1063 Khartoum Medical Journal (2015) Vol. 08, No. 01, pp.

1063 - 1070

Indications and short-term outcome of major lower extremity

amputations in Khartoum Teaching Hospital
Ahmed Yousif, Seif Eldin Ibrahim Mahdi, Mohamed ElMakki Ahmed*
Dept. of Surgery, Faculty of Medicine, University of Khartoum

Abstract
Introduction: Major lower extremity amputation (MLEA) is a common emergency operation in
Khartoum Teaching Hospital (KTH). Diabetic septic foot is the main indication for amputation, which is
always performed by the resident surgical registrar. Post amputation stump infection is the most depressing
complication for a patient who had been suffering from a foot sepsis for a long duration. The objective of
this study was to report the indications and short-term outcome of major lower limb amputation, specifically
post amputation stump infection.
Methods: This was a prospective cross sectional hospital based study done on patients who underwent
MLEA in KTH during the period from March to December 2014. Most patients were later followed up in
Jabir Abu Eliz Diabetic Center (JADC).
Results: Hundred patients were included. The age range was between 11-90 years with a mean age of
57.39±17.93(SD). The majority of patients were in their 4th and 5th decades of life (69%). The M:F ratio
was 2.3:1.0.Seventy seven patients were diabetic, 17 patients were hypertensive, 28 patients with renal
impairment and 29 patients were smokers.
The commonest cause of amputation was diabetes related complications in 77 patients(77%), of whom 58
patients had neuropathic foot and 19 patients had neuroischemic foot. Peripheral vascular disease without
diabetes was the second cause of amputation, occurring in 15 patients (15%).
Stump infection was reported in 43 patients (43%), of whom 23 patients had amputation through a
potentially infected site. Thirty patients of those who developed infection of the stump ended with complete
healing, 21 patients healed after frequent debridement and secondary suture, while nine required proximal
re-amputation. The remaining 13 patients of those who developed infected stump died (10 patients because
of septicaemia and septic shock and 3 from myocardial infarction).
The period of healing ranged from three to 12weeks. Stump infection was significantly associated with
prolonged time of healing. The time of healing in patients without stump infection ranged from three to 6
weeks (n=49) versus 6 to 12 week in those with infected stump (n=30) (P=0.00).

Complete healing was achieved in 79 patients (79%), (49 patients had primary healing, and 30 patients had
secondary healing following stump infection). The perioperative mortality rate was 21% (n=21).
Conclusion: The commonest cause of MLEA was diabetic sepsis, followed by peripheral vascular disease.
Major lower extremity amputation was associated with a considerable rate of morbidity and mortality.
Extra perioperative care is needed to reduce the rate of post amputation stump sepsis.
*Corresponding author: : Dept. of Surgery, Faculty of Medicine, University of Khartoum. Email:rasheid@usa.net

Introduction
Major Lower extremity amputation is performed to
remove ischemic, infected, necrotic tissue or locally
unresectable tumor, and at times, is a life-saving
procedure. Peripheral arterial disease alone or in
combination with diabetes mellitus, contributes to
more than half of all amputations. Trauma is the
second leading cause. The second Trans-Atlantic
Inter-Society Consensus Working group (TASC
Ahmed Yousif, Seif Eldin Ibrahim Mahdi, Mohamed ElMakki Ahmed 1064

II) documented an incidence of major amputations
due to peripheral arterial disease ranging from 12
to 50 per 100,000 individuals per year(1). The aging
population is expected to increase this number
by 50 percent in the next 15 years (2). This study
was done to review the indications, and short-term
outcome of MLEA in KTH.
Patients and methods
This is a prospective cross sectional hospital based
study done on patients who underwent MLEA
in KTH. A hundred consecutive patients who
underwent MLEA during the period from March
to December 2014 were included in the study.
Data were collected using a pre tested, coded
questionnaire, which included personal data,
symptoms, signs and investigation at presentation.
Presence of previous amputation and its indication,
postoperative complications and outcome were
also noted. All operations were done at KTH, and
most patients were sent later for further follow up
in JADC.
The study analysis was done using statistical
package for social science (SPSS) version 22.
Descriptive statistics frequencies, cross tabulation
and multivariate analysis were performed as
appropriate and P< 0.05 was taken to be significant.
Predictive factors for stump infection and mortality
were determined using stepwise logistic regression
analysis.
Results
Hundred consecutive patients were studied. The
age ranged between 11-90 years with a mean age
of 57.39 ±17.93(SD). The majority of patients were
in their 4th and 5th decades of life (69%). The M:F
ratio was 2.3:1.
patients. The commonest cause of amputation was
diabetes related complication in 77 patients. Fifty-
eight patients (58%) had neuropathic ulcers with
uncontrolled sepsis and 19 patients (19%) had
non-salvageable neuroischemic foot. Peripheral
vascular disease (PVD) in non-diabetic patients
was the second cause of MLEA in 15% of patients
(n=15), the remaining number (8%) of patients
had various causes. All patients had intravenous
antibiotics before surgery, mostly third generation
cephalosporins or ceftazidime for the first 3 to 5
days followed by oral antibiotics for one week; in
some patients, detailed data were missing.
The commonest complication following MLEA was
infection of the stump in 43 patients (43%), of whom
30 patients (69.8%) ended with complete healing,
21 patients healed after frequent debridement and
secondary suture, while 9 patients (20.9%) required
higher level second amputation. The remaining 13
patients with infected stump died 10 patients due
to sepsis and 3 because of thromboembolic disease.
Stump infection was reported within the first three
weeks in 38 patients (84.4%), and in 5 patients
(11.7%) after more than 3 weeks.
Both univariate and multivariate analysis showed
stump infection was significantly associated with
preoperative sepsis and cardiac problem. (see
table.1)

Seventy-seven patients were diabetic and 23 were

non-diabetic. Sixty patients had type II and 17
patients had type I diabetes mellitus. Seventeen
patients were hypertensive, 28 patients had renal
impairment and 29 patients were smokers.

Forty-seven patients had previous amputation, it

was minor (toe, rays, fore foot) in 39 patients and
major amputation (above and below knee) in eight
1065 Indications and short-term outcome of major lower extremity amputations in Khartoum Teaching Hospital

Table.1 Univariate, multivariate and regression analysis for stump infection in patients who underwent
major lower extremity amputation from March to December 2014.

Variables Stump infection P value1 P value2 R square

Diabetes (%) 0.019 0.019 0.055
Yes 38out of77(49.4)
No 5 out of 23(21.8)
Hypertension 0.868
Yes 7 out of 17(41.2)
No 360ut of83(43.4)
Smoking 0.834
Yes 12out of29(41.4)
No 310ut of71(43.7)
CVA&IHD 0.041 0.041 0.042
Yes 9 out of 13(69.2)
No 34out of87(39)
Systemic feature of 0.048 0.048 0.081
sepsis**
Yes
No 22out of40(55)
21out of60(35)
Local feature of 0.05 0.07 0.056
cellulitis
Yes 14out of20(70)
No 29out of80(36.2)
High TWBCS 0.026 0.015 0.058
˃11.000 36out of79(45.5)
˂11.000 7 out of 21(33.3)

High creatinine 0.160

˃1.5
˂1.5 15out of28(53.5)
28out of72(38.8)
Level of amputation 0.979
Below knee
Above knee 26out of58(44.8)
17out of42(40.4)
Drain 0.532
Yes 9 out of 24(37.5)
No 34out of76(44.7)

*P value1= chi square test *P value2= multivariate analysis *R square= Regression test ** fever and
toxicity
CVA= Cerebrovascular accident IHD= Ischaemic Heart Disease
Ahmed Yousif, Seif Eldin Ibrahim Mahdi, Mohamed ElMakki Ahmed 1066

The period of wound healing ranged from three to
12 weeks, diabetic patients and those with infected
stump were significantly associated with prolonged
period of healing (P˂0.05). Patients without stump
infection had wound healing in 3 to 6 weeks (n=49),
and those with infected stump took 6 to 12 weeks
to heal (n=30), four non-diabetic patients had their
wounds healed in less than 3weeks. (see table 2).

Table 2. Duration of healing after major lower extremity amputation in diabetic

versus non-diabetic patie nts
DM n=77 Others n=23

Duration of healing Diabetic Others* Total

˂ 3weeks 0 4 4
3—6 weeks 38 11 49
6-12 weeks 23 3 26

Total 61 18 79

*Others: Ischemia, Traumatic, Malignancy, Mycetoma.

Complete healing was achieved in 79 patients

(79%), 49 patients had primary healing and 30
patients had secondary healing following stump
infection management. The mortality rate was
21% (n=21).Both univariate and multivariate were
significantly associated with pre-operative cardiac
problems, leucocytosis, elevated creatinine and
post-operative stump sepsis. (see table 3).
1067 Indications and short-term outcome of major lower extremity amputations in Khartoum Teaching Hospital

Table 3: Univariate, multivariate and regression analysis for mortality in patients who underwent
major lower extremity amputation from March to December 2014.

Variables Death P value1 P value2 R square

Diabetes (%) 0.921 No significant
Yes 16out of77(20.7) difference

No 5 out of 23(21.7)
Hypertension 0.907 No significant
Yes 3 out of 17(17.6) difference

No 18out of83(21.6)
Smoking 0.961 No significant
Yes 6 0ut of 29(20.6) difference

No 15out of71(21.1)
CVA&IHD 0.000 0.000 0.148
Yes 8 out of 13(61.5)
Significant
No 13out of87(14.9)
difference
Decreased level of 0.020 0.020 0.054
consciousness
Yes Significant
8 out of 20(40)
difference
No 13out of80(16.2)
High TWBCS 0.070 0.049 0.039
˃11.000 21out of79(26.5)
˂11.000 0 out of 21(0)
High creatinine 0.002 0.018 0.108
˃1.5 11out of28(39.2)
Significant
˂1.5 10out of72(13.8)
difference
Stump infection 0.049 0.049 0.039
Yes 13out of43(30.2)
Significant
No 8 out of 57(14.0)
difference
Level of amputation 0.584 No significant
Above knee difference
Below knee 10out of42(23.8)
11out of58(20.7)

P value1= chi-square test

P value2= multivariate analysis

Discussion
Major Lower extremity amputation is a common
surgical procedure performed by orthopedic, general,
vascular and trauma surgeons for therapeutic reasons
to save patient’s life. However, it is often associated
with profound economic, social and psychological
effects on patients and their family (3,4).
In recent years, an increasing number of studies
have found a decrease in the incidence of major
Ahmed Yousif, Seif Eldin Ibrahim Mahdi, Mohamed ElMakki Ahmed
lower amputations in diabetic patients. In patients
with arterial disease without diabetes moderate
reductions have been reported in some studies.(5)
In Sudan in 1986, a rate of 38% MLEA was
reported in diabetic patients with advanced foot
sepsis in KTH (6). However, recent data from the
same hospital records for the same period of our
study showed significant reduction with MLEA
performed in 123 out of 483 diabetic patients with
foot sepsis (25%) (7). Reduction in MLEA rates
is consistent with recent studies of trends in the
amputation rate(8,9). In addition, indicate an improved
effectiveness in the diabetes care, possibly due to
multidisciplinary actions. The male preponderance
among amputees in the present study agrees with
the findings by other authors.(10-12). The majority of
our patients were in the 4th and 5th decades, which
is comparable with other studies done in, Niger,
Pakistan, and Tanzania(13-15).
This study highlights diabetic foot sepsis as the
major indication for limb amputation in 77%
(n=77), followed by peripheral vascular disease in
the form of dry and wet limb ischemia 15% (n=15).
These were the same indications for MLEA reported
by Doumi et al from El Obeid Sudan,(16) and Zidane
BZ et al at KTH,(12) and are also in agreement
with a study reported from Tanzania(13). This is in
contrast to that reported from the western world,
where peripheral vascular disease is the leading
cause of limb amputation(17). In Nigeria trauma
was reported as the commonest cause of MLEA(18).
More recently that trend might have changed and
peripheral vascular disease unrelated to diabetes
mellitus was the most common cause of MLEA in
Kenya(19).
Goodney et al in USA reported that, patients with
peripheral vascular disease at risk for amputation
have a better chance of keeping their limb if
they reside in a region where vascular care is
commonly provided(20). Unfortunately, most often
patients in the underdeveloped countries present
late when extensive gangrene has occurred, and
revascularization and limb salvage is not a feasible
option.
1068
Stump infection is one of the serious complications,
and it is important because in some cases it can lead
to higher-level amputations. In our study stump
infection was the commonest complication 43%
(n=43) with 38 patients being diabetic (88.3%).
Univariate and multivariate analysis showed stump
infection was significantly being associated with
diabetes, pre-operative evidence of sepsis and
cardiac problem (p˂ 0.05). Fifty three percent of
patients (n=23) who developed stump infection had
amputation through potentially infected site aiming
to save the knee joint.
Several factors known to contribute to wound sepsis
come into play with amputations due to ischaemia,
pre-existing limb ulceration and gangrene, patient
co-morbidities and wound contamination. Careful
selection of the amputation level, optimal surgical
techniques and appropriate antibiotic prophylaxis
are required to minimize infection rates(21).
In the present study the rate of stump infection for
below knee amputation (BKA) was 44.6% while
that of above knee amputation (AKA) was 40.5%
with no significant difference, which is far different
from previously reported rates of 61% for AKA
and 16% for BKA from the same hospital(10)
Toursarkissian et al, in a series of 113 diabetic related
MLEAs, reported a postoperative complication rate
of (40%). In their series , wound complications
were more frequent with AKA than BKA (P=0.04)
(22)
. Patients with infected stump underwent surgical
debridement, and/or higher-level amputation,
debridement and secondary suture was done for
stump infection in 69.7% of patients (n=30), similar
data had been reported from KTH: (70.6%) (12) and
other neighbouring countries: (60%)(23).
Proximal re-amputation rate was 30.3%
(n=12),which was more than the 22.6% rate
reported by Zidane et al(12), and less than 38%
reported by Kanade et al in South Wales UK(24).
In this study complete healing was achieved in
79%(n=79), (49 patients had primary healing, and
30 patients had secondary healing following stump
infection), it is a good outcome compared to other
studies previously published by Lepantalo et al,
1069 Indications and short-term outcome of major lower extremity amputations in Khartoum Teaching Hospital
who reported 72.9% good outcome,(25) and similar
to a previous study performed by Low et al, who
reported a 78.3% good outcome(26), but locally it is
less than that reported by Zidane et al of 82.26% (12).
The mortality rate in the present study of 21% is
similar to that reported by Mohamed et al of 20%
from KTH (11), but higher than that reported by
Chalya et al in Tanzania(16.7%).(13). The reasons
for a high mortality rate in our study were diabetic
related complications, wound sepsis and other co-
morbidities.
The limitation in this study was the deficient hospital
records as regard diabetes monitoring with random
blood sugar and HbA1c as well as bacteriological
culture and sensitivity of the diabetic foot wounds.
Conclusion
Post amputation morbidity and mortality rates are
high and need more careful assessment and extra
care. Amputation through infected site in order to
preserve the knee joint should entail extra surgical
care for delayed wound closure with proper
antibiotic cover according to culture and sensitivity.
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