Eur J Vasc Endovasc Surg (xxxx) xxx, xxx

Epidemiology of Non-Traumatic Lower Extremities Amputations in West

Africa: Nationwide Data from Togo
Martin K. Tchankoni a,b,c, Roméo M. Togan b, Grégoire A. Abalo d, Latame K. Adoli b, Atchi Walla e, David E. Dosseh f, Boyodi Tchangaï g,
Pierre-Marie Preux a, Victor Aboyans a,h,*, Didier K. Ekouevi b,c
a
Inserm U1094, IRD U270, Univ. Limoges, CHU Limoges, EpiMaCT - Epidemiology of Chronic Diseases In Tropical Zone, Institute of Epidemiology and Tropical
Neurology, Omega Health, Limoges, France
b
Public Health Department, Faculty of Health Sciences, University of Lomé, Togo
c
African Research Centre in Epidemiology and Public Health (CARESP), Lomé, Togo
d
Traumatology-Orthopedics Department of the Sylvanus Olympio University Hospital (CHU) of Lomé, Faculty of Health Sciences of the University of Lomé, Lomé, Togo
e
Department of Orthopaedics, Campus Medical Teaching Hospital, Lomé, Togo
f
Department of General Surgery, Faculty of Health Sciences, University of Lomé, Lomé, Togo
g
Department of Visceral Surgery, University Teaching Hospital, Lomé, Togo
h
Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France

WHAT THIS PAPER ADDS

This is the first report to provide nationwide and contemporary data on the incidence of non-traumatic lower
limb amputation in the general population in Togo, a West African country. An average annual incidence of 8.5/
million inhabitants was found between 2016 and 2021, more frequent among men than women. These were
mostly (> 90%) major amputations, with a 48 fold increased risk in those with diabetes. Less than 20% of those
had any vascular imaging before amputation. It highlights the gap in the early diagnosis, management, and
follow up of patients with conditions and diseases leading to limb amputations in this country.

Objective: Non-traumatic lower limb amputation (NT-LLA) has consequences at individual and public health
levels. Population based studies in sub-Saharan Africa are scarce and often related to single centre series. This
study aimed to estimate the incidence of NT-LLA (minor and major) and to describe epidemiological, clinical,
and prognostic aspects in Togo.
Methods: This was a population based observational study conducted among all patients who underwent NT-
LLA. Traumatic amputations were excluded. Sociodemographic, clinical, and work up data were collected from
clinical files in any Togolese health centre from 1 January 2016 to 31 December 2021. Incidence rates were
adjusted for age.
Results: Over the six year period, 352 patients (59% males) underwent NT-LLA (mean
standard deviation age
60
15.7 years). The average age adjusted incidence rate of NT-LLA was 8.5 per million/year (95% confidence
interval [CI] 7.6 e 9.4). Men were 1.7 times more likely to undergo a NT-LLA than women. The relative risk of NT-
LLA was 48 times higher in patients with diabetes than in patients without diabetes. Around 61.0% of the NT-LLAs
occurred within the 50 e 74 age group and 54.3% had diabetes mellitus. Among amputees, 54.5% had a
diagnosis of peripheral artery disease (PAD) and 52.8% had diabetic ulcers, with co-existence of several
factors. Less than 5% of participants had a history of smoking tobacco. Average length of hospital stay was 12
days. The in hospital mortality rate was 8.8% (9.0% for major, 6.7% for minor amputations). Only 18.2% had
duplex ultrasound performed and 1.7% angiography prior to amputation. No patient underwent vascular
intervention prior to amputation.
Conclusion: This is the first study to report nationwide and contemporary epidemiological data on NT-LLAs in
West Africa, highlighting several specificities. Large scale interventions are needed to ameliorate the care of
diabetes and PAD and improve facilities for optimal management of patients at risk of amputation in Africa.

Keywords: Diabetes, Epidemiology, Incidence, Limb amputation, Peripheral artery disease, Sub-Saharan Africa
Article history: Received 26 May 2023, Accepted 30 January 2024, Available online XXX
Ó 2024 Published by Elsevier B.V. on behalf of European Society for Vascular Surgery.

* Corresponding author. Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France.

E-mail address: vaboyans@live.fr (Victor Aboyans).
@AboyansV
1078-5884/Ó 2024 Published by Elsevier B.V. on behalf of European Society for Vascular Surgery.
https://doi.org/10.1016/j.ejvs.2024.01.088

Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
2 Martin K. Tchankoni et al.
INTRODUCTION
Peripheral artery disease (PAD) affects more than 230
million people worldwide, with most of them living in low
and middle income countries (LMICs).1e3 The burden of
PAD in sub-Saharan Africa (SSA) is increasing, reaching that
of high income countries, even exceeding a prevalence of
50% in some high risk populations.4 Some studies suggest
that PAD is increasing more rapidly than other forms of
cardiovascular disease in SSA.5e7
Most epidemiological studies on PAD in LMICs are per-
formed based on a low ankle brachial index,2 and para-
doxically data on the most severe modes of presentation
are very scarce in those countries.
It is well known that many of those with an abnormal ABI
can remain asymptomatic throughout their lifetime. At the
other end of the disease spectrum, patients with tissue
lesions often do not undergo ABI measurements due to
pain and technical issues such logistics and training,8
although they present the most severe form of the dis-
ease. Lower limb amputation (LLA) is the last available form
of care when other interventions, especially revascularisa-
tion and wound care fail. Additionally, the burden of dia-
betes and its complications is increasing in LMICs.9 Recent
data suggest a high incidence of diabetes related LLA in
Africa.10
Little is known about the epidemiology of non-traumatic
LLA (NT-LLA) in Africa. Data are sparse, and mostly come
from single centre surgical series.11e14 Therefore, this study
aimed to estimate the incidence of NT-LLA in the general
population and to describe its epidemiological, clinical, and
prognostic aspects in Togo.
MATERIALS AND METHODS
Study design
This was a retrospective study on all NT-LLAs performed in
Togo between 1 January 2016 and 31 December 2021. First,
all nine public and private health centres where amputa-
tions are performed were identified through a national
survey. In each hospital registry the patients coded for
amputations were identified and each file individually
reviewed.
Study setting
Togo has a population of 8.8 million, covering 57 000 km2
with an average density of 149 inhabitants/km2, with 57.2%
of the population being rural. Life expectancy was esti-
mated to be 62.1 years in 2020.15 In 2021, the population
prevalence of hypertension, tobacco use, and diabetes was
27.4%, 5%, and 4.9%, respectively.16
Togo’s health system is organised into three healthcare
level facilities from top to bottom as follows: (1) the central
(national) level, which includes the office of the Minister of
Health, national guidelines, and the three university hos-
pitals; (2) the intermediate (regional) level, including six
regional hospitals; and (3) the peripheral (district) level,
Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
which includes district hospitals, maternal and child pro-
tection centres, and peripheral care units.
Data collection
Data were retrieved from 23 April to 5 August 2022 from
the clinical files of patients with amputations. Data were
collected using an electronic questionnaire developed with
Kobo toolbox software. Demographic and clinical data were
anonymised, and daily monitoring was performed to ensure
the quality and completeness of the collected data. When
more than one LLA for a single limb was found in the record
for a single hospitalisation for a patient, only the highest
level was counted.
Study population
All patients who underwent minor or major amputation of a
lower limb between 2016 and 2021 in any of the health
facilities of Togo were included, regardless of the type of
healthcare facility (private or public), and who had a clinical
file containing at least sociodemographic characteristics and
clinical and work up data relating to LLA. Patients with upper
limb amputation or LLA for traumatic causes were excluded.
Variable definitions
NT-LLA refers to LLA from all causes, excluding amputations
due to trauma. Minor amputation was defined as any
procedure that resulted in amputation below the ankle,
including the forefoot or toe. Major amputation was
defined as any procedure resulting in amputation at or
above the ankle. Secondarily major amputations were
defined as above, through and below the knee.
The following variables were collected from the clinical
files: (1) sociodemographic characteristics including age,
sex, level of education, employment status, and marital
status; (2) risk factors and comorbidities including history of
diabetes, hypertension, tobacco smoking, and excessive
alcohol consumption; (3) clinical data including amputation
indication and aetiology (amputation causes), and ampu-
tation level (minor or major); (4) work up data including
vascular imaging such as duplex ultrasound or computed
tomography angiography (CTA); and (5) the prognostic as-
pects of the amputation patients during their hospital-
isation period (new amputation, discharge, death).
The manuscript was drafted in accordance with the
STROBE guidelines.17
Statistical analysis
The descriptive analysis results were presented as the mean

standard deviation for quantitative variables, and fre-
quencies and proportions for categorical variables.
Comparative analysis was carried out using Pearson’s chi
square or Fisher’s exact tests for categorical variables, and
Student’s t test for quantitative variables. Some records
contained incomplete information, notably sociodemo-
graphic characteristics, and biological parameters (haemo-
globin, white cell count, etc.); multiple imputation methods
Epidemiology of Non-Traumatic Lower Extremities Amputations in Togo 3

(multivariable imputation by chained equations [MICE]) were
used to impute the missing data.17 For biological parameters,
the missing data were such that imputation was not possible.
These data were not used in the results. Age specific national
incidence rates were calculated and adjusted using the direct
age adjustment method. The standard population was the
population of Togo from the general census of population and
housing census in 2010. Data on the annual prevalence of
diabetes in Togo were extracted from the International Dia-
betes Federation database.18
A ManneKendall trend test was used to determine any
trend for NT-LLA incidence over time. The relative risks of
NT-LLA by sex, as well as those with diabetes vs. those
without, were calculated with their 95% confidence interval
(CI). All analyses were performed using the R statistical
package (version 4.2.3, Vienna, Austria) and p < .050 was
considered statistically significant.
RESULTS
Over the six year period, a total of 415 patients underwent
NT-LLA. Among those, 63 (15.2%) cases were due to trauma
and were thus excluded from the analyses, leaving 352
patients with NT-LLA. Figure 1 shows the geographic dis-
tribution of NT-LLA cases in Togo according to health cen-
tres. Because of referrals and or lack of surgeons in certain
health facilities in the north of the country, the place of
amputation may not be the patient’s place of residence. The
majority of NT-LLAs (37.8%) were performed in Lomé, the
capital city with the most concentrated population.
According to amputation level, 91.5% (n ¼ 322) were
major amputations: 61.6% below the knee, 28.1% above the
knee, and 1.7% through the knee (Fig. 2).
Patients’ sociodemographic and clinical characteristics
Approximately 60.0% amputees were male. Patients ranged
in age from 21 to 80 years, with an average age of 60
16
years and a median age of 60 years (interquartile range 50,
70). About 40% of the NT-LLAs occurred in the 50 e 64 age
group. The average age differed by sex (men: 58
15 years,
women: 64
16 year; p < .001). Diabetes mellitus was the
most common comorbidity among amputees (54.3%, n ¼
191) followed by hypertension (23.9%, n ¼ 84). Less than
5% had a tobacco smoking history. Other sociodemographic
and clinical characteristics are presented in Table 1 (by sex)
and in Table 2 (by amputation level).
Among NT-LLAs cases, 54.5% of amputees had PAD,
52.8% had diabetic ulcers, 40.3% had an infection and, 2.0%
had malignant tumours (Fig. 3).
Lower limb amputation incidence
The incidence of NT-LLA increased from 7.4 in 2016 to 12.0
per million/year in 2021, with more than three quarters

5
H1
Savanes

35
H2

Kara 54
H3

2
H4

Centrale
9
H5

Plateaux
30
H6
Maritime 0 750 1 500 km

Grand Lomé 78
H7
6
133 H8
H9

Figure 1. Geographic distribution (number of amputations performed in health centre) of non-traumatic lower
limb amputation cases in Togo, 2016e2021 (n ¼ 352). H1 ¼ RHC Dapaong; H2 ¼ THC Kara; H3 ¼ RHC Kara;
H4 ¼ RHC Sokodé; H5 ¼ RHC Atakpamé; H6 ¼ PHC Kpalimé; H7 ¼ Saint-Jean de Dieu Hospital; H8 ¼ Lomé
Surgical Clinic; H9 ¼ THC Sylvanus Olympio; PHC ¼ Prefectural Hospital Centre; RHC ¼ Regional Hospital
Centre; THC ¼ Teaching/Tertiary Hospital Centre.

Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
4 Martin K. Tchankoni et al.

8.5% Minor
rate (178.9 per million/year). The average age adjusted
(below the ankle) incidence of NT-LLA in Togo between 2016 and 2021 was 8.5
per million/year (95% CI 7.6 e 9.4) (Table 3). The average
28.1% Major age adjusted incidence was 10.1 per million/year among
(above the knee)
males, and 6.0 per million/year among females. Men were
1.7 times more likely to experience NT-LLA than women
(Fig. 4A). Furthermore, the relative risk of NT-LLA was 48
times higher among people with diabetes than among those
without (164.0 vs. 3.4, per million/year) (Fig. 4B). Overall,
1.7% Major no significant change in incidence was observed (p ¼ .060).
(through the knee)
The average rate was 6.5 and 0.6 per million/year for major
and minor amputation, respectively (Fig. 5).
61.6% Major
(below the knee) Pre-operative work up and evolution after amputation
Figure 2. Non-traumatic lower limb amputation level of patients Only 18.2% (64/352) of patients had a vascular duplex
in Togo, 2016e2021 (n ¼ 352). ultrasound (VDU) and 1.7% (6/352) had a CTA prior to
amputation. These proportions did not differ by sex:
16.6% in women vs. 19.3% in men (p ¼ .51) for VDU, and
1.4% in women vs. 1.9% in men (p ¼ 0.90) for CTA. The
occurring among elderly people ( 75 years) and an average length of hospital stay was 12 days. The in hos-
average rate of 8.5 per million/year. Among age categories, pital mortality rate was 8.8%: this rate was 9.0% for major
those aged 0 e 49 years had the lowest age specific NT-LLA amputations, and 6.7% for minor amputations (Table 4).
incidence (2.1 per million/year during the study period), No patient underwent vascular intervention prior to
while those over age 75 years had the highest age specific amputation.

Table 1. Sociodemographic and clinical characteristics of Togolese amputation patients by sex, 2016e2021, n [ 352

Characteristics Overall (n [ 352) Male (n [ 207) Female (n [ 145) p value

Age e y 60
16 58
15 64
16 <.001
Age range e y <.001
< 50 75 (21.3) 51 (24.6) 24 (16.5)
50e64 139 (39.5) 90 (43.5) 49 (33.8)
65e74 75 (21.3) 42 (20.3) 33 (22.8)
75þ 63 (17.9) 24 (11.6) 39 (26.9)
Education level <.001
No formal education 198 (56.2) 88 (42.5) 110 (75.9)
Primary 72 (20.5) 48 (23.2) 24 (16.6)
Secondary 63 (17.9) 56 (27.1) 7 (4.8)
Higher 19 (5.4) 15 (7.2) 4 (2.7)
Professional status <.001
Private sector employee 20 (5.7) 16 (7.7) 4 (2.8)
Civil servant, student, or teacher 90 (25.6) 56 (27.1) 34 (23.4)
Informal sector* 114 (32.4) 61 (29.5) 53 (36.6)
Retired 64 (18.2) 46 (22.2) 18 (12.4)
Unemployed 26 (7.4) 7 (3.4) 19 (13.1)
Not indicated 38 (10.8) 21 (10.1) 17 (11.7)
Marital status <.001
Married 291 (82.7) 181 (87.4) 110 (75.9)
Single or Divorced 16 (4.5) 11 (5.3) 5 (3.4)
Widowed 45 (12.8) 15 (7.3) 30 (20.7)
History of disease, health, and lifestyle
Diabetes mellitus 191 (54.3) 109 (52.7) 82 (56.6) .47
Hypertension 84 (23.9) 46 (22.2) 38 (26.2) .38
Excessive alcohol consumption 66 (18.8) 50 (24.2) 16 (11.0) <.001
Tobacco smoking 15 (4.3) 14 (6.8) 1 (0.7) .005
Amputation level .36
Major 322 (91.5) 187 (90.3) 135 (93.1)
Minor 30 (8.5) 20 (9.7) 10 (6.9)
Data are presented as n (%) or mean
standard deviation.
* Informal sector: driver, shopkeeper, motorcycle cab driver.

Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
Epidemiology of Non-Traumatic Lower Extremities Amputations in Togo 5

study, the risk of amputation was 48 times higher among

Table 2. Sociodemographic and clinical characteristics of
Togolese amputated patients by level of limb amputation,
people with diabetes than among people without diabetes.
2016e2021, n [ 352 An increase was observed from 2016 to 2019 and then a
decrease to 2021 (from 123.3 in 2016 to 198.3 in 2021
Characteristics Major Minor p among people with diabetes). This finding is in accordance
(n [ 322) (n [ 30) value with those reported elsewhere in Africa: in Ghana, the
Age e y 60
16 59
17 .22 average incidence rate of diabetes related NT-LLAs
Age range e y .52 increased from 600 per million follow up years in 2010 to
< 50 67 (20.8) 8 (26.7) 10 900 per million follow up years in 2015,10 and in South
50e64 125 (38.8) 14 (46.7)
65e74 71 (22.0) 4 (13.3)
Africa there was an increase in the rates of diabetes related
75þ 59 (18.3) 4 (13.3) NT-LLAs between 2013 and 2017.20 This may be explained
Education level .013 by the fact that in individuals with diabetes, PAD or neu-
No formal education 183 (56.8) 15 (50.0) ropathy can cause gangrene and ulceration of the foot
Primary 61 (18.9) 11 (36.7) leading to NT-LLA. This could be secondarily explained by
Secondary 62 (19.3) 1 (3.3)
Higher 16 (5.0) 3 (10.0)
the fact that in Togo or in developing countries in general,
Professional status <.001 patients do not have access to a multidisciplinary podiatry
Private sector employee 18 (5.6) 2 (6.6) team and that detection of foot problems is very often
Civil servant, student, or 82 (25.4) 8 (26.7) delayed. Additionally, in most LMICs, lack of financial re-
teacher sources, high patient workload, lack of adequate sanitary
Informal sector* 106 (32.9) 8 (26.7)
Retired 57 (17.7) 7 (23.3)
facilities, and appropriate staff in hospitals were identified
Unemployed 21 (6.5) 5 (16.7) as major factors.21 Altogether, these can also explain the
Not indicated 38 (11.8) 0 (0.0) very high proportion of major amputations. Because of the
Marital status <.001 higher risk of NT-LLA among people with diabetes, targeted
Married 264 (82.0) 27 (90.0) management of these individuals through early detection
Single or divorced 16 (5.0) 0 (0.0)
Widowed 42 (13.0) 3 (10.0)
and more sophisticated management could alleviate the
History of disease, health, and burden associated with NT-LLA.22 In many LMICs, such as
lifestyle Togo, blood glucose control is the focus of diabetes care,
Diabetes mellitus 174 (54.0) 17 (56.7) .78 and patient education and knowledge about the disease
Hypertension 79 (24.5) 5 (16.7) .33 and vascular risk control are not adequately emphasised. As
Excessive alcohol 64 (19.9) 2 (6.7) .076
consumption
a result, patients’ lack of knowledge leads to delays in
Tobacco smoking 15 (100.0) 0 (0.0) .62 seeking care for poor foot care.21 The high risk of NT-LLA
Sex .36 among patients with diabetes will guide decisions to
Female 135 (41.9) 10 (33.3) implement national medical strategies, including early
Male 187 (58.1) 20 (66.7) detection of diabetes and medical follow up of patients with
Data are presented as n (%) or mean
standard deviation. diabetes (making insulin and foot care more accessible).
* Driver, shopkeeper, motorcycle cab driver.
The results contrast sharply with those reported in some
countries outside the African continent where the incidence
of NT-LLA has decreased over the past two decades such as
DISCUSSION in Japan,23 Taiwan,24 Denmark,25 and Australia.26 Data on
This study provides the first report of nationally represen- NT-LLA during 2010 e 2014 from 12 countries in Europe and
tative estimates of all cause NT-LLA in a West African Australasia participating in the VASCUNET collaboration
country. Little is known about NT-LLA incidence and PAD reported an annual incidence of major amputations be-
among amputees in SSA. The incidence of NT-LLAs was 48 tween 7.2% and 41.4% with an overall decline.27 Further-
times higher among individuals with diabetes. The highest more, the same study reported that major amputations
incidence during the study period (2016 e 2021) was found were more frequent in countries with the lowest national
among individuals aged 75 years and above with diabetes, gross domestic product per capita and healthcare expen-
reaching an average of 178.9 per million/year. The NT-LLAs ditures. The gross domestic product per capita varied be-
were mostly related to diabetes and or PAD. Most cases tween 23 500 US dollars (USD) in Hungary and 63 700 USD
had no vascular work up. in Norway while the average in Togo during the study
Different methods have been used to estimate and period was only 860.5 USD.28 Nevertheless, in the VASCU-
report NT-LLA incidence rates across studies, making com- NET collaboration, the high life expectancy in these Euro-
parison difficult. Additionally, heterogeneity in the counting pean countries (variation between 75.3 years and 82.8
of NT-LLA cases and the lack of clarity in the methods of years vs. 62.0 years in Togo29) is striking.
some studies (the method for sex or age adjustment) led to The downward trends in NT-LLA in industrialised countries
the complexity of determining the incidence of NT-LLA and compared with those recorded in the study can be explained
to the current lack of consensus on the methods of inci- in part by improvements in diabetes care in the former,
dence reporting.19 Some SSA studies have focused on the including patient information and education on foot
risk of amputation among individuals with diabetes. In this screening, early management, availability of medications and
Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
6 Martin K. Tchankoni et al.

Diabetes PAD
(n = 186; 52.8%) (n = 192; 54.5%)

Diabetes and
PAD
Diabetes only 15 (4.3%) PAD only
100 (28.4%) 125 (35.5%)

Diabetes
and PAD and
infection
Diabetes
3 (0.9%)
and PAD and
infection infection
68 (19.3%) 49 (13.9%)

Infection
(n = 142; 40.3%)

Infection only
22 (6.3%)
Other*
Tumour (n = 7)
(n = 6)

7 (2.0%) 6 (1.7%)

Figure 3. Aetiology of lower limb amputations among patients in Togo, 2016e2021 (n ¼ 352). Numbers
outside the brackets represent the numbers and those in brackets are the proportions related to the entire
population of amputee patients (n ¼ 352). PAD ¼ peripheral artery disease. *Other ¼ necrosis of the ampu-
tation stump; gangrene of the right foot in sickle cell disease; lymphoedema; extensive bone necrosis; necrosis
of the right little toe following athlete’s foot; ankylosis.

coordinated, specialised care, and the introduction of
multidisciplinary diabetic foot care clinics.25,30e32 In addition,
the increasing incidence of diabetes and metabolic syndrome
in Africa could contribute to the increase in amputation
rates.33,34 In a retrospective study (2010 e 2020) conducted
at a tertiary hospital in Togo among adult patients who un-
derwent NT-LLA, diabetes mellitus was the predominant risk
factor.11 Similar observations were also reported else-
where.10,35e37 Several studies reported diabetic complica-
tions as the leading indication for amputation.33,38,39 A very
alarming progression of diabetes in developing countries
could even lead to increased amputation rates in the future;
the number of people with diabetes in Africa will increase
from 14.2 million in 2015 to 34.2 million in 2040.40
In this study, the proportion of tobacco consumption was
4.3%. According to the World Health Organisation funded
STEPS Togo surveys, the prevalence of tobacco smoking in
the general population in 2010 was 8.5% (95% CI 7.4 e
9.6)41 and 5% (95% CI 4.1 e 5.9)16 in 2021. In line with
national data on tobacco consumption in Togo, the results
differ from those found elsewhere. In Western countries,
according to the Organisation for Economic Cooperation
and Development, the proportion of active smokers is
higher in countries with the highest rates of major ampu-
tation (Hungary, Slovakia, and Austria).27
In the study, on average, the overall age adjusted inci-
dence rate in the general population was 1.7 times higher
among men than among women, in line with data from
Nigeria where a sex ratio of three was reported,42 similar to
another report from Spain between 2001 and 2019.43 These
results can be explained by the fact that within the Togolese
population, diabetic foot complications and PAD are pre-
dominant in males.44 Studies have shown that 25 e 90% of
NT-LLAs are associated with diabetes mellitus, due to the
combination of peripheral neuropathy and infection
resulting from diabetes mellitus.45,46
There are notable inadequacies in the imaging and par-
aclinical examinations to be performed prior to amputation
in Togo. In this study, only 18.2% of patients were found to
have had VDU and 1.7% CTA prior to amputation. These

Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
Epidemiology of Non-Traumatic Lower Extremities Amputations in Togo 7

Table 3. National age specific and age adjusted lower limb amputation incidence rates for years 2016e2021 (per million/year of
inhabitants) in Togo

Cases and rates 2016 2017 2018 2019 2020 2021 Average
(2016e2021)
New cases of lower limb 48 47 51 66 60 80 352
amputation e n
Age specific incidence rates
0e49 2.3 1.7 1.7 1.8 2.5 2.3 2.1
50e64 30.0 27.3 33.0 39.8 41.5 50.4 37.4
65e74 53.0 62.4 71.1 95.0 40.8 78.8 67.1
75þ 168.0 180.8 139.6 201.6 145.3 232.0 178.9
Age adjusted incidence 7.4 7.1 7.7 9.9 9.0 12.0 8.8
rates, 95% CI (5.6e10.0) (5.3e9.5) (5.6e9.9) (7.3e12.0) (6.3e10.6) (8.4e13.2) (7.6e9.4)

A 12

11
9.9
10 9.6 9.3
9 8.7
Incidence rate per million

8 8.2

7 6.2
6.2 6.3
6
6.2 6.3
5
4.0 4.7
4

0
2016 2017 2018 2019 2020 2021
Female Male

B 350

300
Incidence rate per million

250 230.8
172.3 198.3
200

144.2
150 123.3 116.2

100

50
3.2 3.1 2.8 2.4 3.4 5.2
0
2016 2017 2018 2019 2020 2021
With diabetes Without diabetes

Figure 4. Time trend of the age adjusted non-traumatic lower limb amputation (LLA) rate in Togo per million/
year individuals. (A) Time trend by sex. The average rate was 10.1 per million/year among males, and 6.0 per
million/year among females with a relative risk (male/female) of 1.7. Men are 1.7 times more likely to have
an amputation than women. (B) Time trend in people with and without diabetes. The relative risk of LLA was
48 times higher in people with diabetes than among those without diabetes (people with diabetes 164.0 vs.
people without diabetes 3.4 per million/year). Testing an overall trend (ManneKendall trend test): The
corresponding two sided p value is p ¼ .060. Thus, there is no statistically significant evidence that a trend is
present.

Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
8 Martin K. Tchankoni et al.

9 8.6

8 7.5
Cumulative incidence – per million
6.6
7
5.8
6 5.5
5.2

2
1.0
0.5 0.5 0.7
1 0.5 0.5

0
2016 2017 2018 2019 2020 2021
Major amputation Minor amputation

Figure 5. Time trend of major and minor non-traumatic lower limb amputation rates in Togo per million in-
dividuals. The average rate was 6.5 per million/year for major amputation, and 0.6 per million/year for minor
amputation with a relative risk (major/minor) equal to 10.6.

examinations are entirely at the patient’s expense. In Togo,
VDU costs approximately 65 USD and CTA, 275 USD, while
the inter-professional minimum wage in the country is 87
USD.47 Thus, the economic context and the modest tech-
nical resources of the country’s hospitals may be factors
explaining this low proportion of examinations carried out.
Low socioeconomic status48 and the limited number of
vascular surgeons available to perform endovascular or
open revascularisation may be factors favouring amputa-
tions. None of the 352 NT-LLAs had revascularisation due to
the lack of specialists. Vascular surgery in Togo is at its
starting point of the process and specialists are being
deployed throughout the country. This result is in line with
previous studies conducted between 2010 and 2020 in
Togo’s two largest teaching hospitals where no revascular-
isation procedures were performed prior to
amputation.11,49
The in hospital mortality rate in the study was 8.8%. This
rate is similar to that reported in a retrospective study
conducted in South Africa among 348 patients who un-
derwent NT-LLA during a five year period (2013 e 2018)
where they found a rate of 8%50 but lower than that re-
ported in Tanzania (16.7%).35 However, it should be
emphasised that many patients in African countries leave
hospitals very quickly after interventions because of lack of
financial affordability, and so short term mortality may be
underestimated.
The proportion of minor amputations in the study is only
8.5%. Similar results were found in previous studies carried
out in Togo, with 4.1%11 and 1.1%49 minor amputations,
highlighting a specific feature of the country. Most Togolese
people rely on traditional medicine as first line treatment.51
Patients who are ill turn to traditional healers and only
when the situation becomes more severe, do they seek
management in health centres. As their case becomes
critical, and because of lack of revascularisation procedures
during the study period in the country, major amputation
becomes the only solution for most of them.

Table 4. Pre-operative work up and evolution after amputation of Togolese amputation patients by level of amputation, 2016e2021
(n [ 352)

Imaging and outcomes Patients, total Major (n [ 322) Minor (n [ 30) p value
Duplex ultrasound performed .47
No 288 (81.8) 262 (81.4) 26 (86.7)
Yes 64 (18.2) 60 (18.6) 4 (13.3)
Computed tomography angiography .92
No 334 (94.9) 304 (94.4) 30 (100.0)
Yes 6 (1.7) 6 (1.9) 0 (0.0)
Not indicated in the medical records 12 (3.4) 12 (3.7) 0 (0.0)
In hospital outcome .003
Death 31 (8.8) 29 (9.0) 2 (6.7)
Discharge* 307 (87.2) 281 (87.2) 26 (86.6)
New amputation 14 (4.0) 12 (3.8) 2 (6.7)
Data are presented as n (%).
* Of the 307 patients discharged, 12 (3.4%) were discharged because of an inability to afford the hospital stay following their amputation.

Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
Epidemiology of Non-Traumatic Lower Extremities Amputations in Togo
Limitations
There are several limitations to this study. First, the data
were collected retrospectively from the patient’s clinical
files and some variables were missing but handled by
MICE. This is the situation in many studies performed in
LMICs, where the lack of human resources in some
hospitals makes completion and maintenance of patient
records a secondary concern. Additionally, data on long
term outcomes or complications of the amputees are not
available. Finally, over the study period, patients did not
have access to revascularisation due to the lack of spe-
cialists. Future investigations should compare data
before and after the availability of revascularisation
procedure.
To address the above mentioned limitations, a prospec-
tive study is planned to establish a national registry of limb
amputations in Togo to obtain comprehensive data, spe-
cifically on the long term outcomes of patients with
amputations.
Conclusion
The increasing incidence of NT-LLAs over the years is a
public health challenge in Africa, and especially in Togo. The
incidence of NT-LLAs was 48 times higher among people
with diabetes, a condition booming in Africa. Specific pri-
mary prevention interventions should be implemented to
diagnose early and follow up patients with these diseases to
avoid complications such as NT-LLA in low income countries.
CONFLICT OF INTEREST
V.A. received honoraria for projects unrelated to the current
study, from the following companies: Amarin, AstraZeneca,
Bayer, Boehringer-Ingelheim, and NovoNordisk. The other
authors have no competing interests to declare.
FUNDING
None.
ACKNOWLEDGEMENTS
We are grateful to the hospital directors who agreed to
conduct this study in their departments and to the final
year medical students of the “Faculté des Sciences de la
Santé-Université de Lomé” who performed the data
collection.
ETHICS STATEMENT
Ethics approval was obtained from the “Comité de Bio-
éthique de Recherche en Santé” (Bioethics Committee for
Health Research) from the Togo Ministry of Health (No.
038/2022/CBRS). Permission to conduct the study was ob-
tained from all directors of the study health facilities. In
addition, the anonymity of the participants was respected.
REFERENCES
1 Criqui MH, Matsushita K, Aboyans V, Hess CN, Hicks CW,
Kwan TW, et al. lower extremity peripheral artery disease:
Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
9
contemporary epidemiology, management gaps, and future di-
rections: a scientific statement from the American Heart Associ-
ation. Circulation 2021;144:e171e91.
2 Global Burden of Disease Study 2013 Collaborators. Global,
regional, and national incidence, prevalence, and years lived with
disability for 301 acute and chronic diseases and injuries in 188
countries, 1990-2013: a systematic analysis for the Global Burden
of Disease Study 2013. Lancet 2015;386:743e800.
3 Fowkes FGR, Aboyans V, Fowkes FJI, McDermott MM,
Sampson UKA, Criqui MH. Peripheral artery disease: epidemi-
ology and global perspectives. Nat Rev Cardiol 2017;14:156e70.
4 Johnston LE, Stewart BT, Yangni-Angate H, Veller M,
Upchurch Jr GR, Gyedu A, et al. Peripheral arterial disease in sub-
Saharan Africa: A Review. JAMA Surg 2016;151:564e72.
5 Robbs JV, Paruk N. Management of HIV vasculopathy e a South
African experience. Eur J Vasc Endovasc Surg 2010;39:S25e31.
6 Moran A, Forouzanfar M, Sampson U, Chugh S, Feigin V,
Mensah G. The epidemiology of cardiovascular diseases in sub-
Saharan Africa: the Global Burden of Diseases, Injuries and Risk
Factors 2010 Study. Prog Cardiovasc Dis 2013;56:234e9.
7 Velescu A, Clara A, Peñafiel J, Grau M, Degano IR, Martí R, et al.
Peripheral arterial disease incidence and associated risk factors in
a Mediterranean population-based cohort. The REGICOR Study.
Eur J Vasc Endovasc Surg 2016;51:696e705.
8 Aboyans V, Criqui MH, Abraham P, Allison MA, Creager MA,
Diehm C, et al. Measurement and interpretation of the ankle-
brachial index: a scientific statement from the American Heart
Association. Circulation 2012;126:2890e909.
9 Zhang P, Zhang X, Brown J, Vistisen D, Sicree R, Shaw J, et al.
Global healthcare expenditure on diabetes for 2010 and 2030.
Diabetes Res Clin Pract 2010;87:293e301.
10 Sarfo-Kantanka O, Sarfo FS, Kyei I, Agyemang C, Mbanya JC.
Incidence and determinants of diabetes-related lower limb am-
putations in Ghana, 2010e2015 e a retrospective cohort study.
BMC Endocr Disord 2019;19:27.
11 Kouevi-Koko TE, Amouzou KS, Sogan A, Apeti S, Dakey YEL,
Abalo A. Lower extremity amputations (LEAs) in a tertiary hos-
pital in Togo: a retrospective analysis of clinical, biological,
radiological, and therapeutic aspects. J Orthop Surg 2023;18:155.
12 Grudziak J, Mukuzunga C, Melhado C, Young S, Banza L, Cairns B,
et al. Etiology of major limb amputations at a tertiary care centre
in Malawi. Malawi Med J J Med Assoc Malawi 2019;31:244e8.
13 Owolabi EO, Adeloye D, Ajayi AI, McCaul M, Davies J, Chu KM.
Lower limb amputations among individuals living with diabetes
mellitus in low- and middle-income countries: a systematic review
protocol. PLoS One 2022;17:e0266907.
14 Abbas ZG, Boulton AJM. Diabetic foot ulcer disease in African
continent: ‘From clinical care to implementation’ e review of
diabetic foot in last 60 years e 1960 to 2020. Diabetes Res Clin
Pract 2022;183:109155.
15 Worldometer. Togo Demographics 2020 (Population, Age, Sex,
Trends) [Internet] [Cited 2022/09/21]. Available from: https://
www.worldometers.info/demographics/togo-demographics/
#urb; 2020.
16 Ministère de la Santé, de l’Hygiène Publique et de l’Accès Uni-
versel aux Soins, Service des Maladies Non Transmissibles de la
Division de l’Epidémiologie. Rapport final de l’enquête STEPS Togo
2021. Togo: OMS/OOAS; 2012.
17 von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC,
Vandenbroucke JP, et al. The Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) statement: guide-
lines for reporting observational studies. Int J Surg 2014;12:1495e9.
18 IDF Diabetes Atlas, 10th edition - Togo Diabetes report 2000-
2045. 2021. Available at: https://diabetesatlas.org/data/en/
country/198/tg.html [Accessed 6 September 2023].
19 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 J Br Diabet Assoc
2011;28:1144e53.
10
20 Somasundram P, Davashni P, Deepak S, Romashan P. Diabetes-
related amputations in the public healthcare sector in KwaZulu-
Natal: a five-year perspective. Are we winning? J Endocrinol
Metab Diabetes South Afr 2019;24:32e6.
21 Dagadu HE, Patterson EJ. Placing a Health Equity Lens on Non-
communicable Diseases in sub-Saharan Africa. J Health Care
Poor Underserved 2015;26:967e89.
22 Hicks CW, Selvin E. Epidemiology of peripheral neuropathy and
lower extremity disease in diabetes. Curr Diab Rep 2019;19:86.
23 Kamitani F, Nishioka Y, Noda T, Myojin T, Kubo S, Higashino T,
et al. Incidence of lower limb amputation in people with and
without diabetes: a nationwide 5-year cohort study in Japan. BMJ
Open 2021;11:e048436.
24 Lai Y-J, Hu H-Y, Lin C-H, Lee S-T, Kuo S-C, Chou P. Incidence and
risk factors of lower extremity amputations in people with type 2
diabetes in Taiwan, 2001-2010. J Diabetes 2015;7:260e7.
25 Jørgensen ME, Almdal TP, Færch K. Reduced incidence of lower-
extremity amputations in a Danish diabetes population from 2000
to 2011. Diabet Med 2014;31:443e7.
26 Kurowski JR, Nedkoff L, Schoen DE, Knuiman M, Norman PE,
Briffa TG. Temporal trends in initial and recurrent lower extremity
amputations in people with and without diabetes in Western Australia
from 2000 to 2010. Diabetes Res Clin Pract 2015;108:280e7.
27 Behrendt C-A, Sigvant B, Szeberin Z, Beiles B, Eldrup N,
Thomson IA, et al. International variations in amputation practice:
a VASCUNET report. Eur J Vasc Endovasc Surg 2018;56:391e9.
28 World Bank national accounts data, and OECD National Accounts
data files. GDP per capital (current US$) - Togo. 2021. Available
at: https://tinyurl.com/swdvhj4b [Accessed 9 August 2023].
29 World Bank national accounts data, and OECD National Accounts
data files. Life expectancy at birth, total (years) - Togo. 2021.
Available at: https://urlz.fr/nb1Z [Accessed 9 August 2023].
30 Narres M, Kvitkina T, Claessen H, Droste S, Schuster B, Morbach S,
et al. Incidence of lower extremity amputations in the diabetic
compared with the non-diabetic population: a systematic review.
PLoS One 2017;12:e0182081.
31 Wilbek TE, Jansen RB, Jørgensen B, Svendsen OL. The diabetic
foot in a multidisciplinary team setting. Number of amputations
below ankle level and mortality. Exp Clin Endocrinol Diabetes
2016;124:535e40.
32 Chen I-W, Yang H-M, Chiu C-H, Yeh J-T, Huang C-H, Huang Y-Y.
Clinical characteristics and risk factor analysis for lower-extremity
amputations in diabetic patients with foot ulcer complicated by
necrotizing fasciitis. Medicine (Baltimore) 2015;94:e1957.
33 Boateng D, Ayellah BB, Adjei DN, Agyemang C. Contribution of
diabetes to amputations in sub-Sahara Africa: a systematic review
and meta-analysis. Prim Care Diabetes 2022;16:341e9.
34 Motala AA, Mbanya JC, Ramaiya K, Pirie FJ, Ekoru K. Type 2
diabetes mellitus in sub-Saharan Africa: challenges and opportu-
nities. Nat Rev Endocrinol 2022;18:219e29.
35 Chalya PL, Mabula JB, Dass RM, Ngayomela IH, Chandika AB,
Mbelenge N, et al. Major limb amputations: a tertiary hospital
experience in northwestern Tanzania. J Orthop Surg 2012;7:18.
36 Abalo A, Sanon G, Walla A, Akakpo A, Dossim A. Amputations de
membres inferieurs: aspects epidemiologiques, facteurs etiologiques
et aspects evolutifs. J Rech Sci L’Université Lomé 2011;13:61e7.
Please cite this article as: Tchankoni MK et al., Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo,
European Journal of Vascular and Endovascular Surgery, https://doi.org/10.1016/j.ejvs.2024.01.088
Martin K. Tchankoni et al.
37 Oliveira YS, Mba Angoue JM, Nguimbi Mbadinga AM,
Feimokib D, Magossou P, Ibinga AF, et al. Amputation des
membres inférieurs et appareillage: expérience du centre de
réadaptation et d’appareillage pour handicaps «La Raison de
Vivre, Le Droit d’Espérer» à Libreville. J Réadapt Médicale Prat
Form En Médecine Phys Réadapt 2014;34:53e9.
38 Tuglo LS. Prevalence and determinants of lower extremity am-
putations among type I and type II diabetic patients: a
multicenter-based study. Int Wound J 2023;20:903e9.
39 Ntuli S, Letswalo DM. Diabetic foot and lower limb amputations at
central, provincial and tertiary hospitals-underscores the need for
organised foot health services at primary healthcare level. Foot
(Edinb) 2023;56:102039.
40 Sante Diabète. Le Diabète : Une “Épidémie” En Afrique. 2022.
Available at: https://santediabete.org/le-diabete/ [Accessed 24
September 2022].
41 Ministère de la Santé, Service des Maladies Non Transmissibles de
la Division de l’Epidémiologie. Rapport final de l’enquête STEPS
Togo 2010. Togo: OMS/OOAS; 2012.
42 Thanni LOA, Tade AO. Extremity amputation in Nigeriada re-
view of indications and mortality. Surgeon 2007;5:213e7.
43 Lopez-de-Andres A, Jimenez-Garcia R, Hernández-Barrera V, de-
Miguel-Diez J, de-Miguel-Yanes JM, Omaña-Palanco R, et al.
Time trends (2001-2019) and sex differences in incidence and
in-hospital mortality after lower extremity amputations among
patients with type 1 diabetes in Spain. Cardiovasc Diabetol
2022;21:65.
44 Djibril AM, Mossi EK, Djagadou AK, Balaka A, Tchamdja T,
Moukaila R. [Epidemiological, diagnostic, therapeutic and
evolutionary features of diabetic foot: a study conducted at the
Medico-surgical Clinic, University Hospital Sylvanus Olympio in
Lomé]. Pan Afr Med J 2018;30:4.
45 Barnes JA, Eid MA, Creager MA, Goodney PP. Epidemiology and
risk of amputation in patients with diabetes mellitus and peripheral
artery disease. Arterioscler Thromb Vasc Biol 2020;40:1808e17.
46 Agarwal S, Sud K, Shishehbor MH. Nationwide trends of hospital
admission and outcomes among critical limb ischemia patients:
from 2003-2011. J Am Coll Cardiol 2016;67:1901e13.
47 Wage Indicator Foundation. Minimum Wage e Togo. 2023.
Available at: https://wageindicator.org/salary/minimum-wage/
togo [Accessed 14 August 2023].
48 Venermo M, Manderbacka K, Ikonen T, Keskimäki I, Winell K,
Sund R. Amputations and socioeconomic position among persons
with diabetes mellitus, a population-based register study. BMJ
Open 2013;3:e002395.
49 Tamegnon D, Hodabalo TT, Irokoura K, Komlan A, Kokou K,
David DE. The amputations of limbs at the Kara University Hos-
pital Center (Togo). Arch Surg Clin Case Rep 2020;3:123.
50 Khan MZ, Smith MT, Bruce JL, Kong VY, Clarke DL. Evolving
indications for lower limb amputations in South Africa offer op-
portunities for health system improvement. World J Surg 2020;44:
1436e43.
51 Cheikhyoussef A, Shapi M, Matengu K, Ashekele HM. Ethnobo-
tanical study of indigenous knowledge on medicinal plant use by
traditional healers in Oshikoto region, Namibia. J Ethnobiol Eth-
nomedicine 2011;7:10.