RSS Feed
The Journal of Diabetic Foot Complications

The Journal of Diabetic Foot Complications, 2011; Volume 3, Issue 1, No. 4, Pages 17-21 © All rights reserved.

OUTCOME OF DIABETES RELATED AMPUTATION IN RURAL KENYAN HOSPITALS

Authors: Julius A. Ogeng’o BSc, MBChB, PhD1; Moses M. Obimbo MBChB, MSc1; John King’ori, MBChB, MMed2, Sarah W. Njogu MBChB3

Abstract:

Objective:
To compare the outcome of diabetes related amputation with that of non diabetic cases in rural Kenyan Hospitals.

Research Design and Method:
This was a retrospective study at Kikuyu and Tenwek hospitals in rural Kenya involving 291 patients (228 males, 63 females) who underwent amputation between January 2001 and December 2008. The cases were divided into those related to diabetes mellitus and those due to other causes. Each category was examined for length of hospital stay, change of amputation site, revision and infectio

Results:
The majority (69.7%) of patients who underwent non diabetes related amputation had a successful outcome compared to 41.7% of those related to diabetes mellitus. In diabetes related amputation, hospital stay was longer, change of amputation site and infection were more frequent compared to those due to other causes (p<0.05). n. Data were analyzed using statistical package for social sciences (SPSS) for Windows version 11.50.

Conclusion:
Diabetes related amputations in rural Kenya carry a high morbidity from infection and change of amputation site, and may impose a higher economic burden from longer hospital stays. Vigilant diabetic foot care, as well as strict glycaemic and infection control are recommended.

 

Key words: Diabetes. amputation. outcome. rural. Kenya

Corresponding author:

Moses M. Obimbo,
P.O.BOX 30197, 00100 Nairobi GPO Kenya.
Phone: +254721585906

Email: obimbo24@yahoo.com

Affiliations:

  1. Department of Human Anatomy, University of Nairobi
  2. Department of Orthopaedic Surgery, University of Nairobi
  3. Tenwek Mission Hospital, Bomet, Kenya
 


 

Introduction

Outcome of diabetes related amputation varies between countries 1,2. Comparative data on the outcome between diabetic and non-diabetic cases is conflicting with some reporting equivocal results 3,4 and others worse outcome among those with diabetes 5,6. In Kenya, diabetes mellitus is a leading cause of amputation in both urban and rural hospitals. 7-9 Data comparing outcomes among diabetes related amputations and other cases are important to inform prevention and management strategies. However, reports from Sub-Saharan Africa countries are scarce, and altogether absent from Kenya. This study therefore aimed at describing the outcome of diabetes related amputation in comparison with other cases in two Kenyan rural hospitals.


 

Subjects and Methods:

This was a retrospective study at two missionary hospitals, Kikuyu and Tenwek, in rural Kenya. Both are level IV referral health facilities that serve mainly low to middle class natives from Central and Rift Valley provinces of Kenya. Each hospital has an annual inpatient turnover of 300,000 – 400,000 and does 7–10 major surgeries per week. They both have at least one resident surgeon, 3–4 other medical consultants and several medical officers and assistants. Ethical approval for the study was granted by the respective hospital management boards. Cases of limb amputation between January 2001 and December 2008 were retrieved from the hospital registry. They were categorized by cause into those related to diabetes mellitus and those due to other causes. The cases were examined for duration of hospital stay, change of amputation site, revision, and infection. Revision of amputation was defined as repetition of surgery at the same site after the initial unsuccessful one, while change of amputation site was defined as re-amputation at a more proximal site. Only those cases in which all these data were available and diagnosis confirmed were included in the study.

Data collected were analyzed using the statistical package for social sciences for Windows TM version 11.50 (SPSS, Inc, Chicago Illinois). Descriptive statistics were applied to determine frequencies. A confidence interval of 95% was assumed and the difference considered significant at p≤0.05. Results are presented using tables and bar charts.


 

Results

Three hundred and two amputations were performed in the two hospitals over the study period. Eleven were excluded from the study: six in whom the amputation site was not stated and five in whom the cause of amputation was not specified. Two hundred and ninety one cases (228 males, 63 females) were analyzed. Of these, 60 (20.6%) [42 males, 18 females] were diabetes mellitus related. The remaining 231 (79.4%) amputations were subsequent to other causes. The sites of amputations are shown in Table 1.

Site of amputation
Diabetic
%
Non-diabetic
%
Toe/toes
7
12
9
4
Transmetartarsal
21
35
32
14
Below knee amputation
26
43
96
42
Above knee amputation
5
8
77
33
Finger/fingers
0
0
8
3
Hand
1
2
4
2
Below elbow
0
0
3
1
Above elbow
0
0
2
1
Total
60
100
231
100

Table1: Sites of amputation by cause

 

missing image file

Figure 1: Duration of hospital stay by cause.
(click to enlarge)

The outcome indicators varied between the two causes. The majority (69.7%) of patients who underwent amputation from non-diabetic related causes had a successful outcome compared to those with diabetes (41.7%). Also, the majority (53.2%) of patients with amputations from other causes were discharged from the hospital in the 1st week compared to only 21.7% of those amputated due to diabetes related complications. Most (78.3%) of the diabetes related amputees were discharged during the second week and after, compared to 46.8% of the other cases (Figure 1).

More diabetes related amputations required a change to a more proximal site than non diabetic cases. The majority of these were due to failure to heal as a result of unrelenting infection. Infections per se were more common among diabetes related amputations than the other cases. Revision of stump, mainly due to infection, was the only one more common among the non diabetic cases. The difference in the latter was, however, not statistically significant. [Table 2]

Fate/Outcome
Diabetes (%)
Non diabetic (%)
P value
Change of site
10 (16.6)
11 (4.8)
0.049
Revision
5 (8.3)
24 (10.4)
0.195
Infection
35 (58.3)
60 (26)
0.028
Successful
25 (41.7)
161 (69.7)
0.038
Table 2: Comparative outcomes of amputation.


 
 
 

 

Discussion

Observations of the current study reveal, similar to literature reports, that outcome of diabetes related amputation is worse than that of non diabetic cases 2,6. They, however, are at variance with some of the previous studies which reported no statistically significant difference 3,4. These findings suggest wide diversity which may be related to local hospital and patient factors such as preoperative care, level of amputation, infection and glycaemic control.

The mean duration of hospital stay was 19 days in diabetic and 11 days in non diabetic patients (p= 0.251). Length of hospital stay following diabetes related amputation varies between countries and change with time 2,10. The relatively longer hospital stay (although not statistically significant) demonstrated in the current study after diabetes related amputation is concordant with literature reports 3,11. Other studies have also reported no significant difference between these two groups 4. The inconsistencies between studies suggest that there may be variations in factors that affect post-operative hospital stay.

These factors include infection, care for diabetic foot ulcers and number of amputations. Indeed, when patients with diabetic foot infections are excluded from analyses, there is often no difference in hospital stay between diabetic and non diabetic subjects.3 Further, improving management of diabetic foot ulcers leads to a decrease in mean duration of hospital stay10 and patients who undergo multiple amputations stay in hospital longer11. Although, the difference in duration of post operative hospital stay is not statistically significant, it is clinically important because of the economic burden it imposes on the individual and community12.

Diabetic patients often undergo a second amputation to the same or contralateral limb.4 Nearly 17% of the cases in the present series required change of amputation level. Other studies have reported such changes in 24 – 28% of patients.5,13 Variations in these figures may result from lack of universally accepted method of determining the level of amputation for successful wound healing or for preventing subsequent higher amputations. Generally, however, with advances in surgical techniques and modern prosthetics, all categories of patients are benefiting from surgeries in which a longer residual limb can be kept and where appropriate biomechanical considerations are taken into account14. An observation of the present study in support of this is that nearly 50% of amputations involved the foot only and 90% were below knee.

Observations of the current study are at variance with some literature reports that in diabetes related amputations, the need for revision is increased.6 This complication is related to non-healing, infection and poor soft tissue revascularization.5 The low frequency of revision observed in the present series may be related to greater need for change of amputation to a more proximal site.

Infection has been implicated in stump revision, change of amputation site and prolonged hospital stay.5,6 Observations of the current study reveal that infection was more frequent in diabetes related amputations than the other cases, and may have been a factor in the outcome. This implies that infection control will improve the outcome in diabetes related amputation. Indeed, case control studies on use of antibiotic beads have reported better outcomes.13 The higher frequency of infection and change of amputation site cumulatively contribute to prolonged hospital stay. In this regard, the most practical way of reducing hospital stay and attendant cost is to avoid amputation12, improve management of diabetic foot ulcers,10 or channel diabetes patients through a foot care team before amputation.15


 

 

Conclusion

Diabetes related amputations in rural Kenya carry a high morbidity from infection and change of amputation site and may impose a higher economic burden from longer hospital stay. Vigilant diabetic foot care, strict glycaemic and infection control are recommended.


 

Acknowledgements

We wish to thank registry staff of Kikuyu and Tenwek hospitals for availing records and Ms Catherine Chinga for typing the manuscript.


 

References

  1. Viswanathan V, Wadudj, Madhavan S, Rajasekav S, Kumptla S, Lutale J, Abbas Z. Comparison of post amputation outcome in patients with type 2 diabetes from specialized foot care centres in three developing countries. Diabetes Research and Clinical Practice 2009; 88: 146 – 150.
  2. Van Houtum WH, Lavery LA. Outcomes associated with diabetes-related amputations in the Netherlands and the state of California in USA. J Int Med 1996; 240: 227 – 31.
  3. Aragon-Sanchez J, Hernandez-Herrero MJ, Lazaro-Martinez JL, Quintana-Marrero Y, Maynar-Molinar M, rabellino M, Cabrera-Galvan JJ. In-hospital complications and mortality following major lower extremity amputation in a series of predominantly diabetic patients. Int J Low Extremity wounds 2010; 9: 16 – 23.
  4. Papazafiropoulou A, Tentolouris N, Soldatos RP, Liapis CD, Dounis E, Kostakis AG, Bastounis E, Katsilambros N. Mortality in diabetic and nondiabetic patients after amputations performed from 1996 to 2005 in a tertiary hospital population: a 3 year follow-up study. J Diabetes Complications 2009; 23: 7 – 11.
  5. Van Damme H, Rovire M, De Nooorthout BM, Quaniers J, Scheen A, Limet R. Amputations in diabetic patients: a pleas for foot sparing surgery. Acta Chir Belg 2001: 101: 123 – 9.
  6. Van Damme H, Limet R. Amputation in diabetic patients. Clin Podiatr Med Surg 2007; 24: 569 – 82.
  7. Muyembe VM, Muhinga MN. Major limb amputation at a provincial general hospital in Kenya. East Afr Med J 1999; 76:163–166.
  8. Ogeng’o JA, Obimbo MM, Kingori J. Pattern of limb amputation in a Kenyan rural hospital. International Orthopedics (SICOT) 2009; 33: 1449-1453.
  9. Obimbo MM, Ogeng’o JA, Njogu SW. Diabetes related amputation in a rural African population: Kenyan experience. J Diabetic Foot Complications 2010; 2(1): No. 2 pp 6 -11 (Open access publishing)
  10. Van Houtum WH, Rauwerda JA, Ruwaard D, Schaper NC, Bakker K. Reduction in diabetes related lower extremity amputations in the Netherlands: 1991 – 2000. Diabetes Care 2004; 27: 1042 – 6.
  11. Van Houtum WH, Lavery LA, Harkless LB. The costs of diabetes-related lower extremity amputations in the Netherlands Diabet Med 1995; 12: 777 – 781.
  12. Apelquist J. Wound healing in diabetes: outcome and costs. Clinics Podiatr Med Surg 1998; 15: 21 – 39
  13. Krause FG, de Vries G, Meakin C, Kalla TP, Younger AS. Outcome of transmetatarsal amputations in diabetics using antibiotic beads. Foot Ankle Int 2009; 30: 486 – 493.
  14. Davies BL, Kuznicki J, Praveen SS, Sferra JJ. Lower-extremity amputations in patients with diabetes: Pre and Post surgical decisions related to successful rehabilitation. Diabetes Metab Res Rev 2004; 20(suppl1): S45 – 50.
  15. Larsson J, Eneroth M, Apelquist J, Stenstrom A. Sustained reduction in major amputations in diabetic patients: 628 amputations in 461 patients in a defined population over a 20 year period. Acta Ortho 2008; 79: 665 – 73.

 

One Comment

  • job omari says:

    can you please give me the statistics on incidences of amputation in male as compared to female in kenya today. also you can comment on the difference in terms of the causing factors.

Leave a Comment
  • Some HTML is acceptable.