Shenaaz I., et al Surg Chron 2019; 24(2): 64-69.
the country is undergoing [1] [2]. Diabetes mellitus and
Outcomes Of Patients Post Major
Lower Limb Amputation At A
Regional Hospital In Durban, South
Africa.
Shenaaz Ismail1,2, Sumayyah Ebrahim1, Bhugwan Singh1
1Department
of Surgery, Nelson R. Mandela School of Medicine, University
of KwaZulu-Natal, Durban, South Africa
2Department of Surgery, Addington Hospital, Durban, South Africa
Abstract
Background: The prevalence of various non-communicable
diseases has steadily increased in South Africa with diabetes
mellitus and peripheral vascular disease now amongst the
foremost causes of morbidity and mortality. Despite major
advances in the treatment of peripheral arterial disease, a
significant proportion of patients require major lower limb
amputation (LLA). Clinical and functional outcomes of
patients undergoing major LLAs in South Africa have been
poorly researched. This study aims to audit major LLA and
mobility of patients post amputation at a regional hospital in
Durban, South Africa.
Methods: A retrospective clinical audit was conducted.
Eligible patients were identified from electronic patient
records over a two-year study period. Data on demographic
characteristics, comorbidities, procedural characteristics
and mobility post LLA were collected.
Results: Median age of patients was 60 years old
(interquartile range [IQR]: 50-69). Predominant ethnicities
were Black African (n=96; 46.6%) and Indian (n=82; 39.8%).
Diabetes mellitus and hypertension were the most prevalent
comorbidities in the study population (74.3% [153/206] and
49.5% [102/206] respectively). Overall inpatient mortality of
patients was 12.1% (25/206). 37.9% (22/58) of patients had
a functional prosthesis, and of these 22.7% (5/22) had an
above knee prosthesis with more below knee amputees
77.3% (17/22) receiving prostheses.
Conclusion: The prevalence of postoperative inpatient
mortality following LLA was high with few patients
ambulating with a functional prosthesis. There is a need to
strengthen existing patient education and primary
healthcare initiatives on diabetic foot care, chronic disease
management and optimization of medical treatment in
order to prevent these morbid complications.
Keywords: Amputation, Lower Extremity, Hospital
Mortality, Prosthesis
Introduction
The prevalence of various non-communicable diseases has
steadily increased in the South African population since
1994, a sign of the current epidemiologic transition which
peripheral arterial disease are now amongst the foremost
causes of morbidity and mortality in South Africa [3] [4].
Advanced disease from delays in diagnosis and suboptimal
medical management of these conditions may sometimes
manifest as complications involving the lower limbs
including diabetic foot sepsis, and critical limb ischaemia [5]
[6]. The diabetic foot can be defined as “infection, ulceration
and/or destruction of deep tissues associated with
neurologic abnormalities and various degrees of peripheral
vascular disease in the lower limb” [7]. While limb salvage
through revascularization remains the first choice for
surgical intervention in afflicted patients, the less desirable
option of amputation might be necessary [8]. Despite the
major advances in the treatment of peripheral arterial
disease a significant proportion of patients require major
lower limb amputation (LLA) [9]. LLA has been defined as “a
complete loss in the transverse anatomical plane of any part
of the lower limb for any reason. A distinction must be made
between “major” and “minor” LLA. A minor amputation is
any amputation which is distal to the ankle joint and a major
amputation is any amputation through or proximal to the
ankle joint”. It is usually done as a lifesaving procedure when
the lower limb is considered to be non-salvageable following
severe injury (e.g. war injury or road traffic accident) or when
there is tissue loss (necrosis) due to vascular occlusive
disease, or to control infection [10].
The prevalence of major lower extremity amputation is
around 120 to 500 per million per year in Western countries,
and this proportion increases with age. Ischaemic
amputation is still quite a common procedure, even in
settings where aggressive revascularization for limb salvage
is advocated, and occurs more often among blacks than
whites in the United States [11]. Approximately 40±60% of
all LLAs are related to diabetes mellitus and in some areas
proportions as high as 70±90% have been described. In the
United States of America (USA) more than 60,000 diabetes-
related amputations are performed annually [7]. However,
data from Africa, specifically Nigeria reported that the most
common indication for amputation was trauma (34.0%) and
diabetic gangrene in 12.3% of cases. Other indications for
LLA were infections (5.1%), neoplasms (14.5%), complication
of traditional bonesetting (23%) and peripheral arterial
disease (2.1%) [12].
The clinical and functional outcomes of patients
undergoing major LLAs in South Africa have been poorly
researched. The question remains, what happens to patients
after they leave hospital? Major LLA remains one of the most
widely performed hospital procedures with a broad
spectrum of causality, of which ischemia is the most
common indication. In a prospective cohort study conducted
in the United Kingdom, the incidence of amputations
secondary to vascular disease was found to increase with
age; 13% in patients <55 years of age increasing to 38% in
those aged over 75 years. Between 27% and 61% of vascular
patients who underwent amputation surgery were diabetic
[9]. Limited research is available about long-term outcomes
following major lower limb amputations. Common causes of
death were infection and cardiovascular events with
1

subsequent multi-system organ failure. Thus, a
multidisciplinary team approach is required to manage these
conditions thereby decreasing the risk of death from other
comorbidities [13].
In general for those with non-traumatic amputations
there is a decline in health status following the procedure
with five year mortality rate as high as 77% [14].
Management should be directed towards preserving
functional status of individuals and minimizing long term
care and institutionalization. Maintenance of ambulation; be
it limb salvage or prosthesis is a key determinant associated
with maintaining independence of individuals. The
procedure for attaining prosthesis in South Africa is a
complicated one, with lack of resources and adequately
trained prosthetic staff being important factors to consider
[14].
Ambulation after major lower limb amputation has not
been well researched. Studies are required to evaluate the
various preoperative characteristics and postoperative
functional outcomes to design management
recommendations for patients requiring major LLA [9].
“Patients with limited preoperative ambulation, age >70,
dementia, end-stage renal disease (ESRD) and advanced
coronary artery disease (CAD) perform poorly and should be
categorized with patients who are bedridden”. These
patients are best managed with a palliative above knee
amputation (AKA). Younger, healthy patients with a below
knee amputation (BKA) have good functional outcomes
comparable to those who have had lower limb
revascularization [15], [16], [13]. This study aims to audit
major LLA and mobility of patients post major LLA at a
regional hospital in Durban, South Africa.
Patients and methods
Study design, population, and setting
A retrospective clinical audit was conducted. All adult
patients (≥18 years old) who underwent primary, non-
traumatic unilateral lower limb amputations (LLA) between
1st January 2011 and 31st December 2012 at the Addington
Hospital in Durban, South Africa were included in the study.
We specifically studied primary unilateral AKA, BKA and
through knee amputation (TKA) as these LLA procedures are
the most commonly performed and have been associated
with high postoperative mortality in other settings [17] [18].
Addington Hospital is a 571-bed regional hospital and offers
various general specialist services, including surgical
services. Generalist surgeons performed the amputations
according to standardized surgical protocols at Addington
Hospital.
Data collection
Eligible patients were identified from theatre logs and
electronic patient records at the hospital over the two-year
study period. Data on demographic characteristics (age,
gender, ethnicity); preoperative comorbidities (diabetes
mellitus, hypertension, coronary artery disease, chronic
kidney disease and occlusive vascular disease); and
procedural characteristics (urgency of procedure, level of
amputation, duration of surgery and duration of hospital
stay) were collected for each patient. Where additional
Shenaaz I., et al Surg Chron 2019; 24(2): 64-69.
information was required (regarding receipt of social grants
and prosthesis and methods of ambulation post LLA),
patients were contacted telephonically and responses
recorded. The study outcomes were determined from
patient discharge summaries. Data was entered and
managed using the Microsoft Excel programme.
Statistical Analyses
Baseline variables were summarized as follows: percentages
for categorical variables, and mean or median for continuous
variables. The age variable was categorized as follows: <20
years, 20-24 years, 25-49 and ≥50 years. Due to the small
sample size (n=206) and lack of an appropriate comparison
group, the study was not powered to test for statistical
associations and only descriptive statistics are presented as
per the study protocol. Data were analyzed with SAS
statistical package version 9.4 (SAS Institute, Inc., Cary).
Ethical approval
The study was approved by the Biomedical Research Ethics
Committee of the University of KwaZulu-Natal, South Africa
(Protocol BE501/15).
Results
Demographic characteristics
The study population comprised 206 patients (Table 1). The
median age of patients was 60 years old (interquartile range
[IQR]: 50-69 years). Just over half (n=105; 50.9%) of patients
were female. The predominant ethnicities in the study
population were Black African (n=96; 46.6%) and Indian
(n=82; 39.8%), with whites comprising a relatively small
proportion of the study population (n=10; 4.9%). Most
patients had emergency (n=191; 92.7%), guillotine BKAs
(n=157; 76.2%). Twelve patients had elective procedures
namely revision of the amputation stump, the primary
procedure being a guillotine amputation done prior to the
period of data collection. Information on time to revision of
the stump from initial procedure was not available from
hospital records analyzed.
Comorbidities were documented as per Figure 1 below.
Diabetes mellitus and hypertension were the most prevalent
comorbidities in the study population (prevalence of 74.3%
[153/206] and 49.5% [102/206] respectively). 33.5%
(69/206) had both diabetes mellitus and hypertension.
Among Black African patients: prevalence of hypertension
was 44.8% (43/96) and diabetes mellitus was 68.8% (66/96).
Prevalence of hypertension and diabetes mellitus among
Indian patients was higher at 57.3% (47/82) and 82.9%
(68/82) respectively. Among White patients, prevalence of
hypertension was 50.0% (5/10) and diabetes mellitus 80.0%
(8/10).
2
 Shenaaz I., et al Surg Chron 2019; 24(2): 64-69.

Table 1: Baseline Demographic Characteristics (N=206)

Category Distribution
Age in years <20 1.5% (3/206)
20-24 1.5% (3/206)
25-49 20.8% (43/206)
≥ 50 72.8% (150/206)
Missing information 3.4% (7/206)
Gender Female 50.9% (105/206)
Male 48.1% (99/206)
Missing information 1.0% (2/206)
Ethnicity Black 46.6% (96/206)
White 4.9% (10/206)
Indian 39.8% (82/206) Figure 2: Distribution of duration of procedure by amputation
Missing information 8.7% (18/206) type. AKA: above knee amputation, BKA: below knee
Type of Above knee 23.3% (48/206) amputation and TKA: through knee amputation
amputation amputation
Below knee 76.2% (157/206) Duration of Hospital Stay
amputation
Through knee 0.5% (1/206)
The overall length of hospital stay had a median of 13 days
amputation (IQR: 10-15 days). The median duration of hospital stay for
Type of procedure Emergency 92.7% (191/206) patients who underwent AKA and BKA was similar: 13 days
Elective (Revision of 5.8% (12/206) (IQR: 8-15 days) and 13 days (IQR: 10-15 days) respectively.
the stump) Only one patient had a TKA and length of hospital stay was
Missing information 1.5% (3/206)
21 days (Figure 3).

Chronic Kidney Disease 12

Peripheral Vascular… 34

Coronary artery Disease 9

Hypertension 102

Diabetes Mellitus 153

0 50 100 150 200

Figure 1: Distribution of Comorbidities

Outcomes post amputation: Perioperative Mortality
The overall inpatient mortality of patients who underwent
any level of amputation was 12.1% (25/206). Of these,
68.0% (17/25) were female and 32.0% (8/25) were male.
Some of the documented causes of death were due to sepsis
(3/25), renal failure (2/25), pneumonia (2/25), stroke (1/25)
and myocardial infarction (2/25). Of the total number of
AKAs, 25.0% (12/48) demised vs. 8.3% (13/157) of patients
who underwent BKA. Of the 191 emergency procedures
conducted, 24 patients demised (12.6%). There was no
information in the electronic medical records regarding
morbidity related to the amputation itself, such as bleeding
and haematoma formation, wound infection and delayed
wound healing, thus these are not reported in the study.
Duration of procedure
The overall procedure time irrespective of the level of
amputation had a median of 45 minutes (IQR: 30-
35minutes). The median duration of an AKA was longer at 55
minutes (IQR: 47.5-72.5 minutes). The median duration of a
BKA was 40 minutes (IQR: 25-50 minutes). Only one patient
had a TKA which took 80 minutes to complete (Figure 2).
Figure 3: Distribution of duration of hospital stay by amputation
type
Telephonic interviews
Patients were contacted after discharge to ascertain
postoperative outcomes. Figure 4 refers; 206 patients
underwent LLAs: of these, only 80 patients had telephone
numbers recorded accurately on the electronic patient
records. 72.5% (58/80) of patients were contacted and
interviewed and 22 patients were not contactable for
various reasons including phone number changes and the
number being unavailable. Information retrieved from these
telephonic interviews were the patient’s current method of
ambulation shown in Figure 5: either crutches, wheelchair or
the use and receipt of a prosthesis. 37.9% (22/58) patients
had a functional prosthesis, and of these 22.7% (5/22) had
an above knee prosthesis with more below knee amputees
77.3% (17/22) having functional prostheses. Median age of
AKA prosthesis recipients was 30 years (IQR: 28-39 years)
and of BKA prosthesis recipients was 38 years (IQR: 31-48
years). Of the 44 patients who had received either a
wheelchair or a prosthesis, the median time to receipt of
these was 12 months (IQR: 4-20 months). 94.8% (55/58)
patients contacted had access to a valid social grant.
3

Adult patients who
underwent major LLA in the
study period (n=206)
Patients with telephone
Patients with accurate
numbers not recorded/not
telephone numbers
available on electronic
recorded (n=80)
patient records (n=126)
Patients contacted & Patients not
interviewed (n=58) contactable (n=22)
Figure 4: Summary of patients contacted and interviewed
(N=206)
Figure 5: Method of ambulation (N=206)
Discussion
Our findings reflect those of a predominantly Black African
population with an associated high burden of comorbidities
such as diabetes mellitus and hypertension. As expected,
among the Indian patients in the study, prevalence of
hypertension and diabetes mellitus was high. These findings
are in keeping with a prior description of cardiac risk factors
among South African vascular surgery patients [19]. Globally,
diabetes mellitus is a leading cause of all non-traumatic LLAs,
with the risk of LLA being 15-46 times higher in patients with
diabetes mellitus compared to non-diabetics. Known risk
factors for amputation of the diabetic foot are “peripheral
neuropathy, structural foot deformity, ulceration, infection
and peripheral vascular disease”. The risk of foot lesions in
diabetic African and Indian patients was high compared to
patients from developed/first world settings due to
progressive foot infection and delayed treatment [13]. The
AKA: BKA ratio in our study was approximately 1:3. This ratio
has been reported as 1:1 in Britain [20]. We report a high
prevalence of inpatient mortality following LLA. However,
this estimate lies within the range of 4-20% in first world
settings [21]. Data on mortality following LLA among diabetic
patients in developing countries is sparse. In a case-control
study from Barbados, the 1-year and 5-year survival rates
was high at 69% and 44% respectively among diabetic
patients who had LLAs compared to control subjects who
were diabetic without LLA: 1-year and 5-year survival rates
Shenaaz I., et al Surg Chron 2019; 24(2): 64-69.
of 97 and 82% respectively in this group [22]. In a Nigerian
study, that reviewed indications and mortality post
extremity amputation; the primary indication for the LLA was
trauma, hospital mortality post amputation was 10.9% due
to late presentation of patients with sepsis and anaemia [12].
Traditionally, AKA has been found to be associated with
a higher postoperative mortality rate when compared with
BKA [23]. This may be due to the presence of generalized
atherosclerotic disease, ischaemia and poorer overall clinical
state of patients who require a primary AKA compared to
those requiring BKA [23]. In our study 25% of patients with
AKAs demised vs. 8.2% who had BKAs. Jones et al, have
proposed that algorithms be developed and used to
determine amputation level just before surgery as decisions
regarding the level of amputation are usually determined by
surgeon expertise and preference [24]. In this study,
decisions regarding the level of LLA were mainly due to the
degree of sepsis and/or tissue necrosis. We found that all
patients who underwent elective surgery (revision
amputation) survived; this is due to operative conditions
being more favorable when these procedures are carried out
and this is in keeping with recommendations by Scott &
Bowrey et al [25].
We had found that there is a difference in the duration
of the procedure depending on the level of amputation
performed. The median time for performing an AKA was 55
minutes and BKA was 40 minutes indicating that it takes
longer to perform an AKA. Possible reasons for this are a
large amount of muscle bulk to incise, as well as a longer
length of time to achieve haemostasis.
The median duration of hospital stay for patients who
underwent AKA and BKA were both 13 days. This finding is
unexpected; patients who have AKAs traditionally have a
longer length of hospital stay due to difficulty in ambulation,
wound complications and various morbidities associated
with having a higher level of amputation. A likely reason for
our findings would be that most patients were transferred to
a step-down facility for further wound care and
rehabilitation, thus time spent at this facility would need to
be factored in to the duration of overall hospital stay. This
data was not available from the hospital records.
The postoperative mobility and independence of patients
post major LLA is important. The aim of rehabilitation of
amputees is to restore them to the best possible functional
status. In the USA, average rehabilitation time post-surgery
was reduced from 128 to 31 days in patients who had
immediate postoperative lower limb prosthetic application.
In contrast, in West Africa and likely other developing
countries with limited resources, many amputees never
receive prosthesis following major LLA as they mobilize
permanently on crutches [26]. Only 10% of all patients in the
study had a functional prosthesis and or a wheelchair; with a
similar proportion (10.5%) being bedridden. This suggests
that very few of our patients are ambulating post
amputation with a functional prosthesis. Of note, the
majority of the prostheses were below knee. Patients with a
BKA are easier to rehabilitate with a prosthesis and this is
due to decreased energy expenditure, less morbidity and
having a functional knee joint compared to patients with an
4

AKA [27]. We also found that patients who received a
prosthesis following AKA were younger compared to BKA
prosthesis recipients suggesting that these patients were
more likely to have a better overall functional state and
therefore able to cope with an above knee prosthesis.
Our study had strengths and limitations. A strength of
this study is that we present data from a South African
setting. This is important as findings from developing
countries and African settings are not well described in the
literature. A limitation of this study is that it was a
retrospective study from a single regional facility, with
limited numbers of patients. We could not explore findings
related to wound healing and morbidity related to LLA as this
data was not available from the records used. Similarly, data
on the clinical assessment of patients such as preoperative
medications used, Human Immunodeficiency Virus (HIV)
status, smoking, clinical examination findings related to the
level of peripheral vascular disease, and anaesthetic-related
factors were not available. Furthermore, we did not have
information on whether or not patients had undergone
reconstructive vascular operations prior to amputation. This
reflects challenges in using hospital records for data
collection and perhaps the need for prospective,
comprehensive data collection methods for future similar
studies. Another limitation is the lack of access to accurate
patient telephone records, and the need to improve the
current system to allow reliable patient follow-up. It is an
integral part of medicine to ensure that patients are followed
up timeously, therefore improving systems for patient
follow-up will significantly improve our patient care.
Conclusion
The prevalence of postoperative inpatient mortality
following LLA in our study was high, but within the estimated
range reported in overseas settings, suggesting the need for
better risk communication and risk stratification in patients
undergoing LLA at South African hospitals. Also, there is a
need to strengthen existing patient education and primary
healthcare initiatives on diabetic foot care, chronic disease
management and optimization of medical treatment in
order to prevent these morbid complications. Accurate
patient record keeping is of paramount importance to
ensure adequate patient follow-up and continuity of care.
We recommend additional research be conducted, with
more sites and larger patient numbers to confirm our
findings and address the study limitations we have
identified.
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 Shenaaz I., et al Surg Chron 2019; 24(2): 64-69.

Corresponding author:
Dr. Shenaaz Ismail
Department of Surgery, Nelson R. Mandela School of Medicine, University
of KwaZulu-Natal, 719 Umbilo Road, Congella, South Africa, 4013
Email: shenaaz.b.ismail@gmail.com
Telephone: +27 712811401