Pattern of limb amputations in Liberia.

Background: Amputation is one of the oldest known surgical procedures. It has been one of the modalities of applying judgment and treatment. Its method and indications has evolved over time. Modern amputation is regarded as a part of treatment rather than failure of treatment. Amputation is the removal of a limb or part of a limb through on or more bone. When through a joint is referred to as disarticulation. Data on the profile and pattern of amputation in Liberia will add to the body of knowledge. Aim and
Objectives: Is to describe the pattern of limb of amputations in Liberia. Also to describe the anatomical variations of limb amputations in Liberia. Patients and Method: A retrospective study of all patients that underwent limb amputation surgeries in the John F Kennedy Memorial (JFK M), Hospital , Monrovia Liberia between January 2010 to December 2015.
Results: 100 patients had limb amputations between 2010 and 2015. Males(73) to female(27) ratio were 2.4:1. The age range was 9 - 91 years. Mean age was 42.9 years. The indications for amputations were Trauma 24%, Diabetes 29%, Gangrene (6%), Chronic ulcer (25%), Tumour (5%). Below knee(47%), Above Knee(45%), Below elbow(2%), Above Elbow(2%), Knee Disarticulation(2%), and Big Toe Disarticulation(2%).
Conclusion: The profile of Limb amputation in Liberia is not very different from what is obtaining in the region. However the limitations of histology and other investigative procedure have affected the accurate diagnosis of certain conditions like tumours.

INTRODUCTION

Amputation is one of the oldest known surgical procedures. It has been practiced by the Egyptian since the Babylonian times. It has been one of the modalities of applying judgment and treatment. Its method and indications have evolved over time. Modern amputation is regarded as a part of treatment rather than a failure of treatment. Amputation is the removal of a limb or part of a limb through one or more bone. When through a joint is referred to as disarticulation, it is term major if the amputation is carried out above the wrist or the ankle.[12] Globally, the indications for amputations varies with trauma and diabetes limb disease being the leading cause in developing countries and peripheral vascular disease, diabetic limb disease constituting the leading indications in the developed nations.[2] In the USA, an estimated 180,000 limb amputations are carried out every year.[3] In developing countries such as Nigeria and Rwanda, it has been reported that the prevalence of amputation is 1.6–3.2/100,000 population.[45]

Liberia which is a typical developing country has a population of 4,943,490.[6] There is no document data on the extent of limb amputation in the country. Amputation has a life-changing effect on the patient because of the permanent disability if cause. It affects patients psyche and morals. The patient dignity and livelihood may be eroded. Thus, there is a major cultural and often social rejection associated with amputation.[78]

Data on the profile and pattern of amputation in Liberia will add to the body of knowledge. However, most importantly, it will serve to highlight the burden of the problem and also serve as a possible yardstick for the government and the community to increase educational programs and policies that will ensure early intervention in disease processes and prevention of complications that will result in amputations.

PATIENTS AND METHODS

A retrospective study of all patients that underwent limb amputation surgeries in the John F Kennedy Memorial (JFK M) Hospital, Monrovia, Liberia, between January 2010 and December 2015. The JFK M, Hospital, Monrovia, is the largest tertiary hospital in Liberia. The most patient requiring orthopedic intervention like amputations is referred to the facility. Records were obtained from the operating theater register; and in certain cases, further information was obtain from the patient's case record. Information regarding demography, indication for amputation, type of amputation, complications, and length of hospital stay. Data obtained were analyzed using SPSS Version (IBM SPSS Statistics for Windows, Version 24.0, IBM Corp., Armonk, NY).

The result was presented in descriptive statistics.

RESULTS

100 patients had limb amputations between 2010 and 2015 [Table 1 and Figure 1]. Males (73) to female (27) ratio were 2.4:1.) [Table 2 and Figure 2]. The age range was 9 - 91 years. Mean age was 42.9 years [Figure 3]. The indications for amputations were Trauma 24%, Diabetes 29%, Gangrene (6%), and chronic ulcer (25%), Tumour (5%) [Table 3]. Below knee(47%), Above Knee(45%), Below elbow(2%), Above Elbow(2%), Knee Disarticulation(2%), and Big Toe Disarticulation(2%) [Table 4].

Table 1

Frequency of amputation per year

Year	Frequency (%)
2010	10 (10.0)
2011	25 (25.0)
2012	24 (24.0)
2013	21 (21.0)
2014	9 (9.0)
2015	11 (11.0)
Total	100 (100.0)

Figure 1

Number of amputation/year

Table 2

Gender distribution of patient

	Frequency (%)	Valid (%)	Cumulative (%)
Male	73 (73.0)	73.0	73.0
Female	27 (27.0)	27.0	100.0
Total	100 (100.0)	100.0

Figure 2

Gender distribution of patients

Figure 3

Age distribution of patients

Table 3

Indication for amputation

	Frequency (%)	Valid (%)	Cumulative (%)
Trauma	24 (24.0)	24.0	24.0
Diabetic	29 (29.0)	29.0	53.0
Gangrene	6 (6.0)	6.0	59.0
Ulcer	25 (25.0)	25.0	84.0
5.00	16 (16.0)	16.0	100.0
Total	100 (100.0)	100.0

Table 4

Surgical procedures

	Frequency (%)	Valid (%)	Cumulative (%)
Below knee	47 (47.0)	47.0	47.0
Above knee	45 (45.0)	45.0	92.0
Below elbow	2 (2.0)	2.0	94.0
Knee disarticulation	2 (2.0)	2.0	96.0
Below elbowAmputation	2 (2.0)	2.0	98.0
Big toe	2 (2)	2	100.0
Total	100 (100.0)	100.0

DISCUSSION

Records of 100 patients that had limb amputations between 2010 and 2015 were analyzed. Male: female ratio was 2.4:1. The age range was 9 and 91 years with a mean of 42.9 years. The male: female ratio is similar to what was obtained studies carried out around the African region of 2.5–4.4:1.[12791011] However, it is lower than what is obtain in the Europe and the USA.[1213] The fact that males are more affected might not be unconnected to the higher number of males that are engage in predisposing factors such as travels, military activities, and working in farms and factories. The mean age 42.9 years is consistent with similar studies in Africa and other developing countries because of the relative younger age population and because trauma which is the major cause in this environments is more common among the youth populations.[1279101415]

90% of amputations involve the lower limb. This is consistent with most studies globally.[12712131416] The lower limb is particularly at risk of trauma, diabetic foot peripheral vascular disease.[124578] There was a prevalence of 100% unilateral amputation in our study. This slightly differs with studies around the region whereby most have low but significant prevalence of bilateral amputations.[12791213141516] Diabetic-associated gangrene is the leading indication for amputation (29%). This is similar to what was obtain most studies around the region.[2121417] There is also a high prevalence of trauma-associated amputations (24%). Some studies around the subregion also indicated a high prevalence of trauma-associated amputations.[19] The number of patients, its chronic leg ulcers leading to infective gangrene is quite common (25%). This may be due to the limited ability to make microbiological diagnosis. Thus, appropriate sensitive antibiotics may not be identified for use in the treatment of infected leg ulcers. Like most reports from the subregion, peripheral vascular disease is low (6%).[121417] In general, there is a lower prevalence of peripheral vascular disease in Africa compared to the Europe and North America and Asia.[12713]

Tumors, though low, are not uncommon. Due to the lack of facilities for histological diagnosis, we relied on cytology and clinical diagnosis to make a presumptive diagnosis of tumors. Sixteen patients had amputations from a presumptive diagnosis of tumor. This prevalence is consistent with what was obtained in other studies around the region.[12715] Like most global reports, lower limb amputations are more are more (92%),[19121416] with below knee slightly more than above knee 47 and 45, respectively. This is largely similar to what was obtained in majority of amputations obtained around the region.[19121416] This may not be unconnected to the fact that trauma to the leg is the most common indication for amputation in the African region.[1259]

CONCLUSION

The profile of limb amputation in Liberia is not very different from what is obtaining in the region. However, the limitations of histology and other investigative procedure have affected the accurate diagnosis of certain conditions such as tumors. This has made the diagnosis to be mainly clinical.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.