrene which was seen in 21 (44.7%) patients followed by diabetic foot gangrene which in 12 (25.5%) patients. Peripheral vascular disease burns injury and a limb that constituted a damn nuisance accounted for 1 (2.1%) patient each, as shown in [Table 1].
Table 1: Indications for amputation

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Twenty-two (46.8%) of the patients were farmers, while 15 (31.9%) of the patients had no job. Six (12.8) of them engaged in business, 3 (6.4%) were artisans, and 1 (2.1%) of them was a driver.

Guillotine amputation was done initially in 8 patients while 39 patients had definitive primary amputation. Twenty-two (46.8%) patients had below-knee amputation, which was the most common type of amputation in this study followed by above-knee amputation done in 12 (25.5%) patients. Other types of amputation done in this study were above elbow, below elbow, ray amputation, disarticulation, and Gritti-stokes, as shown in [Table 2].
Table 2: Types of amputations

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The most common postoperative complication was surgical site infection seen in 5 (10.7%) patients, while phantom limb sensation occurred in only 1 (2.1%) patient, as shown in [Table 3].
Table 3: Complications of amputation

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  Discussion Top


During the study period, 47 patients had limb amputations, constituting about 11% of all orthopedic surgical procedures done during this period. Majority of the patients were male, which is understandable since most of the cases occurred directly or indirectly following trauma and males are generally more injury prone than females. This finding is similar to that of Enweluzo et al. in Lagos and Mamuda et al. in Kano, where male preponderance was reported.[11],[12]

The youngest patient was 6 years old while the oldest patient was 70 years old, with a mean age of 35.7 ± 19 years. This report has a mean age located in between the findings by Ajibade et al. (30.43 ± 16.28 years) and Onyemaechi et al. (40.9 ± 20.5 years).[6],[10] These reports all show, however, that amputation is more common among the young, productive members of the population. This is of significant economic consequence, especially since many of these amputees are unable to return to their premorbid economic activities and in fact become dependent members of the community.

About 75.6% of these patients were found to have no formal education. While this may reflect the high level of illiteracy in the community, the contribution of illiteracy and poverty to the preventable conditions requiring amputation remains to be conclusively established.

Majority of the patient had no job, while others are low-income earners. This may account for why the patronage of TBS for trauma and herbalists for diabetic foot syndrome was high as there is a general belief that orthodox medicine is more expensive than the traditional healers' care.

The most common indication for amputation was TBS gangrene. This is quite common in children because they are usually forced to comply with the tight splint applied by the TBS even when they feel very uncomfortable with the splint, until the limb becomes gangrenous. However, a few adult patients with TBS gangrene in the upper and lower limbs were also seen during this study. Majority of the population in this part of the country believe more in TBS for the treatment of fractures than orthodox medicine. This may be due to the high level of poverty, low educational status, or low number of orthopedic surgeons relative to the entire population.[16],[17] Almost all cases of fresh fracture or fracture-like lesions present to TBS first only to present to the hospital much later after complications have set in. In some instances where the patients were brought to hospital directly from the site of injury, they discharge themselves against medical advice and go to TBS. These may account for why TBS gangrene was the highest indication for amputation in this environment.

The second most common indication was diabetic foot gangrene. Enweluzo et al. found that diabetic foot gangrene was the most common indication for amputation in their report from a tertiary center in Lagos.[11] While it may be expected that the prevalence of diabetes mellitus may be lower in the young, rural, and semi-urban population of this study, we also found that many diabetic patients in our environment seek care from herbalists who give them herbal concoctions which fail to control their blood sugar. This poor glycemic control results in a high rate of poorly healing diabetic foot ulcers which may eventually progress to gangrene. Late presentation after sustaining wound on the leg is another reason for high amputation rate in diabetic foot syndrome.

Acute trauma ranked third on the list, unlike in some other parts of the country where it was the most common indication for amputation.[6] This result may, however, need to be viewed with caution. We were unable to determine how many of the patients with TBS gangrene actually had traumatic injuries that would have required amputation even if they had presented to the hospital first.

Malignancies ranked fourth on the list of indications. There was a patient with osteosarcoma of the proximal tibia; one patient had malignant melanoma of the foot and another patient had squamous cell carcinoma of the foot. All of them presented late to the hospital and were referred to a regional oncology center for further treatment after the amputation.

Three patients had camel bites on the forearms leading to gangrene of their limbs. This is a presentation of gangrene that is peculiar to centers in this part of the country. It is important to create public awareness aimed at the local population to seek proper treatment for camel bites to avoid gangrene.

The most common type of amputation in this study was below-knee amputation because majority of the patients presented with gangrene of the foot or distal leg.

The most common complication was surgical site infection seen in 5 (10.7%) patients. Four of these patients had diabetic foot syndrome with poor glycemic control persisting in the immediate postoperative period. One of the patients was a case of TBS gangrene who had associated septicemia before the surgery. All these patients had their infection controlled with wound dressing and antibiotics according to the wound swab sensitivity pattern and all the wounds healed eventually. Flap necrosis was seen in three patients who had below-knee amputation: two were for diabetic foot syndrome and one was a case of TBS gangrene. All three had refashioning of their amputation stumps. None of the other sites of amputation in our study developed flap necrosis. One of the patients with above-knee amputation had phantom limb, which was noticed within 72 h after surgery. The phantom limb started telescoping after about 3 weeks and disappeared within 6 months of the procedure.

The major challenge in rehabilitation of these patients was nonavailability of prostheses locally. Those that found prostheses available in other parts of the country were unable to afford them. Limb prostheses are not available in any of the federal government centers located in north-west zone of Nigeria, where this hospital is located. Provision of appropriate prosthesis with appropriate technical support is essential to proper rehabilitation of these patients. This limitations of this study include its small sample size which did not allow comparative analysis of the types of amputation and its retrospective design with attendant missing data.


  Conclusion Top


Complications of TBS intervention was the leading cause of amputation in this study. Gangrene following camel bites was also found to be a peculiar cause for amputation in this environment. Appropriate public health interventions are necessary to reduce the incidence of preventable gangrene leading to amputation. Provision of prosthesis with adequate technical support is essential to proper rehabilitation of the amputees and reduction of the menace of beggars on our streets.

Acknowledgment

We would like to thank all doctors in orthopedic unit, Federal Medical Centre, Birnin Kebbi.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Paudel B, Shrestha BK, Banskota AK. Two faces of major lower limb amputations. Kathmandu Univ Med J (KUMJ) 2005;3:212-6.  Back to cited text no. 1
    
2.
Robinson KP. Historical aspect of amputation. Ann Roy Coll Surg 1991;73:134-6.  Back to cited text no. 2
    
3.
Thanni LO, Tade AO. Extremity amputation in Nigeria – A review of indications and mortality. Surgeon 2007;5:213-7.  Back to cited text no. 3
    
4.
Abou-Zamzam AM, Ternya TH, Killeen JD. Major lower extremity amputation in an academic vascular centre. Ann Vasc Surg 2003;17:86-90.  Back to cited text no. 4
    
5.
Kidmas AT, Nwadiaro CH, Igun GO. Lower limb amputation in Jos, Nigeria. East Afr Med J 2004;81:427-9.  Back to cited text no. 5
    
6.
Ajibade A, Akinniyi OT, Okoye CS. Indications and complications of major limb amputations in Kano, Nigeria. Ghana Med J 2013;47:185-8.  Back to cited text no. 6
    
7.
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.  Back to cited text no. 7
    
8.
Ogunlade SO, Alonge TO, Omololu AB, Gana JY, Salawu SA. Major limb amputation in Ibadan. Afr J Med Med Sci 2002;31:333-6.  Back to cited text no. 8
    
9.
Chalya PL, Mabula JB, Dass RM, Nyayomela IH, Chandika AB, Mbelenge N, et al. Major limb amputations: A tertiary hospital experience in Northwestern Tanzania. J Ortop Surg Res 2012;7:1-6.  Back to cited text no. 9
    
10.
Onyemaechi NO, Oche IJ, Popoola SO, Ahaotu FN, Elachi IC. Aetiological factors in limb amputation: The changing pattern. Niger J Orthop Trauma 2012;11:79-83.  Back to cited text no. 10
    
11.
Enweluzo GO, Giwa SO, Adekoya-Cole TO, Mofikoya BO. Profile of amputations in Lagos University Teaching Hospital, Lagos, Nigeria. Nig Q J Hosp Med 2010;20:205-8.  Back to cited text no. 11
    
12.
Mamuda AA, Salihu MN, Abubakar MK, Adamu KM, Ibrahim M, Musa MU. Profile of amputations in National Orthopaedic Hospital, Dala Kano. Open J Orthop 2014;4:200-4.  Back to cited text no. 12
    
13.
Edomwonyi EO, Onuminya JE. An update on major lower limb amputation in Nigeria. J Dent Med Sci 2014;13:90-6.  Back to cited text no. 13
    
14.
Yinusa W, Ugbeye ME. Problems of amputation surgery in a developing country. Int Orthop 2003;27:121-4.  Back to cited text no. 14
    
15.
Nwankwo OE, Katchy AU. Surgical limb amputation: A five-year experience at Hilltop Orthopaedic hospital, Enugu, Nigeria. Niger J Orthop Trauma 2004;3:139-49.  Back to cited text no. 15
    
16.
Aderibigbe SA, Agaja SR, Bamidele JO. Determinants of utilization of traditional bone setters in Ilorin, North central Nigeria. J Prev Med Hyg 2013;54:35-40.  Back to cited text no. 16
    
17.
Thanni LO. Factors influencing patronage of traditional bone setters. West Afr J Med 2000;19:220-4.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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