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A clinical study on lower limb amputations

Introduction: Limb amputation is one of the commonly done surgical procedures. Bleeding, shock and sepsis were common risks in the olden days. Amputation should not be considered as a failure of treatment. They are lifesaving procedure during trauma, PVD, and for malignancies. Post amputation prosthesis management is a team approach with a surgeon, physician, physiotherapist, prosthetist, social worker to prevent complications. AIM: To know the various indications and post operative complications of amputations. Methodology: A prospective observational study done in Narayana Medical College and Hospital Nellore during August 2017 to July 2019. Patients who underwent amputations were selected on simple random technique and analysed. Results: In the study mean age was 33.4 years. Diabetes accounts the major cause of amputation in this age group. In the study males were 37 (74%) and females were 13(26%). Forefoot amputation was commonly done procedure. Stump infection was the common complication in the post-operative period. Conclusion: In the era of developed surgical techniques, anaesthesia and rehabilitation methods amputation surgeries are with less procedural morbidity and in the post-operative period. Diabetes, PVD, RTA, tumours are common cause of amputations.


Introduction
Limb amputation is one of the commonly done surgical procedures in the general surgical practice. Bleeding, shock and sepsis were common risks in the olden days. Improvements in the surgical equipment, techniques, anaesthesia made them comfortable [1,2] . 30,000-40,000 amputations were performed yearly in the United States. 1.6 million individuals were estimated to be without limb by 2005 and by 2050, this is expected to rise to 3.6 million [3] . Amputation should not be considered as a failure of treatment. They are lifesaving procedure during severely traumatized limb, peripheral vascular disease with gangrene and rest pain, and for malignancies [4,5] . Main problem with amputation is the post-surgical trauma to the patient, problem with insufficient rehabilitation, follow up problems, stump infection or trauma, change in the life style of the individual [6] . Post amputation prosthesis management is a team approach with a surgeon, physician, physiotherapist, prosthetist, social worker to prevent complications, method of walking with prosthesis, application, removal, pressure sores etc [7,8] .
Aims and Objectives 1. To know the various indications for amputations 2. Post-operative complications during the stay and a short-term follow-up of 6 months

Methodology
This is a prospective observational study done in Narayana Medical College and Hospital Nellore during the period from August 2017 to July 2019.

Inclusion criteria: Patients who underwent lower limb amputations
Exclusion criteria: patients who are not willing for participation Patients were selected on simple random technique. Detailed history, contributing factors, ~ 515 ~ comorbidities, indications for amputations, post-operative say and complications during the stay, short term complications during the study period of 6 months follow up were recorded and analysed.
Statistics: Microsoft excel sheets were used for entering the data. Mean, percentages and averages were used to describe the results. In the study males were 37 (74%) and females were 13(26%)

Discussion
Extremity amputations could be done for vascular pathology, trauma, tumors, infections, congenital deformities [1,2] . Vascular disease is a leading cause in the United States [9,10,11,12,13,14] usually associated with diabetics in elderly smokers. Severe traumatized limb with compound fractures, vascular and neural damage can be managed with amputation than repairing which ends up in painful, non-function limbs [15] . In our study majority of the cases were in the 51-60 years age. Mean age was 33.4 years. Diabetes accounts the major cause of amputation in this age group. In the study males were 37 (74%) and females were 13(26%). In Chalya et al [16] study, in a total of 162 patients the mean age was 28.30 ± 13.72 days, Males outnumbered females by a ratio of 2:1.
In Ekere AU study [20] in 34 cases, male to female ratio was 2.1:1. The patients were between 20-40 years with 67.6%. Diabetic foot was the leading cause of amputation in our study accounting for around 62% and majority undergone forefoot amputation followed by infection of the stump and revision and 2 cases had below knee amputations, above knee amputation in one case.
Trauma was noted in 2 cases of 21-30 years age and in 51-60 years 1 case. Below knee amputation was done in 2 cases and 1 case had above knee amputation. Two cases of Squamous cell carcinoma in the chronic ulcer and a case of case of marjolins ulcer were noted and the cases had above knee amputation. Post-operative stump infection was the common complaint noted in 34% of the cases. Revision amputation was done in 26% and 3 cases died among the study 2 were suffering from PVD and 1 Diabetes. Cause of death was cardiac event associated with DM and vascular pathology in the coronary system. In Chalya et al [16] study in a total of 162 patients diabetic foot complications requiring amputation was in 41.9%, trauma in 38.4% and vascular disease in 8.6%. Below knee amputation was done in 46.3%. Revision amputation rate was 29.6%. Surgical site infection was the most common complication accounting for 21.0%. Mortality rate was 16.7%. In Paudel B et al [17] RTA (74.29%) in was the common cause in adults, postburn contracture (29.54%), Congenital limb conditions (22.72%), Spina bifida with trophic ulcers (20.45%), Tumor (13.63%), Chronic Osteomyelitis (6.81%), Trauma (4.54%) and Arthrogryposis (2.27%) were the othet causes. In Essoh JB et al [18] study in a total of 160 limb amputations in the 156 patients. Trauma (49.9%), diabetic foot sepsis (31.4%), and peripheral vascular disease (13%) were the main indications. Below knee (46.9%) and below elbow (11.2%) amputations were the most common procedures performed. Wound infection was the commonest complication occurring in 42 (26.9%) patients. There were 25 (16%) deaths, out of which 22 were due to sepsis. In Kidmas AT et al [19] in a total of 94 amputations in 87 patients, Trauma, diabetic foot sepsis and malignant conditions of the limb were the main indications in 26(29.9%), 23(26.4%) and 20(23%) patients respectively. Others were peripheral vascular gangrene (PVG) in 9.2%; chronic osteomyelitis 3.5%; chronic leg ulcers 3.5%; Ainhum 3.5% and snake bite 1.1%. Above knee amputation was done in 48.9%, below knee amputation in 37.2%. Mortality was in 12.6%.

Conclusion
In the era of developed surgical techniques, anaesthesia and rehabilitation methods amputation surgeries are with less procedural morbidity and in the post-operative period. Diabetes account for the most common cause of amputation in the elderly complicated with cardiovascular events increasing the mortality and revision surgeries. Road traffic accidents in the machinery era, peripheral vascular disease with gangrene; tumours are the other causes of amputations.
With good rehabilitation methods patients can be managed effectively with prosthetic limbs.