Clinical and therapeutic patterns of lower extremity amputation (LEA) in a tertiary hospital in Togo: a retrospective study

doi:10.21203/rs.3.rs-1359470/v1

PDF

Research Article

Clinical and therapeutic patterns of lower extremity amputation (LEA) in a tertiary hospital in Togo: a retrospective study

https://doi.org/10.21203/rs.3.rs-1359470/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

We analysed the clinical and therapeutic profile of the patients who underwent a surgical lower extremity amputation (LEA) in Togo.

Methods

Retrospective study based on clinical files of the adult patients who underwent a LEA at a single centre (Sylvanus Olympio Teaching Hospital, SOTH) from 1st January 2010 to 31st December 2020. We analysed files with 95% of the studied parameters and excluded those with less than 5%. Data were analysed by CDC Epi Info Version 7 and Microsoft Office Excel 2013 software.

Results

We included 245 cases. The mean age was 59.62 years (15.22SD) (range 15 to 90 years), the sex ratio, 1.99. The medical history of diabetes mellitus was found in 143/222 (64.41%). Gangrene was diagnosed in 212/245 (86.53%) patients; crush syndrome in 23/245 (9.39%); bone tumour in 5/245 (2.04%); osteomyelitis in 2/245 (0.82%); chronic ulcer in 2/245 (0.82%); necrosis fasciitis in 1/245 (0.40%). A Doppler-ultrasound of the lower limbs was performed in 91/245 (37.14%) cases. The anatomical site of LEA found in 241/245 (98.37%) files was leg in 133/241 (55.19%), knee in 14/241 (5.81%), thigh in 83/241 (34.44%), and foot in 11/241 (4.56%) patients. The mean delay from the indication of amputation to surgery retrieved in 239/245 (97.55%) files was 6.75 (1–78) days (11.59 SD). The immediate postoperative complications have been reported in 242/245 (98.78%) files, and no complication in 234/242 (96.69%). There were early complications in 56/238 (23.53%) patients. The mortality rate after LEA was 17/238 (7.14%). The mean duration of hospitalization marked in 241/245 (98.37%) files was 36.30 (1-278) days (36.20SD).

Conclusion

Most patients admitted to SOTH (Lomé, Togo) who underwent LEA had diabetes mellitus at the late presentation, which led to challenging complications. This result entails essential information campaigns to prevent diabetes mellitus and cardiovascular diseases.

amputation

lower extremity

diabetes mellitus

diabetic foot

Togo

The term “amputation” derives from the Latin word “amputare” (to excise, to cut out) that means the removal of part or all of a body part enclosed by the skin. Lower extremity amputation (LEA) is the removal of lower limbs by surgery or by accident [1]. LEA is a severely disabling condition that imposes variable physical and psychological challenges, including alterations in lifestyle, changes in self-concept, decreased quality of life, impairments in physical functioning, and sensory effects [2–5]. LEA occurs as complications of trauma or underlying diseases, such as infections, tumours, cardiovascular or vascular diseases, and neglected congenital conditions [6, 7]. The incidence of LEA varied from 8.8 per 100 000 in the Netherlands in 2004 to 92.5 per 100 000 people in Ireland in 2009 [8, 9]. In recent years, in Western countries, LEA has been reported as declining in the literature [10–12]. In African countries, the causes of LEA are variable, with a predominance of trauma, infections of wounds, and legs ulcers [13–14]. In Togo, Abalo and al. reported a predominance of vascular causes of LEA from January 2000 to December 2004 and, among the vascular disorders, diabetes mellitus accounted for 48.2% [15]. In 2017, Amouzou and al. showed that all the amputations due to leg ulcers were complications of diabetic foot [16]. This study has described the clinical and therapeutic profiles of patients who underwent the LEA intervention in Togo. In particular, we analysed the characteristics of patients with diabetes mellitus who had LEA at Sylvanus Olympio Teaching Hospital (SOTH) from 2010 to 2020, the only hospital in the country equipped with a Wound Healing Unit.

This study was retrospective, based on data retrieved from clinical files of adult (> 15-year-old) patients admitted and treated in the Wound Healing Unit and Traumatology-Orthopaedics department of SOTH in Lomé from 1st January 2010 to 31st December 2020.

The present study was conducted according to the World Medical Association’s Declaration of Helsinki (1964, version 2013)[17] and Good Clinical Practice. The medical Institutional Board of SOTH approved this study. The drafting of the manuscript complied with the STROBE guidelines [18].

From the clinical files, we retrieved the following data:

socio-demographic parameters: age (“aged” patients were those 65-year-old and older), and sex;
past medical conditions and chronic diseases: diabetes mellitus, hypertension, sickle cell disease;
clinical characteristics: ischemic or wet gangrene, tumour, crush syndrome;
biological parameters: haemoglobin rate, white cells count;
radiological findings: vascular lower limb ultrasonography;
therapeutic aspects and operative records of the patients: type of anaesthesia, location, side of amputation, and delay between indication and surgery;
Postoperative course: immediate and early postoperative complications (present or absent); the complications included death, psychological troubles, wound infections (surgical site infections), persistence of ischemia, and disorders on the contralateral limb.

We analysed clinical files including more than 95% of the studied parameters and did not consider the clinical files with less than 5%.

The descriptive statistical analysis of the data was performed with CDC Epi Info Version 7.2.0.1 and Microsoft Office Excel 2013 software, and provided the Chi-square value, degree of freedom, and cell value, if necessary. The cell value was significant under 5%. We used Microsoft Office Excel 2013 software for tables and figures. The mean value was used to measure age of the patients, rate of haemoglobin, hospital stay, delay from indication to amputation.

General data

In the study period of 11 years (2010–2020), a total of 10731 patients were admitted to both the Traumatology-Orthopaedics department and Wound Healing Unit of SOTH. LEA was conducted in 363/10731 (3.38%) patients, the average number of LEAs per year was 33. Figure 1 displays the distribution of all the patients admitted to SOTH, to the Traumatology-Orthopaedics department and Wound Healing Unit (Fig. 1A), to the Traumatology-Orthopaedics department only (Fig. 1B), and to the Wound Healing Unit only (Fig. 1C). The clinical files of 98/363(27%) of the patients operated on for LEA were missing. Clinical files with incomplete information (less than 5% of the considered parameters) accounted for 20/363 (5.51%), and 245/363 (67.49%) clinical files contained enough information to be included in this study. Figure 2 shows the flow diagram of the participants throughout the study phases.

Demographic data

The average age of the patients who underwent LEA was 59.62 years (15.22SD) (range 15 to 90 years); patients above 65 years accounted for 94/245 (38.37%). Figure 3A displays the age distribution of the 245 patients who underwent LEA of this study. The sex ratio of our patients’ population was 1.99.

Medical and social history data

In the medical history of the 245 patients who underwent LEA, 26/245 (10.61%) had a previous LEA. The past medical conditions were missing in 23/245 (9.39%) clinical files. Based on the 222 clinical files with available data, 143 patients had diabetes mellitus; 94 (42.34%) had diabetes mellitus alone, and 49 (22.07%) had diabetes mellitus associated with other diseases (Fig. 3B).

Clinical, biological, radiological data and LEA causes

Gangrene was the clinical presentation of the limb at hospitalization in 212/245 (86.53%) patients. Other clinical presentations were crush syndrome in 23/245 (9.39%) cases, bone tumour in 5/245 (2.04%), osteomyelitis in 2/245 (0.82%), chronic ulcer in 2/245 (0.82%), and necrosis fasciitis in 1/245 (0.40%) (Fig. 4). We found the data about the type of gangrene in 194/212 (91.51%) clinical files that were ischemic in 71/194 (36.60%) and wet in 123/194 (63.40%). Of the 123 clinical files of patients with wet gangrene, 16 (13.01%) were gas gangrene.

Complete Blood Count was registered in 235/245 (95.92%) clinical files. Patients with hyperleukocytosis accounted for 153/235 (65.11%). The count of the white blood cells was in the normal range for 80/235 (34.04%) patients; 2/235 (0.85%) subjects had leukopenia. The average count of white blood cells was 15646 elements/mm³ (9.25SD) (range 3200 to 44700). The rate of white cells anomalies (leukopenia and hyperleukocytosis) was significantly higher in patients with diabetes mellitus compared with those without (98% vs. 43%, p = 0.01). The mean rate of haemoglobin was 9.33 g/dl (2.38SD) (range 2.5 to 17); 36 out of 235 patients had haemoglobin rate under 7g/dl.

Doppler-ultrasound was performed in 91/245 (37.14%) patients; for 18/91 (19.78%) patients, the results were in the normal range, 42/91 (46.15%) subjects displayed arterial abnormality (peripheral artery disease), 6/91 (6.59%) had venous disorders (superficial insufficiency or deep venous thrombosis), and 25/91 (27.48%) showed a combined artery and venous disorders.

The causes of the LEA encompassed infections in 143/245 (58.37%) patients and bone or skin tumours in 5/245 (2.04%) (Fig. 5A). No data about histology types of the tumour was reported. The 143 patients who underwent LEA with diabetes mellitus were involved in infectious and vascular aetiologies; none of them had tumour or crush syndrome of the limb.

Therapeutic data

Anaesthesia was spinal in 242/245 (98.78%) patients and general in 3/245 (1.22%). The side of the LEA was reported in 239/245 (97.55%) clinical files and missing in 6/245 (2.45%). LEA was left in 116/239 (48.54%) patients and right in 123/239 (51.46%). We found the anatomical site of the LEA in 241/245 (98.37%) clinical files: leg in 133/241 (55.19%), knee in 14/241 (5.81%), thigh in 83/241 (34.44%), and foot in 11/241 (4.56%) patients. The anatomical site of amputation below the knee was significantly higher in patients with diabetes than patients without (96% vs. 39%, p = 0.01).

The mean delay from the indication of amputation to the surgery in 239/245 (97.55%) clinical files was 6.75 (1–78) days (11.59 SD).

Complications in the immediate postoperative were reported in 242/245 (98.78%) clinical files; no complication was present in 234/242 (96.69%). Two patients had a stroke after the surgery; one patient had a perioperative state of shock that raised favourably on medical treatment. We did not find any complications occurring in the immediate follow-up in five files. We found early postoperative complications in 238/245 (97.14%) clinical files. Complications were present in 56/238 (23.53%) and absent in 182/238 (76.47%). The type of complications was reported in 47/56 clinical files (83.92%) and missing in 9/56 clinical files (16.08%) (Fig. 5B).

There was no significant difference between age, sex, site of the amputation under the knee, presence or absence of diabetes mellitus, and the early postoperative complications (Table 1).The mortality rate after LEA was 17/238 (7.14%). The mean hospital stay was marked in 241/245 (98.37%) clinical files and consisted of 36.30 (1-278) days (36.20SD).

Table 1

Distribution of early postoperative complications in the follow-up according to age, sex, presence of diabetes and below knee amputation (N = 245).
		Early postoperative complications
		Present		Absent		Total		Chi-2	P-value
Other patients	Row %	111	75,51	36	24,49	147	100,00	0,0822	0.77
Other patients	Col %	111	60,99	36	64,29	147	61,76
Aged patients	Row %	71	78,02	20	21,98	91	100,00
Aged patients	Col %	71	39,01	20	35,71	91	38,24
Total	Row %	182	76,47	56	23,53	238	100,00
	Col %	182	100,00	56	100,00	238	100,00
		Early postoperative complications
		Present		Absent			Total
Men	Row %	123	76,88	37	23,13	160	100,00	0,0023	0.96
Men	Col %	123	67,58	37	66,07	160	67,23
Women	Row %	59	75,64	19	24,36	78	100,00
Women	Col %	59	32,42	19	33,93	78	32,77
Total	Row %	182	76,47	56	23,53	238	100,00
	Col %	182	100,00	56	100,00	238	100,00
		Early Postoperative Complications
		Present		Absent			Total
below knee	Row %	114	80,85	27	19,15	141	100,00	3,6348	0.05
below knee	Col %	114	63,69	27	48,21	141	60,00
Above knee	Row %	65	69,15	29	30,85	94	100,00
Above knee	Col %	65	36,31	29	51,79	94	40,00
Total	Row %	179	76,17	56	23,83	235	100,00
	Col %	179	100,00	56	100,00	235	100,00
		Early postoperative complications
		Present		Absent			Total
Diabetes mellitus	Row %	105	75,54	34	24,46	139	100,00	0,0009	0.97
Diabetes mellitus	Col %	105	64,42	34	62,96	139	64,06
No diabetes	Row %	58	74,36	20	25,64	78	100,00
No diabetes	Col %	58	35,58	20	37,04	78	35,94
Total	Row %	163	75,12	54	24,88	217	100,00
	Col %	163	100,00	54	100,00	217	100,00

Our study has provided the updated pattern of LEA in Togo based on the data collected between 2010 and 2020 at the main hospital (SOTH). The average number of LEA per year of 33 LEA did not substantially change compared to that previously reported of 32 by Abalo et al. in 2004 [15] Therefore, in the last decades, there was no improvement in the prevention of LEA in our country; this is one of the main findings of our study. In particular, the most remarkable increase of patients who underwent LEA was in the Wound Healing Unit of SOTH (Fig. 1C), especially from 2013 to 2020. For the period of our study, we could have retrieved and retrospectively analysed the folders of 245 out of 363 patients who underwent LEA at SOTH, and this is a bias given the considerable number of missing or incomplete clinical files. However, the information obtained in the complete clinical files accounted for relevant features about the LEA pattern.

Regarding demographic features, the mean age of patients who underwent LEA in our study was 59.6 years. Ouchemi et al. in Tchad found a mean age of 47.0 years in 2016, and Abalo et al. in Togo reported a mean age of 43.1 years in 2011, while Kouassi et al. in Ivory Coast showed a mean age above 40 years in 2016, and Tobome et al. in Benin displayed a mean age of 37.4 years in 2015 [13–15, 19]. The high incidence of underlying cardiovascular disorders, such as diabetes mellitus and hypertension, could be associated with the higher mean age of our series of patients. The sex ratio of our patients’ population was 1.99, aligned with worldwide literature that reports a higher prevalence of LEA in men than in women. Abalo et al. in Togo (2011) and Mendelevich et al. in Argentina found a sex ratio of 2.2; Kouassi et al. in Ivory Coast of 1.72; Tobome et al. in Benin of 3.7; Ouchemi et al. in Tchad of 2.3 [1, 13–15, 19, 20]. Usually, men are more unobservant and involved in trauma than women, leading to complications[21], and this condition could explain the higher proportion of men than women in our study.

In our series, diabetes mellitus was the predominant risk factor of LEA accounting for 64.61% of the patients, confirming the findings of previous studies at SOTH [15, 16, 21]. The LEA complications frequently occur in patients with undertreated or not monitored diabetes mellitus, who often discover their disease with the limb problem stirring LEA; for example, Djibril and al. in Togo reported LEA in 51.62% of patients presenting a diabetic foot [21]. The Doppler-ultrasound imaging of the limbs helps evaluate the vascular status of the patients who underwent LEA when arteriography is not available. Nevertheless, during 2010–2020, the Doppler-ultrasound was not performed for all the patients as it has only recently been available at SOTH. Moreover, in the period of our study, the clinical and socio-economic conditions of the patients did not allow access to healthcare provided by private centres equipped with a Doppler-ultrasound apparatus. Moreover, our patients with diabetes mellitus had a significantly high percentage of white cells anomalies (hyperleukocytosis or leukopenia) as a biological sign of infection. However, there was no significant difference among diabetic and nondiabetic patients in the early postoperative complications of LEA. In our setting, the first goal for diabetic patients was to remove the gangrene and control infection. Therefore, the indication was a major amputation, most in the leg, far from the infection of the foot. As patients with diabetic foot are at risk for proximal limb loss, a below-knee amputation is the best option and should be preferable to serial, overambitious desperate attempts to foot salvage [22, 23]. In our setting, in case of death, patients and relatives request the amputated limbs for burial alone or with the patient’s body as stated by Malay and Ehman [22, 24]; this habit could explain the lack of post-histologic analysis of the amputated limb to highlight possible tumours.

In our study, the mean duration of hospitalization was 36.3 days. In developing countries, the mean hospital stay for LEA was more than two weeks and longer than that in developed countries. This long hospitalization time can be due to postoperative complications linked, in turn, to limited control of patients’ risk factors (diagnosed diabetes and hypertension, tobacco use) in developing countries that lead to amputation [13–15, 19, 25]. We found a mean delay from the indication of LEA to surgery of 6.75 days. This long delay may have been due to the cultural environment of the population in 2010–2020. Some patients were dismissed and returned to the hospital in case of complications after trying possible traditional treatments when LEA was indicated. Other patients refused LEA when a higher level or other limb interventions were needed. Patients accepted the amputation when the limb became very painful or if the patients were in a coma; in this latter case, the family decided on him. This framework of cultural and social conditions is associated with risk factors and causal disease that could explain the higher rate of complications of LEA, such as deaths after surgery [6].

Patients who undergo LEA require an in-hospital multidisciplinary approach that includes improved soft tissue management after trauma, revascularization equipment, and post-surgery physiotherapy. Also, patients with cardiovascular diseases and risk factors of LEA require long-lasting monitoring. Therefore, this study has highlighted the need for an alliance between in-hospital specialists and the territory, in particular with general practitioners and patients’ associations for LEA prevention campaigns about chronic cardiovascular diseases and, in particular, diabetes mellitus. However, the main difficulty in our socio-economic context is a comprehensive screening and the cost of the follow-up that the patients should afford.

Future studies about LEA in Togo should be prospective and focus on the profile of the subset of the diabetic patients undergoing this disabling surgery by association analyses of a specific database involving cardiologists in a multidisciplinary team.

This study has highlighted a remarkable rate of LEA at SOTH in Togo during 2010–2020, which in most cases correlated to a high incidence of chronic cardiovascular diseases, especially diabetes mellitus. Patients with vascular diseases require clinical and imaging monitoring. In the hospital, the patients who must undergo LEA should benefit from an improved surgical approach and post-surgery physiotherapy. Moreover, preventing the complications of diabetes mellitus and sensitizing the population by dedicated educational campaigns could reduce the high rate of LEA in Togo.

CDC

Centers for Disease Control and Prevention

Fig.

Figure

LEA

Lower Extremity Amputation

Standard Deviation

STROBE

Strengthening the reporting of observational studies in epidemiology

SOTH

Sylvanus Olympio Teaching Hospital

Ethics approval and consent to participate

The authors confirm that any patient, service user, or participant (or that person’s parent or legal guardian) included in this clinical trial has given written consent to the inclusion of material pertaining to themselves, that they acknowledge that they cannot be identified via the paper; and that we have fully anonymized them. The composition of the Ethical Committee of SOTH is currently changing according to the scientific guidelines. For this study, we defend the protocol in the staff of Professor Anani Abalo and Professor Ekoue David Dosseh. Professor Abalo is the author of the epidemiologic study about LEA in Togo published ten years ago. Professor Abalo thought an updated analysis of the current status of the disease in the country is mandatory. We include the written declaration of Prof Abalo.

Consent for publication

All the patients provided written consent to be enrolled in the present study and the publication of the relative article.

Availability of data and materials

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

They authors declare that they have no competing interests.

Funding

Not applicable.

Authors’ contribution

TEKK, KSA designed, made the conception of the study and contributed in drafting the article. TEKK, DYEL helped in acquisition, analysis and interpretation of data. TEKK, KSA, SA, AS, AA helped in revising it critically for important intellectual content. All authors read and approved the final manuscript.

Acknowledgments

Not applicable.

Authors’ information

Dr Kouevi-Koko TE is a surgeon of the Burn and Wound Healing Unit, of Faculté des Sciences de la Santé of Université de Lomé (Lomé, Togo);

Dr Amouzou KS is the responsible of the Burn and Wound Healing Unit, of Faculté des Sciences de la Santé of Université de Lomé (Lomé, Togo);

Dr Sogan A is a surgeon of the General Surgery Department and a member of the Human Anatomy Laboratory of Faculté des Sciences de la Santé of Université de Lomé (Lomé, Togo);

Dr Apeti S is geriatrician of the Geriatry department of Faculté des Sciences de la Santé of Université de Lomé (Lomé, Togo);

Dr Dakey YEL is a resident in General Surgery, of Faculté des Sciences de la Santé of Université de Lomé (Lomé, Togo);

Prof Abalo A is the responsible of the traumatology and Orthopedics Department of Faculté des Sciences de la Santé of Université de Lomé (Lomé, Togo).

Mendelevich A, Kramer M, Maiarú M, Modica M, Ostolaza M, Peralta F. Amputations. A five-year epidemiological study in Buenos Aires City. Medicina. 2015;75:384–6.
Kotha VS, Ragothaman K, Walters E, Attininger C, Steinberg JS. Lower Extremity Amputations in At-Risk Patients. Clin Podiatr Med Surg. 2019;36:483–98.
Li L, Reinhardt JD, Zhang X, Pennycott A, Zhao Z, Zeng X, et al. Physical function, pain, quality of life and life satisfaction of amputees from the 2008 Sichuan earthquake: a prospective cohort study. J Rehabil Med. 2015;47:466–71.
Pierce RO Jr, Kernek CB, Ambrose TA. The plight of the traumatic amputee. Orthopedics. 1993;16:793–7.
Sinha R, Van Den Heuvel WJA, Arokiasamy P. Factors affecting quality of life in lower limb amputees. Prosthet Orthot Int. 2011;35:90–6.
Banza LN, Mkandawire NC, Harrison WJ. Amputation surgery in children: an analysis of frequency and cause of early wound problems. Trop Doct. 2009;39:129–32.
Beckles V, McCahill JL, Stebbins J, Mkandawire N, Church JCT, Lavy C. The African disability scooter: efficiency testing in paediatric amputees in Malawi. Disabil Rehabil Assist Technol. 2016;11:247–50.
Buckley CM, O’Farrell A, Canavan RJ, Lynch AD, De La Harpe D, Bradley CP, et al. Trends in the incidence of lower extremity amputations in people with and without diabetes over a five-year period in the Republic of Ireland. PLoS ONE. 2012;7:e41492.
Fortington LV, Rommers GM, Postema K, van Netten JJ, Geertzen JHB, Dijkstra PU. Lower limb amputation in Northern Netherlands: unchanged incidence from 1991–1992 to 2003–2004. Prosthet Orthot Int. 2013;37:305–10.
Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, et al. Lower extremity amputations–A review of global variability in incidence. Diabet Med. 2011;28:1144–53.
Varma P, Stineman MG, Dillingham TR. Epidemiology of limb loss. Phys Med Rehabil Clin N Am. 2014;25:1–8.
Imam B, Miller WC, Finlayson HC, Eng JJ, Jarus T. Incidence of lower limb amputation in Canada. Rev Canadienne Santé Publique. 2017;108:e374-80.
Tobome SR, Hodonou AR, Dadjo AY, Ahononga BC, Haoudou R, Gayito RC at al. Amputations de membre dans un hôpital de zone du Nord- Bénin: à propos de 122 cas. Med Afr Noire 2015;62:165 – 72.
Kouassi KJE, Yao LB, Sery BJLN, M’Bra K, Assere Y, Kodo M. Causes d’amputation majeure de membre. Rev Int Sc Méd. 2016;18:265–8.
Abalo A, Sanon G, Walla A, Akakpo A, Dossim A. Amputations de membres inférieurs: aspects épidémiologiques, facteurs étiologiques et aspects évolutifs. J Rech Sci Univ Lomé (Togo) 2011; Série D, 13:61–7.
Amouzou KS, Kouevi-Koko TE, Domtse KM, Abalo A, Dossim A. Leg ulcers in tertiary public hospital in a sub-Saharan African country (Togo). Wound Healing Southern Afr. 2017;10:20–4.
World Medical Association. World Medical Association Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects. JAMA. 2013;310:2191–4.
van Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP. for the STROBE initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: guidelines for reporting observational studies. Int J Surg. 2014;12:1495–9. https://pubmed.ncbi.nlm.nih.gov/25046131/.
Ouchemi C, Abdoul T, Dionadji M, Chaib MAA, Okim AM, Maide MK. Les amputations majeures des membres à l’hôpital général de référence nationale de N’djamena, Tchad. Eur Sc J. 2016;12:270–80.
Ahmad N, Thomas GN, Gill P, Chan C, ToreLEA F. Lower limb amputation in England: prevalence, regional variation and relationship with revascularisation, deprivation and risk factors. A retrospective review of hospital data. J Royal Society Med. 2014;107:483–9.
Djibril AM, Mossi EK, Djagadou AK, Balaka A, Tchamdja T, Moukaila R. Pied diabétique: aspects épidémiologique, diagnostique, thérapeutique et évolutif à la Clinique Médico-chirurgicale du CHU Sylvanus Olympio de Lomé. Pan Afr Med J [En ligne] 2018 Mai [12/01/2019];4: [5pages].
Malay DS. Editor’s Introduction to Chaplain Ehman’s Comments on Amputation and Limb Burial. The Journal of Foot and Ankle Surgery 2020;59:449.
Van Damme H, Limet R. Amputation in Diabetic Patients. Clin Podiatr Med Surg. 2007;24:569–82.
Ehman JW. Patient Requests for Burial of Amputated Limbs. J Foot Ankle Surg. 2020;59:450–1.
Boffeli TJ, Thompson JC. Partial Foot Amputations for Salvage of the Diabetic Lower Extremity. Clin Podiatr Med Surg. 2014;31:103–26.
Ahmad N, Thomas GN, Chan C, Gill P. Ethnic differences in lower limb revascularization and amputation rates. Implications for the aetiopathology of atherosclerosis? Atherosclerosis. 2014;233:503–7.

PDF

Reviews received at journal
25 Apr, 2022
Reviewers invited by journal
25 Apr, 2022
Editor assigned by journal
18 Apr, 2022
First submitted to journal
06 Apr, 2022

You are reading this latest preprint version

Clinical and therapeutic patterns of lower extremity amputation (LEA) in a tertiary hospital in Togo: a retrospective study

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Background

Methods

Results

General data

Demographic data

Medical and social history data

Clinical, biological, radiological data and LEA causes

Therapeutic data

Discussion

Conclusion

List Of Abbreviations

Declarations

References

Status:

Version 1