Appraisal of lower-limb amputations and some rehabilitation problems of amputees: a retrospective study in Nigeria.
This study reviewed the patterns of lower-limb amputations and evaluated the rehabilitation problems faced by the patients at the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria, between January 1992 and December 2001.
Relevant information and data were obtained from hospital records from the Medical Records Department, and the Physiotherapy Department.
Forty-seven lower-limb amputation surgeries were performed, with a male-female ratio of 3:1. The levels of amputation frequently performed were: above the knee (48.9%), and below the knee (42.6%). The most common cause of amputation was trauma due to road traffic accidents. The mortality rate was 19.1%, occurring at the average age of 42.
Referrals for physiotherapy were often late. There were no records of rehabilitative intervention by occupational therapists, clinical psychologists and vocational counsellors. Most of the patients could not afford prosthesis.
It was concluded that physiotherapeutic attention for patients with lower-limb amputation should be sought, not only at the postoperative stage, but also at the pre-operative stage whenever possible. A multi-disciplinary approach, ensuring occupational rehabilitation, was also emphasized.
Key words: lower-limb amputation, rehabilitation
Amputation is the partial or total removal of a body part. (1) It has been accepted as a positive form of treatment when part of a limb is dead. It is considered in cases of arterial occlusion in diabetes resulting in gangrene, in Buerger's disease, and in Raynaud's disease. (2) Cases of severe fracture with partial amputation due to road traffic accidents (RTAs), gunshot wounds or bomb blast injuries are also predisposed to amputation. Amputation is also indicated in congenital deformities. In such cases, amputation may be necessary to improve the quality of life of the individual.
After amputation, rehabilitation to enable the patient live an optimally independent life depends on the co-operative effort of a multidisciplinary team comprising the surgeon, nurse, physiotherapist, prosthetist, occupational therapist, social worker, clinical psychologist and the vocational counsellor. (3)
Generally, the rehabilitation programme for the amputee is divided into three stages, viz:
1. pre-operative stage
2. early postoperative or pre-prosthetic stage
3. prosthetic stage
The overall success of rehabilitation, among other things, depends on the quality of postoperative care, timely referral to or consultation with a physiotherapist, and subsequent progressive physiotherapy care. Pre-operative physiotherapy enables the patient to become familiar with the exercises that will prevent cardiorespiratory complications, muscle atrophy and deformity after the operation. (4) It is also essential that the physiotherapist sees the patient in the early postoperative stage. (2)
The aims of postoperative physiotherapy are to:
* prevent cardiorespiratory complications
* prevent contracture
* strengthen and mobilize the uninvolved leg (in cases of unilateral amputation)
* strengthen and coordinate the muscles controlling the stumps
* strengthen and mobilize the trunk
* retain balance * re-educate the healed stump
* control oedema of the stump * re-educate the patient on sitting, standing and walking
* teach the patient to regain independence in functional activities
Since ambulation is a major concern in attaining functional independence, timely prosthetic application is a sine qua non for early bipedal ambulation. Prosthetic application, however, does not obviate the need for occasional use of the wheel chair.
The roles of the physiotherapist and the prosthetist become crucial, without prejudice to the ancillary roles of others and periodic medical surveillance by the surgeon.
The objectives of this study therefore include:
i. Establishment of age, sex, occupation and annual distribution of the lower-limb amputees in OAUTHC, Ile-Ife, Nigeria
ii. Identification of the indications for amputation, and the level of amputation
iii. Identification of postoperative complications
iv. Determination of mortality and survival rates of the amputees
v. Assessment of pre and postoperative physiotherapy
vi. Identification of evidence for prosthetic affordability
1. Patients' case notes on lower-limb amputation surgery done at OAUTHC, Ile-Ife, over a period of ten years--1992 to 2001.
2. Patients' referral register of the Department of Physiotherapy OAUTHC, Ile-Ife (1992-2001).
3. Patients' case notes from the Department of Physiotherapy (outpatient) OAUTHC, Ile-Ife for the same period (1992-2001).
The hospital and surgery registration numbers of patients who had undergone lower-limb amputation over a period of ten years (January 1992 to December 2001) were obtained from the Medical Records Department of the hospital while the individual case notes were obtained from the Medical Records Library. The case notes were scrutinized and the relevant information was retrieved. To facilitate data collection, a proforma was devised which contained twenty-one items: patient's name, hospital number, age, sex, occupation, level of amputation, indications for amputation, complications of amputation, date of admission, evidence of operation, date of operation, date of referral for physiotherapy, evidence of pre-operative, postoperative and prosthetic physiotherapy referral, duration before referral, evidence of pre-operative assessment, treatment and prosthetic training, number of visits before ambulation stability, total number of visits before discharge, evidence of prosthetic referral and affordability, and condition at the time of discharge. The number of survivals or deaths, and the date of discharge were extracted from the case notes.
Other important and relevant information were also obtained from the patient's referral register and case notes from the outpatient department of the Department of Physiotherapy, OAUTHC, Ile-Ife.
The data obtained were then organized and analysed using descriptive statistics of mean, frequency distribution range and percentages.
A total number of 47 lower-limb amputation surgeries were recorded. Of these, 36 (76.6%) were male and 11 (23.4%) were female; this proportion gives an approximate ratio of 3:1. The ages of the patients ranged from 4 months to 85 years. The highest incidence was recorded among the 21-30 year age group with 13 cases (27.7%), followed by the 41-50 year group with 7 cases (14.9%), and the 51-60 year age group with 6 cases (12.8%). The 4 months-10 year group had 5 cases (10.6%). The lowest incidence was recorded among the 81-90 year age group which had only 1 case (2.1%) (see table 1). Of these patients, 34 (72.3%) were under 50 years, while the remaining 13 patients (17.7%) were above 50 years.
Figure 1 summarizes the annual distribution of the patients. The highest number of surgeries was performed in 1993, on 8 patients (17.0%). The lowest number--on one patient (2.1%)--was done in 1996. The histogram did not show any definite patterns, but a gradual decline was observed from 1999 to 2001. Table 2 shows that civil servants constituted the highest proportion of these patients (29.8%), followed by traders (23.4%) and students (21.3%). These categories of patients are in the active stage of life which is characterized by intense use of vehicular movement.
[FIGURE 1 OMITTED]
Table 3 shows that trauma and crush injuries due to road traffic accidents (RTA) accounted for the highest number of cases of amputation (51.0%). Other causes of amputation included diabetes, peripheral vascular diseases (PVD), and infection. There was only one case of congenial deformity.
Four different levels of amputation were identified in this study as shown in table 4. The commonest was above-knee amputation (AKA). The majority of the patients (35) had no postoperative complications (table 5). Five patients had septicaemia, three had anaemia and one had acute renal failure which led to their deaths between the first day of operation and three months after the operation.
Table 6a shows that there were no referrals for pre-operative physiotherapy. Thirty-seven patients (78.7%) were referred for postoperative physiotherapy. Of this number, only one was seen for prosthetic physiotherapy training. Table 6b shows the duration of the interval before physiotherapy intervention, following referral after the operation. Approximately 62.9% of the patients received physiotherapy intervention early (22.9% on the first day and 40% on the second and third days). Of the number that received postoperative physiotherapy only 17 were seen again after they had gained stability on crutches.
Table 7a shows that only 18 patients (38.3%) were referred for lower-limb prostheses, and of this number, 17 could not afford the price of the prostheses. There were no records of interventions by occupational therapists, medical social workers, clinical psychologists, or vocational counsellors.
In this study, the male to female ratio of lower-limb amputees was approximately 3:1. This finding confirms the result of the study by Ham and Van de Ven (5) that male amputees usually outnumber the 5 female amputees. The annual distribution of amputations observed in the study did not follow any particular pattern, though factors responsible for amputation can be the major determinants of distribution. If the causes of amputation are prevented, the annual distribution will be drastically reduced. The lowest incidence of amputations, which was observed in 1996, followed by that of the year 2001 gives a ray of hope. Over the last three years of the study, the yearly incidence reduced from 6 to 2.
The leading cause of amputation identified from this study was crash injury (table 3a). This is due to the high incidence of RTA in our environment. On the contrary, in a related study on most common causes of limb deficiency referred to limb fitting centers in Great Britain, Gregory-Dean (6) found PVD, 6 being 30%, to be the leading cause. Trauma was observed to be 10%, due to the lower rate of RTA in their environment. Other results obtained, such as DM being 20% and malignancy being less than 5%, from their study, correspond with the outcome of this study, in which DM was found to be 19.1% and malignancy 4.3%.
In the last couple of years, the Federal Road Safety Corps of Nigeria has intensified the enforcement of sensible driving on the Federal highways. The use of safety belts by drivers and front-seat passengers has also been enforced, with effect from 1st January, 2003. It is envisaged that these measures will reduce the rate of the severity of vehicular accidents on our highways, and hence the necessity for amputations that might have been caused by RTA.
This study also revealed that the majority of the amputations, as a result of trauma, occurred more in under 50 year age groups i.e. younger age groups. On the other hand, PVD and DM were indications for amputation in over 50 year age groups--table 3b. This confirms the result of Ham and Van de Ven (5), that PVD and diabetic gangrene are diseases associated with the elderly, and account for the majority of lower-limb amputation. Gregory-Dean (6) also found out that most of the patients with PVD are in the 8th or 9th decade of life, while those with DM are in their 50s and 60s. From the study, amputation due to congenial deformity occurs mainly below 50 years of age, especially the 0-10 year group. This also confirms the study by Payton, (13) that amputation for congenial deformity and limb length discrepancies are usually performed on children and young adults. In these cases, surgery is best delayed until the patient is old enough to decide whether to have the amputation performed or not.
AKA and BKA appeared to be the commonest surgeries observed in this study, which appeared in a ratio of 1:1 for both types, accounted for 91.5% of the cases amputated. This finding is in support of the result obtained by Waters et al. (7) that over 90% are AKA or BKA, in approximately equal numbers, because these levels provide stump suitable for good functioning prostheses.
The majority of the surgeries in this study were highly successful. About 75% of patients had no complications. Since cases of amputation sequel to trauma of RTA accounted for 51% of amputations under survey, it is obvious that most operations would have been done in emergency situations. In other words, there might not be rooms for preoperative referral for physiotherapy. Amputation following cold cases like peripheral vascular diseases, infection and malignancy requires preoperative rehabilitation intervention in an ideal setting. It was however not certain whether rehabilitation problems of these later cases might have emanated pre-operatively by the non referrals reported in this survey. From table 5, it was revealed that 12 cases and had postoperative complications ranging from acute renal failure, anaemia to septicaemia. These led to death between the first day of operation and three months after the operation. Other complications like contractures and pressure sores were avoidable secondary conditions which timely physiotherapy and adequate nursing case could have obviated. Mortality of 19.1% was recorded. Mortality rate was predominantly among the AKA group. This observation confirms the result of Sethia et al. (8) who stated that before amputation, it is important that the physiotherapist (PT) should partake in preparing the patients for surgery and subsequent rehabilitation. The PT must carry out careful assessment as required. It is very essential that he also spends enough time with the patient, pre-operatively. (9) The result obtained from this study revealed that no patient was referred for pre-operative physiotherapy, and no pre-operative assessment and treatment was carried out. It is essential that the PT sees a patient pre-operatively. This will enable the patient get used to the exercises that will prevent muscle atrophy and flexion deformities after the surgery. The reason for the non-referral could be due to an inadequacy in the multi-disciplinary team approach and communication lag. Ham et al. (4) stated that the physiotherapist is an essential member of the multi-disciplinary team, and is often the professional link in carrying out the complete programme treatment. An appreciable figure of 78.7% of patients were referred postoperatively for physiotherapy. This shows that the level of awareness of the role of physiotherapy at this stage of rehabilitation is outstanding enough, because 8 out of these 10 patients not referred died due to postoperative medical instability. The reason for non referral may not be far-fetched from those earlier stated. Of those referred, 94.6% cases were seen, assessed and treated by the physiotherapist. Clyne (10) stated that due to muscular imbalance following amputation, there is always a tendency for patients to develop flexor contracture of the hip joint in AKA or of knee joint in BKA, and their avoidance is one of the most important aspects of postoperative physiotherapy.
From the study, 75.6% of the patients were referred for physiotherapy around the second to forth week after operation. Early physiotherapy intervention and treatment have been highlighted as prerequisites for effective rehabilitation. Olaogun (11) also stressed that late referrals for physiotherapy has its socio-economic and behavioral consequences. Early referral for physiotherapy produces good measurable outcomes, enhances effective prosthesis usage and prevents postoperative complications. Van de Ven (2) also emphasized that chest physiotherapy and isometric strengthening exercises should commence on the first day following operation, and transfer out of bed into a wheelchair should be achieved on the first or second day post-op. (2)
A few patient (38.3%) were referred for prosthesis. This is explained by Michael and Antony, (12) that various factors such as level of amputation, sex, age, medical status, obesity, strength, range of motion and compliance, determine prosthesis prescriptions. Payton and Poland (13) identified that one of the key factors responsible is the nature of cost versus benefits. High costs of prosthetic fitting and training to a large extent determine the decision regarding whether to fit the patients with prosthesis or not. This also explains why a majority of the patients referred for prostheses showed poor evidence of prosthesis affordability. The study also demonstrated the role of physiotherapy in prosthetic rehabilitation. The only patient referred after getting the prosthesis was trained by the physiotherapist on how to use it. The goal of the physiotherapist is not only to ambulate the patient and stop there, he must continue to achieve all the others set postoperative physiotherapy aims and objectives, until the patient is discharged home from the hospital. Further rehabilitative procedures should continue in the Outpatient department and finally in the community.
Physiotherapy management used as revealed in this study included passive and active exercises, strengthening exercises, bandaging, positioning techniques, chest physiotherapy, massage, the use of transcutaneous electrical nerve stimulation (TENS) in managing postoperative pain. TENS and percussion massage were also used in the management of phantom pains.
The leading cause of lower-limb amputation as revealed in this study is motor vehicular accident. This contrasts with the leading cause elsewhere in the world. Above-knee amputation and below-knee amputation are the predominant types of surgeries. Rehabilitation problems of the amputees included, inadequacy of multi-disciplinary care and poor prosthesis affordability. It behoves the Federal Road Safety Corps of the nation to intensify efforts in preventing or minimizing road traffic accidents along the major roads of the nation. It is recommended that total care of the amputee should be desired in ensuring adequate physiotherapeutic attention (pre-and postoperatively) and occupational rehabilitation by involving other rehabilitationists like the occupational therapists, prosthetists, medical social workers and vocational counsellors. This can be possible when these professionals are all on ground and are involved in the concept of multi-disciplinary team approach.
(1.) Joan AR, Mike W. Watson's Medical and Surgical Nursing and Related Physiology, 4th Edition; London Philadelphia 1972; 884-885.
(2.) Van de Ven CMC. An Investigation into the management of bilateral amputees. British Medical Journal 1981; 283: 707-701.
(3.) Krusen FH. The Scope of Physical Medicine and Rehabilitation in Krusen FH, Kottke FJ Ellwood PM (eds) Handbook of physical Medicine and Rehabilitation (2nd Edition) W.B. Saunders Phil. 1971: 1-13.
(4.) Ham RO, Thornberry DJ, Regan FJ, et al. Rehabilitation of the vascular amputee: one methods evaluated. Physiotherapy Practice 1985: 1: 6-13.
(5.) Ham RO, and Van de Ven CMC. The management of the lower limb amputees in England and Wales today. Physiotherapy Practice 1986; 2: 94-100.
(6.) Gregory-Dean A. Amputation: Statistics and trend. Annals of the royal college of Surgeons of England. 1991; 73: 137-142.
(7.) Waters RK, Perry T, Antonelli O, Histon H. Energy cost of walking of amputees: the influence of level amputation. Journal of Bone and Joint Surgery 1976; 58A: 42-46.
(8.) Sethia KK, Berry AR, et al. Charging pattern of lower limb amputation for vascular diseases. British Journal of Surgery 1986; 73: 701-703.
(9.) Ham RO. Whittake N. The King's amputee stump board, a new design. Physiotherapy 1984; 70:810.
(10.) Clyne CAC. Selection of level of lower limb amputation in patients with severe PUD. Annals of the Royal College of Surgeons of England 1991l 73: 148-151.
(11.) Olaogun MOB. A case report on Socioeconomic and Behavioral results of late physiotheraphy in Nigeria. J. Nigerian Society of Physiotherapy 1992; 1: 2; 21-23.
(12.) Michael JM, Anthony D. Selective criteria for successful long term prosthetic use. Archives of Physical Medicine and Rehabilitation 1985; 65: 1037-1040.
(13.) Payton OD, Poland JL. Aging process: Implications for clinical practice. Physical Therapy 1986; 73: 701-703.
Department of Medical Rehabilitation, College of Health Sciences, Obafemi
Awolowo University, Ile-Ife, Nigeria
Department of Physiotherapy, Obafemi Awolowo University, Teaching Hospitals
Complex Ile-Ife, Nigeria
Correspondence: Matthew OB Olaogun, Email: firstname.lastname@example.org * Tel: 2348037260562
Table 1. Age and Sex Distribution Age (Years) Male Female Total Percentage 0-10 2 3 5 10.6 11-20 3 2 5 10.6 21-30 13 -- 13 27.7 31-40 3 1 4 8.5 41-50 4 3 7 14.5 51-60 6 -- 6 12.8 61-70 2 -- 2 4.3 71-80 2 2 4 8.5 81-90 1 -- 1 2.1 36 11 47 100% Table 2. Occupational Distribution Occupation Total % Traders 11 23.4 Farmers 4 8.5 Civil Servants 14 29.8 Students 10 21.3 Drivers 3 6.4 Operator 3 6.4 Teachers 8 17 Non-workers 2 4.3 Total 47 100 Table 3a. Indications for Amputation Indication Total % Diabetes 9 19.1 Peripheral Vascular Diseases 6 12.8 (PVD) Trauma/Vehicular Accidents 24 51 Malignancy 2 4.3 Infection 5 10.6 Congenial Deformities 1 2.1 Grand Total 47 100 Table 3b. Age Range and Percentage Distribution of the Causes of Amputation Under 50 years Over 50 years Trauma (%) 95.7 4.1 Diabetes Mellitus (%) 44.4 55.6 PVD (%) 0.0 100.0 Infection (%) 100.0 0.0 Malignancy % 50 50 Congenial Deformity 100.0 0.0 Table 4. Distribution According to Level of Amputation Level Total % AKA 23 48.9 BKA 20 42.6 KD 1 2.1 TA 3 6.4 Total 47 100 Legend: AKA Above Knee Amputation BKA Below Knee Amputation KD Knee Disarticulation TA Toes Amputation Table 5. Complications after Surgery Complication Total % Septicaemia 5 * 10.6 Anaemia 3 * 6.4 Acute Renal Failure 1 ** 2.1 Contracture 2 4.3 Pressure sore 1 2.1 No complication 35 74.5 Total 47 100 * Died between 3rd day and 3 months. ** Died after operation, same day. Table 6a. Pre-operative and Postoperative Physiotherapy Referral Rate States of Rehabilitation Referral Total % Status Pre-op physiotherapy R 0 0.0 NR 47 100 Post-op physiotherapy R 37 78.7 NR 10 21.3 Prosthetic R 4 2.1 physiotherapy training NR 46 97.9 Table 6b. Duration of the Interval Before Physiotherapy Intervention after the Operation Day after operation 1st day 8 17 2nd to 3rd day 14 29.8 4th to 7th day 6 12.8 1st to 3rd week 7 14.9 Total 35 74.5 Table 6c. Physiotherapy Attention after Stability on Crutches Treated after stability on crutches 17 Not Treated 15 Table 7a. Prosthetic Referral Total % Referral (R) 18 38.3 Non Referral (NR) 29 61.7 Table 7b. Prosthetic Affordability Affordability Total % Able to afford 1 2.1 Not able to afford 17 36.2