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  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, 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 . 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 .
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.