Lower limb amputation causes and risk factors in Al-Qassim region

Abstract:

Background: Amputation is one of the worst things that can happen to a human. It not only
affects the patient but also has significant economic and social consequences. Amputations have
a variety of reasons and etiologies, including diabetic foot and causes that are incurable, such as
trauma. The results of this research can help in the prevention planning in the future. Aims: To
describe the demographics of amputees in Al-Qassim region from the period between January
2017 to January 2022

Methodology: Our research, an observational study, retrospective chart review. We collected

data from file that fits our inclusion criteria ranging from the period between January 2017 to
January 2022 in King Fahd Specialist Hospital, Buraydah. Data collected included age, sex, the
amputated limb, etiology of limb loss, level of amputation, number of amputation and
postoperative complications. We obtained approval from the regional ethical committee of Al-
Qassim health directorate, then we obtained permission and approval to access the files from the
hospital administration. The data was kept confidential, and the information was protected.

Results: the study was conducted over 315 patients. Most of the operations were conducted in
2021, with an increase of 976 % from the numbers in 2017. Among the patients, we found that
66 % of them were males where the Male: Female ration was about 2:1. The mean age of the
patients was 58.3 years old with standard deviation of 13.75. Among the patients, 29.1 % of the
patients were obese while 54.9 % were overweight and only 25.6 % were at normal weight
according to BMI. 91.4% of amputation surgeries were below the knee and 59.4 % of them was
at toes. On the other hand, 8.6 % were above the knee. Considering the etiology of limb loss,
DM was the main cause of limb loss with 77.1% of patients while vascular etiology was found in
13.7% of patients and trauma about 9.2%

Conclusion: We reported that there is an increase in the incidence of lower limb amputation over
the last five years in Qassim region. This study highlights the diabetic foot as the major
indication for lower limb amputation. Increasing the awareness among diabetic patients about
any change in the foot, preventing of infection and controlling of their diabetic could lead to
reduce the incidence of amputation. Considering foot care, specialized well trained medically
podiatry team and educational program might decrease these numbers in the future

Introduction:

Limb amputation is one of the oldest medical procedures, dating back over 2500 years to time of
Hippocrates. There are many causes that can lead to amputation. When limb recovery is impossible, the
limb is dead or dying, viable but non-functional, or threatens the patient’s life, amputation might be the
only option. Limb loss has significant economic, social, and psychological consequences, particularly in
underdeveloped nations where prosthetics are not available. The most common cause of amputation in
United State is the vascular causes [1].

However , in countries like India and Pakistan trauma is the highest cause of amputation [ 2,3]

In developed countries, peripheral vascular disease is the predominant cause of amputation whereas in
developing countries trauma, infections, uncontrolled diabetes, and malignancies are the main reasons
[4–7]. In developed countries, the majority of amputees are older individuals. However in developing
countries, the majority of amputees are young, and the most common reason for limb amputation
differs from hospital to hospital [8–11].

There are a lot of complication after amputation like Superficial incisional infection, deep incisional
infection, death, pneumonia, pulmonary embolism, renal insufficiency, stroke, MI, Deep venous
thrombosis requiring therapy [12]. Phantom limb pain, wound dehiscence, stump osteomyelitis, stump
overgrowth, phantom limb sensation, painful bone spur, hypertrophic scar or severe depression [ 13].

Main limb amputations with high peri-operative mortality are disfiguring [ 14].

In 2005, 1.6 million people were living with a limb amputation. 38 percent of them had an amputation
due to the vascular diseases with diabetes mellitus as a co-morbid diagnosis. By 2050, it is expected that
the number of people living with a limb loss will be more than doubled to 3.6 million. This number
would be reduced by 225,000 if incidence rates of vascular disease could be reduced by 10% [ 1].
Approximately 185,000 amputations occur in the United States each year [ 15]. Amputations are believed
to have occurred in 25–27 people per 100,000 in Germany [16]. In 14 retrospective studies done between
1977-1990 in Saudi Arabia at Riyadh Medical Rehabilitation Centre (RMRC). The average age was 30.5
years, with the males being slightly older than the females. The average age of lower limb amputees was
32.6 years, on the other hand average age of upper limb amputees was 21.8 years. Overall, males
outnumbered females by a ratio of 6.1:1. In the upper limb amputees, males outnumbered girls 5 to 1
while in the lower limb amputees, males outweighed females 6.3 to 1 [ 17].

Different populations have reported varying rates of various pathologies resulting to limb amputation.
For people newly diagnosed with diabetic foot ulcer, understanding the risk factors for amputation can
be helpful , This study aims to determine the statistics for the causes of amputation in Al-Qassim, and to
enumerate them and find out if the development in the health and the efforts made a difference by
comparing them with previous studies. In the study, the results can help in the prevention planning in
the future.

Methodology:

 Study design
Observational study, retrospective chart review was conducted among all patients who
went through lower extremity amputation from January 2017 to January 2022 in Qassim
region.

 Study setting
The study was applied at King Fahd Specialist Hospital, Buraydah Al-Qassim region

 Sample size
Total coverage including files of cases who went through lower extremity amputation
from January 2017 to January 2022, which is 315 cases.
Sampling technique:
We included all the files that fit our inclusion criteria from January 2017 to January 2022.
who went through amputation.
Inclusion Criteria:
All patients who underwent lower extremity amputation at Qassim region.
Exclusion Criteria:
Any patients other than lower extremity amputation.
Patients who went through lower extremity amputation outside Qassim region.
 Data collection method
In this retrospective chart review study, we obtained the needed information through
patient files using data collection form in King Fahd Specialist Hospital, Buraydah. We
looked through all the files of patients that went through amputation and the incidences of
different pathologies leading to that amputation. Data collected included age, sex, the
amputated limb, etiology of limb loss, level of amputation, number of amputation and
postoperative complications.
  Data analysis plan
Data was analyzed using IBM Statistical Package for Social Science SPSS Statistics for
Windows version 22. Descriptive statistics were used to describe the study population
that went through amputation. The mean and standard deviation were calculated for
continuous variables. Frequencies and proportions were calculated for categorical
variables. Chi-square test was used to compare proportions for categorical variables t-
tests were used to compare continuous variables. Nonparametric tests were used for non-
normally distributed variables. P-value ≤ 0.05 was considered as statistically significant.
❖ Ethical considerations
Ethical approval was obtained from Qassim Research Committee.as well as from National
Ethical Committee. Also, an official approval letter from the manager of selected hospital was
obtained after informing about the aim of this study. All participants information was
confidential with no identifiers. Each subject was assigned a study code number instead. Given
the retrospective cohort nature of the study, no harm was introduced to the patients. All data was
collected and was locked in an electronic format.
Result:

In this study, we collected data for all lower limb amputation that occurred at King Fahd
Specialist Hospital, Buraydah Al-Qassim region in the period between Jan 2017 to Jan 2022. In
this period, we were able to define 474 patients who underwent lower limb amputation however,
159 patients were excluded because of not complete data, thus, the study was conducted over
315 patients. Most of the operation was conducted in 2021, with an increase of 976 % from the
numbers at 2017. The chart below (Figure 1) shows that there is huge increase in the number of
lower limb amputation over time.
 Figure 1: The frequency of limb amputation over years be-
tween 2017-2022
127

66

46
37
26
13

2016 2017 2018 2019 2020 2021 2022 2023

Among the patients, we found that 66 % of them were males, where the Male: Female ratio was
about 2:1. The mean age of the patients with 58.3 years old with standard deviation of 13.75
years and ranging between 2 to 91 years old. 67 % of the patients were aged between 51-75 years
old while 21 % were at 26-50 years old group while 9.8 % were older than 75 years old. The
mean weight and height of the patients were 77.1 Kg and 165.8 cm resulting in mean BMI of
28.2 Kg/m2. Among the patients, 29.1 % of the patients were obese while 54.9 % were
overweight and only 25.6 % were at normal weight according to BMI (Table 1).

Table 1: The general characteristics of the patients who underwent lower limb amputation
Count Column N %
Male 208 66.0%
Gender
Female 107 34.0%
< 25 years old 7 2.2%
26-50 66 21.0%
Age cat 51-75 211 67.0%
> 75 31 9.8%
Mean (SD) 58.3 (13.75)
Weight (Kg) Mean (SD) 77.1 (13.5)
Height (cm) Mean (SD) 165.8 (7.4)
BMI cat Underweight 1 0.4%
Normal 66 25.6%
 Overweight 173 54.9%
Obese 75 29.1%
Mean (SD) 28.2 (4.5)
The main comorbidities found in this study among patients who underwent lower limb
amputation is diabetes mellitus (DM) (96.3 %) followed bey hypertension (HTN) with 67.9 %,
gangrene (40.2 %) and ulcers (31.6 %). Smoking was found in 8.2 % of the patients while
neuropathies, ischemic heart disease (IHD), and peripheral artery disease (PAD) were reported in
24.1 %, 26.9 % and 21.4 % respectively (Figure 2). Among diabetic patients, the mean HbA1C
was 10.5 (SD=5.8) where 46.2 % of the patients had HbA1C over the 10 while 53.8 % had
HbA1c below 10.

In this study, we found that 8.6% were above the knee and 91.4 % were below the knee, No
difference was found between frequency of amputation between two feet where 50.5 % were
conducted at the right foot. Moreover, 27 patients were found to have above- knee amputation.
On the other hand, 288 patients had below knee amputation where 59.4 % at toe. Only 11.1% of
the patients had previous surgery on the same limb before. Considering the etiology of limb loss,
DM was the main cause of limb loss with
77.1% of patients while vascular etiology was found in 13.7% of patients and trauma for 9.2%
(Table 2).

Table 2: The general characteristics of the amputation

Count Column N %
Right 159 50.5%
Amputated limb
Left 156 49.5%
Above-knee amputation
Above knee 27 8.6%
(N=27)
Low below knee 69 21.1%
Below-knee amputation High below knee 5 1.6%
(N=288) Metatarsal 27 8.6%
Toe 187 59.4%
Previous surgery on the same Yes 35 11.1%
limb No 280 88.9%
DM 243 77.1%
Etiology of limb loss Trauma 29 9.2%
Vascular 43 13.7%
 In this study, we found that Figure 2: The incidence of other comorbidi-
etiology of limb loss is ties in patients
significantly different among Other 11.70%
Charcot osteoarthropathy 1.40%
genders (P=0.025), DM was the
Ulcers 31.60%
main cause of limb loss in both Gangrene 40.20%
genders however, in higher percent PAD 21.40%
Neuropathy 24.10%
among females (84.1 % vs 73.5% IHD 26.90%
of male) while trauma was the HTN 67.90%
Smoking 8.20%
cause of limb loss in male higher
DM 96.30%
than females (12.5% vs 2.8 %). The
same was found among different age groups, trauma was the only cause of limb loss in patients
under the age of 25 years old and responsible for 22.7 % of injuries at group age of 26-50 years
old. Vascular cause is significantly more present among older patients (16.1% of age group of
51-75 and 12.9 % in those > 75 years compared to 7.6 % in 26-50 age group and 0.0 % in those
younger than 25 years). Incidence of vascular cause increase with increasing of BMI and found
in 14.7 % of obese patients compared with 9.1 % of normal patients however, this difference is
not significant. Moreover, it was found that trauma cause was responsible for 40.0%% of those
who underwent high below knee amputation while amputation of toes is related with diabetes
mellitus (Table 3).

Table 3: The relation between etiology of limb loss and general characteristics of the patients
Etiology of limb loss
DM Trauma Vascular
Coun Cou
Count N% N% N%
t nt
73.5 12.5 13.9
Male 153 26 29
% % % 0.02
Gender
84.1 13.1 5*
Female 90 3 2.8% 14
% %
Age cat 100.0 0.00
< 25 years old 0 0.0% 7 0 0.0%
% 0*
69.7 22.7
26-50 46 15 5 7.6%
% %
51-75 171 81.0 6 2.8% 34 16.1
% %
 83.9 12.9
> 75 26 1 3.2% 4
% %
100.0
Underweight 1 0 0.0% 0 0.0%
%
86.4
Normal 57 3 4.5% 6 9.1%
% 0.91
BMI cat
72.8 12.1 15.0 9
Overweight 126 21 26
% % %
78.7 14.7
Obese 59 5 6.7% 11
% %
66.7 11.1 22.2
Above-knee 18 3 6
% % %
Low below 71.0 13.0 16.0
49 9 11
knee % % %
PROCEDU High below 20.0 40.0 40.0 0.00
1 2 2
RE knee % % % 0*
74.0 11.1 14.9
Metatarsal 20 3 4
% % %
82.9 10.7
Toe 155 12 6.4% 20
% %

Discussion:

The incidence of amputation may differ not only between different countries but also within the same
country based on many factors including degree of modernization, living standards and accessibility to
the medical and surgical care. We aimed in this study to give better picture of the physical and
pathological distribution of amputations in Qassim region of Saudi Arabia. During the last decades, the
incidence of extremity injuries has increased, and these injuries may be caused by a wide spectrum of
mechanisms [18]. In our study, the incidence of amputation increased by 976 % in 2021 compared with
recorded patients in 2017. The same was reported in previous study conducted in Saudi Arabia in 1993
and showed that during the period of 1977-1990, the total number of amputees was 32100 with a general
increase in new cases since 1981 [17]. A retrospective study done in Iran was discussing demographics
including age, sex, the amputated limb, etiology of limb loss and level of amputation showed that the
main age was about forty, the male gender had more amputation than female, the toe is the most
amputated and the most common cause is trauma [14]. A retrospective study done in Saudi Arabia, Riyadh
in Sultan Bin Abdulaziz Humanitarian City showed that the main age is also around forty, the male
gender had more amputation, the vascular cause was more common, and trauma came after and
Transtibial amputations were the most typical followed by trans-femoral amputation [19].

. A meta-analysis study identified that the male sex, a smoking history, a history of foot ulcers,
osteomyelitis, gangrene, a lower body mass index, and a higher white blood cell count are all risk factors
for amputation in DFU patients [20].

In this study, we found a significant male predominance among patients who underwent lower limb
amputation with male/female ration of about 2:1. This is in agreement with the results of many previous
studies regardless of the ethnicity and geographical distribution [ 21,22]. In a previous meta-analysis among
diabetic patients, the authors reported that male had higher risk of 1.3 folds than female to have lower
limb amputation [20]. This predominance of male could be related to the fact that men had more severe
peripheral artery condition, more susceptibility to accidents and injuries and higher smoking rates.
Another explanation for this correlation between male sex and amputation incidence is the fact that male
patients had inferior level of foot care than females as men do not view their feet as often as women and
may visit physician later than women in case of any foot problems [ 20,23]. Moreover, estrogen has an effect
on reducing the vascular pathology [24] which may explain the lower incidence of amputation related to
vascular disease among female and higher incidence of amputation because of trauma among men found
in this study.

In this study, diabetic mellitus was the main cause of amputation which was responsible for 79 % of
amputation of lower limb. Diabetic patients had a 15- fold greater risk for amputation when coupled and
the increasing rate of diabetes mellitus as well as other vascular disease could the reason of the high lower
limb amputation and this would increase the importance of early detection, medical education, reasonable
glycemic control and patients’ compliance among this population [ 18]. Diabetes is responsible for around
40 to 60 percent of all lower extremity amputations, and in some areas, it can be as high as 70 to 90
percent. Heel ulcers are the most dangerous of all the ulcers observed in diabetic patients, and they
frequently result in below-the-knee amputation [25].

Diabetic neuropathy may lead to loss of sensation, deformity and abnormal gait which may be associated
with increased chance of foot pathology that increase the risk for lower limb amputation when coupled
with vascular abnormality associated with DM. Moreover, DM may be associated with increased risk for
ulcers which invites infection especially deep wound and osteomyelitis infection which may lead to
amputation [26]. A history of ulcers increases the risk of another ulcer in diabetic foot ulcer [ 27]. In our
study, 31.6 % of patients who underwent amputation had ulcers. A previous study showed that 20-58 %
of patients develop another ulcer within one year of wound healing [28]. A meta-analysis study showed
that recurrent foot ulcer increase the risk for amputation by 2.23 fold [ 20]. Therefore, patients who
admitted with repeated foot ulcers may be needed to have great attention in order to identify the relevant
factors associated with recurrence of ulcer and adopt effective measures to avoid recurrence of these
ulcers and prevent progression of them which may save patients’ limb.

This study highlights the diabetic foot as the major indication for lower limb amputation which is in
contradistinction to what is reported in developed countries where peripheral vascular disease is the main
cause for limb amputation [8–10]. In a previous study in Nigeria, the authors reported that diabetes was
responsible for amputation in 26 % of cases [29].

In our study, trauma was responsible for 8.9 % of the lower limb amputation represented as the third
cause of amputation after DM and vascular condition. In previous study, trauma was the second observed
cause of amputation in developed countries however, it was the first cause of amputation in developing
countries [14]. In our study, we also found that trauma was the first and only cause of amputation among
patients under the age of 25 years and responsible for 22.7 % of those aged between 26-50 years old. This
result is similar to the results of previous study, which showed that trauma was the most common reason
for amputation in young adults [18]. Moreover, this is in agreement with WHO report that showed that
road traffic accidents are among the top causes of death in those younger than 29 years old [ 31].
Moreover, we found that vascular disease- related amputation incidence was higher in older people. This
is similar to the results of previous studies, that showed that older patients are more likely to have more
than one ailment that may result in amputation because of vascular etiology [ 32].
In conclusion, we reported that there is an increase in the incidence of lower limb amputation over the last
five years in Qassim region. This study highlights the diabetic foot as the major indication for lower limb
amputation. Increasing the awareness among diabetic patients considering the care of foot, noticing any
change in the foot, preventing of infection, and controlling of their diabetic could lead to reduce the
incidence of amputation. Considering foot care, specialized well trained medically podiatry team and
educational program might decrease these numbers in the future.

Our study has many limitations, the sample is small and several needed data were not
documented in the charts, and it was limited to one hospital.

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