Etiology of major limb amputations at a tertiary care centre in Malawi

IntroductionAmputations in low- and middle-income countries (LMICs) represent an important cause of disability and economic hardship. LMIC patients are young and suffer from preventable causes, such as trauma and trauma-related infections. We herein studied the etiology in amputations in a Malawian tertiary care hospital over a 9-year period.Methods Operative and anaesthesia logs at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi, were reviewed for 2008–2016. Baseline demographic and clinical variables and type of amputation performed were collected. Only major limb amputations, defined as above or below the knee, above or below the elbow, and above the wrist, were included in this study. Results A total of 610 patients underwent 630 major amputations during the study period. Of these, 170 (27%) patients were female, and the median age of the cohort was 39 (interquartile range [IQR] 25–55). Of these patients, 345 (54.8%) had infection or gangrene recorded among the indications for amputation, 203 (32.2%) had trauma, 94 (14.9%) had cancer and 67 (10.6%) had documented diabetes. Women underwent diabetes-related amputations more often than men (37 out of 67, or 56.1%), and were significantly younger when their amputations were due to diabetes (median age 48 vs 53 years old, P=0.004) or trauma (median age 21 vs 30 years old, P=0.02). The commonest operative procedures were below the knee amputations, at 271 (43%), and above the knee amputations, at 213 (33.8%). ConclusionAmputations in Malawi affect primarily the young, in the most economically productive time of their lives, in contrast to amputees in high-income countries. Preventable causes, such as infection and trauma, lead to the majority of amputations. These etiologies represent an important primary prevention target for public health efforts in LMICs.

Trauma-related mortality decreases after the institution of a general surgery residency program in sub-Saharan Africa: The Malawi experience

BACKGROUND: Many factors contribute to the burden of surgical diseases, such as trauma, in sub-Saharan Africa, including a paucity of international funding, a shortage of trained clinicians, and underdeveloped infrastructure. Training surgical providers is one solution that has been proposed to reduce the mortality and morbidity due to these diseases in the region. Kamuzu Central Hospital in Lilongwe, Malawi, in partnership with the University of North Carolina at Chapel Hill, established a general surgery residency program in 2009. The purpose of this study is to evaluate changes in trauma-related mortality following the institution of this residency program. METHODS: We review data related to the burden of noncommunicable and surgical disease in sub-Saharan Africa, as well as access to surgical providers and the shortage of healthcare workers in the region. We perform a literature review of proposals aimed at improving the access to surgical services in sub-Saharan Africa. We then present Malawi-specific data, including economic and health indicators, healthcare structure, access to surgical providers, and trauma-related burden of disease. Finally, to determine the influence of the general surgery residency on trauma related mortality at Kamuzu Central Hospital, we perform a retrospective analysis of patients in the hospital's trauma surveillance database, from 2009 to 2014. A logistic regression model was constructed to compare the odds ratio of in-hospital death. RESULTS: In 2009 there were 3 general surgery residents at KCH; this number increased to eleven residents in 2014. During the period of study, 82,534 patients were recorded into the trauma registry database at KCH; the majority were male (72.1%), and mean age was 23.1 years (SD: 15.7). Trauma volume increased for each of the years under study, with 8725 patients recorded in 2009 and 15,998 patients in 2014. Odds of in-hospital death decreased every year as compared to the referent year, when adjusted for primary injury type (severity); age; and gender. CONCLUSION: While surgical burden of disease in sub-Saharan Africa is a complicated issue, training general surgeons in a resource-poor setting represents an effective intervention to help reduce trauma mortality in the region.Master of Public Healt