Major Limb Amputations: Etiological and Clinical Profile in a Hospital in Sub-Saharan Africa

Introduction: During the 19th and 20th centuries, the Wars were the cause of many amputations among military and civilians. Despite the absence of armed conflict in our country, we notice a high frequency of major amputations in our activity. Objective: The aim of this work was to study the causes of major amputations observed in our practice in order to develop preventive measures. Materials and Method: This was a descriptive retrospective study over a 6-year period, from January 1, 2008 to December 31, 2014. The following parameters were studied: epidemiological aspects (age according to WHO age groups and gender of patients), type of amputation, level of amputation and causes. Results: Two hundred and fifty-two patients were included. The distribution of amputations by cause and age group showed two distinct entities: The forms of the young subject where there was a predominance of tumour and traumatic causes; and the forms of the elderly person caused by vascular infections and conditions. Infections were the main cause of amputation in both sexes. Conclusion: The causes of major limb amputations vary according to age and limb: tumor and trauma in young people and for the upper limb, infectious and vascular in the elderly and for the lower limb.

Performing a limb amputation is one of the least attractive gestures for a surgeon. This is because of psychological effects and the handicap it causes in a patient who has to adapt to a new way of life.
Management begins with communication with the patient and their family. It then continues with all aspects related to amputation surgery, ending with the principles of prosthetic limb fitting.
Limb amputation seems to be, together with craniotomy, the oldest surgical practice. In fact, traces of upper limb amputations have been found on skeletons dating from the prehistoric Mesolithic period, i.e. before the 9 th millennium BC.
The main causes of these amputations were, of course, the consequences of hunting injuries in the face of wild animals, but also the sequelae of battles between rival clans and tribes. These were done with axes and other carved flints.
One can easily imagine the injuries that these could cause.
During the 19 th and 20 th centuries, the American civil war and the two World Wars were the cause of many amputations among military and civilians.
Nowadays, the causes of these major amputations are rarely studied in the literature [2]. Despite the absence of armed conflict in our country, we notice a high frequency of major amputations in our activity.
The objective of this work was to study the causes of major amputations observed in our practice in order to develop preventive measures.

Materials and Method
We conducted a descriptive retrospective study in a teaching hospital over a period of 6 years, from January 1 st 2008 to December 31 st 2014. We used the admission registers of all the hospital's departments. We also consulted the registers of the operating theatre and the staff of the Orthopaedic-Traumatology department (the only department that performs amputations). Thus, we were able to include all patients who had a major amputation (amputation site above the foot or hand) regardless of age or sex. We then consulted the patients' files.
We carried out a data collection sheet which allowed us to study the following parameters: the demographic aspects (age: according to WHO age groups and the sex of the patients), the type of amputation, the level of amputation and the causes.

Results
A total of two hundred and fifty-two patients were selected. The mean age was 50.9 ± 23 years. Our population was divided into seven (7) (Table 1).
Infections were the main cause with 53.2%, followed by vascular diseases with 17.9% (Figure 3). Trauma and tumors accounted for 11.9% and 11.5% respectively.        (n = 32) and vascular in women (n = 19). The third cause was vascular in men (n = 26) and traumatic in women (12). Trauma was the least common cause in men (n = 18). Tumors were the fourth most common cause in women (n = 7).
There was a higher frequency of infectious (n = 136) and vascular (n = 42) causes in the lower limbs (Table 2). Tumors and trauma accounted for 28 and 23 cases respectively.
Vascular causes represented one (1) case. There were no infectious causes.

Discussion
• Epidemiology The average age in our series was 50.92 ± 22.97 years and the predominance of the male sex (63.4%) is close to those reported in the work of André JM and Paysant J [3].
A lower average age has been described by Souna et al. [4] and by Onuminya et al. [5] with 37.7 years and 30 years respectively. This difference is explained by the predominance of the elderly in our study.
In fact, 66.7% of our patients were >40 years of age. Glaser JD et al. [6] and Lombardo FL et al. [7] reported 77% and 58.6% of diabetes in their work, respectively. The particular susceptibility of diabetics to infections could be related to hyperglycemia, capable of altering the functions of leukocytes (phagocytosis, adhesion, bactericidal, chemotaxis) [8]. Neuropathy and arteriopathy play an aggravating role. Neuropathy leads to indolence which can delay diagnosis in the event of infection [9] [10]. Arterial disease promotes delayed healing and anaerobic infections through hypoxia [11].
In contrast, in the series by Souna BS et al. [4] traumatic causes predominated.
This is due to the higher frequency of young subjects in his study.
Vascular diseases, the second cause in our series (17.9%), represent the first cause of major amputation in the northern countries with 85.8% due to the aging of their population [1].
We must emphasize the particularity of tumor causes in our practice: second cause in men. These results could be explained by the fact that men are generally more exposed to carcinogenic risk factors due to their activities (tobacco, alcohol, asbestos, mine workers, etc.).
These tumors mainly affect children. The indications for amputation at this age are due to a delay in consultation in our countries. In fact, these patients first seek traditional treatment and are often secondarily received at an advanced stage of their disease. This delay in consultation is not only due to beliefs and traditions in our country but also to the high cost of hospital charges.
The limits of our work lie first and foremost, as in any retrospective study, in the selection of patients. Because we could not include all patients who had a major amputation. Secondly, it is a monocentric study. And finally, we did not carry out any statistical analysis that could have given more value to our results.