Factors influencing Major lower extremity amputations in Johannesburg.

introductionMajor lower extremity amputations (MLEA) are common and place an undue burden on society. They result in major morbidity as well as increase mortality for individuals. Little is known in South Africa about the primary causes of amputations. Understanding this will hopefully lead to prevention of amputations.

aimThe aim was to provide insights into the underlying causes, demographic distribution, risk factors for amputations, prior revascularisation attempts as well as to assess the quality of the amputations in the vascular unit at a major tertiary referral hospital vascular unit in Johannesburg (South Africa).

methodsClinical records of the vascular unit at CMJAH, theatre records, and NHLS laboratory results were retrospectively studied to identify all adult patients who underwent MLEA in 2017 and 2018.

resultsA total of 178 patients (64.04% male, 35.96% female) with a mean age of 62.48 years (± 12.19) were studied, with the majority being of African origin (57.86%). The leading cause of amputation was chronic limb-threatening ischemia (73.60%), followed by acute limb ischemia (ALI) (11.12%) and trauma (5.06%). Amputations were performed above the knee in 55% of cases and below the knee in 45%. The rate of conversion from below-knee to above-knee amputation was 12%. Black African patients were more likely to undergo above-knee amputations and were younger at the time of amputation compared to white patients. Among those with peripheral artery disease (PAD) who required amputation, only 30% had undergone a previous revascularization attempt. In the subgroup of patients presenting with ALI (n = 40), only 11 had attempted revascularization. Of those who had prior revascularization, the primary reasons for subsequent amputation were failed revascularisation or ongoing sepsis.

conclusionOur study demonstrates that patients referred to a tertiary vascular referral centre in Johannesburg, are more likely to receive an amputation a decade earlier in life for CLTI, with only 30% receiving an attempt at revascularisation. Furthermore, they are more likely to receive an AKA, and both the level of amputation and lack of revascularisation probably reflect the advanced stage of disease presentation. This study emphasises the importance of improving access to medical care and strengthening referral patterns in order to facilitate earlier referral when limbs are still potentially salvageable.