Indications and outcomes of major limb amputations in children aged 0-18 years in Douala General Hospital and Laquintinie Hospital: a 10-year retrospective study

¹Faculty of Health Sciences, University of Buea, Buea, Cameroon, ²Faculty of Medicine and Biomedical Sciences of Garoua, Garoua, Cameroon, ³Research Division, Winners Foundation, Yaounde, Cameroon

^&Corresponding author
Nathan Ezie Kengo, Faculty of Medicine and Biomedical Sciences of Garoua, Garoua, Cameroon

Introduction    

Amputation is the act of removing the whole or part of a limb by cutting through bone or a joint. Disarticulation will be a more appropriate term when it comes to cutting a limb through the joint, but still considered an amputation. There is a global trend of rising prevalence of amputations in children aged 0-18 years. Despite the relative rarity of amputations in this age group, these cases still require emotional and psychological support from their families [1]. Major amputation is performed above or below a major joint, such as the knee or elbow joint [2]. Major limb amputations usually have three main causes described as the three Ds, namely dead, deadly, or dying limb. These cases present a unique challenge in children, especially in their ability to ambulate and interact with the external environment [3]. Major limb amputation in children is a rare but necessary last resort when the limb is no longer salvageable, despite the common complications involved, such as psychological stigma and disability [4]. Amputations remain a universally accepted and ancient procedure for their value in saving a patient´s limb from a progressively dying, deadly, or dead segment of the limb. There are statistically significant variations in the epidemiological data on extremity amputations within and without countries [2]. This research aims to provide the indications and outcomes in the pediatric age group of these amputations in two major hospitals in Douala Cameroon.

Methods     

Study design: over 3 months, a retrospective descriptive study was conducted in two hospital settings lasting 10 years. The study examined the records of patients who underwent amputations and were between the ages of 0 and 18.

Study period and duration: the study duration spans from January 1^st to April 1^st, 2023. The research was conducted in the pediatric and surgical departments of both the Laquintinie Hospital and Douala General Hospital.

Study area: this study was carried out in the pediatric surgery and surgical units of the Laquintinie Hospital and Douala General Hospital.

Inclusion criteria: files of patients with major limb amputations aged 18 years and younger were received in these hospitals within the past 10 years with relevant medical records.

Exclusion criteria: files of patients with absent relevant data; files of patients whose management is not within our manipulated time frame; files of patients with relevant data but who exceed the manipulated age.

Study population and sampling: a consecutive sampling method during which files of patients less than 18 years old, within the past 10 years admitted or treated for major limb amputations were reviewed and recorded.

Data collection: during this study, a review of the above-mentioned hospital´s pediatric surgical unit and surgical unit as well as lab records was done and recorded using a specially designed data entry form. The following data was collected: patient's socio-demographic characteristics (age, gender, level of education); clinical presentation; indications of major limb amputations; bones affected by the amputations; treatment modality and outcome (mortality, disability, prolonged hospital stay).

Data analysis

Univariate analysis: descriptive statistics was used to summarize data. Categorical variables like sex were summarized using frequency tables. Continuous variables like age were summarized using summary statistics like mean and standard deviation.

Bivariate analysis: at the level of bivariate analysis, simple logistic regression was used to screen predictors that were associated with reamputation.

Multivariate analysis: factors that were significantly associated with re-amputation at the level of the bivariate analyses were further analyzed at the level of the multivariate analyses at a p-value of 0.05.

Data management: data collected using kobotoolbox were cross-checked and entered on Microsoft Excel spreadsheets, then analyzed using the Statistical Package for the Social Sciences (SPSS) version 23. The folder containing the data was password-protected and uploaded to a cloud storage drive, and a backup was done to prevent missing entries. A rigorous check was conducted on a combined total of 4100 records at both the Douala General Hospital (DGH) and the Laquintinie Hospital. Among these files, we discovered 320 cases of patients who had undergone amputation. However, it was determined that 260 individuals fell outside the age bracket of 0-18 years and were therefore excluded. Additionally, 5 files were deemed ineligible for inclusion due to incomplete data. Consequently, our study encompassed a cohort of 55 patients, as illustrated in Figure 1.

Ethical consideration: this study is approved by the Research Ethics Committee at both the Douala General Hospital (214AR/MINSANTE/HGD/DM/04/23) and Douala Laquintinie Hospital (199AE/MINSANTE/DHL/CMA).

Results     

Socio-demographic characteristics: the majority (61.8%) of participants included in our study were from the DGH and 38.2% were from Laquintinie Hospital (Table 1). The mean age of participants was 14.6±2.7 and fell within the age range group 11-15 (47.3%) with a male predominance (63.6%) and were mostly students (90.9%). Most (58.2%) had a secondary level of education, followed by primary education (34.5%) (Table 1).

Indications of amputation among children aged 0-18 years who had undergone amputation: the most common indication for amputation among children in our study was trauma (67.27%) followed by gangrene (21.82%) and infections (3.64%) as shown in Figure 2 and Figure 3 below presents a case of traumatic amputation following a road traffic accident. There was no significant association between age and indication for amputation. (Fisher exact=8.3, p=0.14) as shown in Table 2.

Level of amputation: the majority of amputations were transtibial and the least were transradial amputations (Figure 4).

Post-operative complications: phantom limb sensation (54.55%) was the most common postoperative complication, followed by post-amputation pain (20.00%). Other complications include: an association of infection; post-amputation pain and phantom limb sensation (10.91%), post-amputation pain (3.64%), neuroma stump overgrowth (1.82%), infection (1.82%), hematoma (1.82%). However, 5.45% recorded no complications.

Patients´ outcome: in terms of participant outcomes, a small percentage underwent revision amputation, and the majority were released with a low recorded mortality rate (3.64%). Table 3 shows that the average length of hospital stay was two to three weeks.

Mortality distribution among age and sex: there was no correlation between age and mortality among participants using the Chi-square test of independence (p=0.09). About 1.82% of those who died were within the age group 5-10 and 16-18 years. There was no association between sex and mortality among participants using the Chi-square test of independence (p=0.057).

Discussion     

Limb amputations in the pediatric age group can lead to severe disability and can result in profound economic, social, and psychological effects on the growing child and family [5]. The patterns of indications, levels, as well as complications are variable based on the age of patients, settings, and country in which they are carried out [6]. The majority of participants in our study were males, and the predominant educational level was secondary education. The male predominance is similar as reported in similar studies [7,8]. This is explained by the fact that, in comparison to female children, male children are more active and frequently exposed to trauma. Trauma was the most frequent (67.27%) cause of amputation in our study. Figure 3 presents a case of traumatic amputation following a road traffic accident.

Most participants who presented with trauma were in the age group 16-18 years, and the least affected were <5 years. This is similar to two studies carried out in Nigeria by Akinyoola et al. and Okenwa et al. where the most common cause of amputation was trauma at 27.3% and 74.3% respectively [8,9]. A study in the United Kingdom indicated that road traffic accidents account for 63% of traumatic amputations [10]. However, the study differs from that of Chayla et al. [11] in Tanzania where diabetic amputation accounted for about 41.9% of cases followed by trauma (38.4%) and vascular disease (8.6%). The second most common cause in our study was gangrene, which was shown to generally increase with age, with the most affected age group being 16-18 years. This is probably due to the increase in the prevalence of comorbidities factors such as peripheral vascular disease [8].

Infections were the third leading indicator of amputation. However, crush injury was the predominant injury that affected the participants. These findings are however similar to a study carried out by Akinyoola et al. [8] where trauma accounted for 74.3% of amputations. Malignancy was reported in 4 patients as an indicator of amputation, this is equally similar to a study carried out in the Northwest Region of Cameroon [2] in which 3 cases were reported. Our findings revealed the lower limb as the most commonly affected extremity, with most of the participants being amputated below the knee (transtibial) (43.64%). This can be explained by the fact that most of our patients had an active lifestyle and were exposed to road traffic accidents which resulted in loss of limb. Likewise, Akinyoola et al. [8] and Wamisho et al. [12] noted that there were more lower limb amputations in children than there were upper limb amputations.

Regarding complications, phantom limb sensation was the most common postoperative complication (54.5%), followed by post-amputation pain (20%). Some patients had infections, post-op amputation pain, and phantom limb sensation as complications. This was consistent with what was found in a study in Nigeria where an association was found between phantom limb sensation and post-amputation pain [13]. In contrast, Alegbeleye et al. [2] found hematoma and hemorrhage as the second and third complications respectively after infection. Regarding the outcome of participants, 3.6% of patients had a revision amputation, this was similar to a study done in rural KwaZulu-Natal where the revision amputation rate was 4.3% [14]. About 98.2% were discharged and the mortality among participants was 3.6% which was lower than that reported by Murwanashyaka et al. (9.4%), and Thanni et al. (10.9%) [15,16].

Strength: the study gives us an overview of the indications and outcomes of pediatric amputation in the two main referral hospitals in the littoral region.

Limitation: incomplete records (missing information on the reason for amputation and missing outcome); inability to evaluate the long-term follow-up of patients after discharge.

Conclusion     

Trauma followed by gangrene and infections were the three major indicators of amputation, with the age group 16-18 years being highly affected. Moreover, the majority of the amputation was transtibial, and the rate of re-amputation was 13.1%. Regarding the indications of re-amputation, wound infection, and wound dehiscence contributed to more than half. Post-operative complications were mostly phantom limb sensation, post amputation pain followed by infection. There was generally a low mortality rate after amputation.

Recommendations: based on our findings, we recommended an enhanced sensitization to encourage early presentation to the hospital, thus reducing the number of patients undergoing major limb amputations in the regions. This will subsequently reduce the number of amputees. Also, a need to establish a universal health coverage system to improve the care of patients with amputation irrespective of the setting.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Nkeutcha Simo Gildas Karel: conceptualisation, initial draft, writing, review, final approval. Nana Theophile Chunteng: conceptualisation, initial draft, review. Nathan Ezie Kengo: initial draft, writing, review, data extraction. Efeti Flora Motimbo Ekeku: data extraction, writing, review. Fokam Puis: review, surpervision. Ngowe Ngowe Marcellin: review, surpervision. All the authors have read and agreed to the final manuscript.

Tables and figures     

Table 1: socio-demographic variables of participants

Table 2: association between age and cause for amputation using the Fischer's exact test

Table 3: distribution of outcomes among patients

Figure 1: study flow chart for participants´ recruitment

Figure 2: specific causes of amputation among participants

Figure 3: traumatic amputation

Figure 4: distribution of the different levels of amputation

References