Received 5 April 2016; accepted 24 May 2016; published 27 May 2016
The removal of part or whole limb, amputation, seriously hampers the achievement of the Millennium Development Goals by reducing productivity   . It is a mutilating surgery that alters body image and leads to severe functional deficits. When made at a joint, it is called disarticulation. Any limb amputation painfully affects the patient in his daily activities, his job, his leisure  and a handicap that will effect on many levels and so intricate functional abilities, his social and professional life and psychology. Therefore, its realization is a part of a therapeutic approach in which the risk-benefit ratio should be carefully evaluated  . The limb amputations still represent today a serious public health problem, affecting both human and substantial financial; thus, we are more and more helping to the development of limb salvage concept in the north countries  . In low income countries, amputations are more traumatic. And those affected are not necessarily the older people but young assets  . In the Worldwide, the upper limb amputations are rare, affecting more men, the dominant limb is achieved, traumatic and tumor causes are the majority  . Socio-professional reintegration is not yet well established in most low-income countries like the Democratic Republic of Congo (DRC), where only few studies have focused on this subject, including one conducted in January 1996 by Ahuka and Lusi  and a recent one by Valimungighe MM et al. en 2015  . The objective of this study is to describe the epidemiological and etiological aspects of limb amputation in Kisangani.
2.1. Environment of Study
Kisangani, formerly Stanleyville is the capital of Orientale Province in the DRC. It is the third largest urbanized city in the country and the largest of the cities that lie in the tropical woodlands of the Congo. It is located at 1300 miles from the mouth of the Congo River. In 1999, the city was the site of the first open fighting between Ugandan and Rwandan forces in the second Congo war, when nearly 3000 people died in the cross fire. Despite being adjacent to the equator, the city has a tropical monsoon climate due to the fact that its driest month (January) sees on average below 60 mm of rain. Kisangani experiences an average relative humidity of 86%. It’s the most populous city of the Northern provinces in the RDC, with an estimated 2008 population of 1,200,000 (up from 406,249 thousand in 1993).
2.2. Type of Study
This study is descriptive retrospective over a period of ten years; it was taken to the University Hospital of Kisangani and Hospitals General Referral (HGR) Kabondo and Makiso-Kisangani.
2.3. Study Population
This study involved all patients who underwent amputation or disarticulation from 1st January 2005 to 31st December 2014 (10 years). Included are hospitalized and operated patients having a complete medical file. All patients with incomplete data were excluded from this study. The age, sex, occupation, the amputated limb, the type of amputation, the site or amputation level, the affected side, the etiology, and the patient output modality were the variables of the study. The level of amputation was determined by the progression of the gangrene or the site of open fractures.
Any amputation located above the wrist and the ankle is considered major when she is labeled a minor when she performs below these levels.
2.4. Statistical Analysis
Data were collected using a standardized form from the patient records, the register of the operating room and the register of operating protocols. The percentage calculation allowed to describe the variables categories in various tables, the normal quantitative variables are described as mean and standard deviation. The Excel spreadsheet has facilitated data entry, which was analyzed using SPSS 20 software.
3.1. Main Features
In 422 patients who underwent surgery Membership CUKIS and HGR Makiso-Kisangani and Kabondo during our study period, 62 of them underwent amputation of limbs, a prevalence of 14.69% of cases.
3.2. Socio Demographic Amputees (Table 1)
From Table 1 we notice that people ranged on group age between 57 - 75 years are most affected by the amputation of limbs with 30.7%, masculine predominance in 74.2% sex-ratio male/female being 2.9/1. Among all professional corporations, unemployed represent 51.6%
3.3. Characteristics of Amputees (Table 2)
From Table 2, the vascular etiology (46.8%) is the most criminalized, diabetes mellitus alone represents 30.7%. The lower limb is most affected (88.7%) while the right side was more concerned with 56.5%. The major amputation is most common with 79%, including 32.2% in the leg side. It emerges from Table 3 that 51 (82.2%) amputees were cured whereas 11 (17.8%) died.
The goal of this study was to describe the epidemiological and etiological aspects of limb amputation in Kisangani. There is a limitation of this study due on the limited number of hospitals where we collected data in a big town with over a million people. Nevertheless, we can discuss.
Throughout the explained by the study period from 1st January 2005 to 31st December 2014, 62 patients underwent a limb amputation, a total of 422 interventions concerning limbs, a prevalence of 14.69%. This frequency is comparable to that found by Kanté et al. in Bamako, Mali, which is 31.25%  .
In our study, subjects whose age group was between 57 - 75 years were most affected with 30.7% close to that of Diakité  who recorded 33.3% of lower limb amputees in a range 55 - 64 year old. This high incidence of amputations in old age could berelating to the prevalence of diabetic arterial disease.
Regarding gender, male patients had more limb amputation than those of the female, or 74.2% against 25.8% with a sex ratio of 2.9/1. These results match those of Ahuka and Lusi  at Nyakunde DRC (formerly Zaire) in 1996, who found 71.53% for males against 28.47% for females, with a sex ratio of 2.5/1. This male prediction was reported by other authors  . We estimate that the male predominance can be explained not only by the fact that it is more exposed to road traffic accidents (RTA), but above all, the man is more accepting amputation than a woman, this latter favoring aesthetic considerations.
Table 1. Sociodemographic characteristics of amputees.
Table 2. Amputations characteristics and etiologies.
Table 3. Output modality.
It emerges from the analysis of our results as the unemployed represent the majority of cases of amputation, or 51.6%. Ebskov, Schroder TV, Holstein  in Britain in 1994 had reached similar results (42%). We believe this category of the population, lack of adequate financial resources, consult later when the disease has already evolved and often in an irreversible stage, indicating the amputation. On the other hand, accidents of traffic occurring frequently in unemployed subjects   can explain this amputation rate in this occupational category.
The analysis of our data shows that diabetic gangrene was more frequent (30.7%), followed by 25.8% with open fractures and malignant tumors (16.1%). In France, Mallory in 2014  and Quesnay in 2013  , had noted respectively 85% - 93% of vascular causes, followed by 5% to 16% of traumatic causes. About lower limb amputations, the opinions of the authors differ. Ogundele OJ et al. in Nigeria  instead, as us, has foreground the diabetes mellitus followed by trauma. Ajibade A et al., also in Nigeria, all causes of amputation combined, recorded different distributions of us; trauma and subsequent gangrene in traditional medicine are respectively 42.4% and 31.8%  . It must be stressed the importance of diabetes with 6 million new patients each year and is responsible for more than 4 million deaths annually, 1 million amputations (85% of the total number of amputations) and multiple complications invalidate  .
The results of this work show right side is predominant with 56% against 44% for the left side. Souna  found the same trend with 50.8% the right side to against 49.2 to the left side.
The lower limbs are more concerned with amputations or 88.7% against 11.3% of the upper limbs in our series. In this regard, our results are similar to those of other authors. Sunna et al.  in Mali found 74.1% for the lower limbs and Ahuka and Lusi  in DRC had found 66%. Ogundele OJ et al. Nigeria  reported a rate of 75.8% and 24.2% respectively for the lower limbs and upper limbs. We believe that being a diabetic foot disease develops gradually with a changing saw tooth, and also an inadequate initial support, lets lesions evolve to irreversible complications   . In addition, the lower limbs are conventionally known as the predilection of diabetic arterial disease   . Also, the legs are exposed to road traffic accidents because they are at the height of bumpers and tire’s rolling machines  .
The analysis of our data shows that major amputation is the most common with 79%. Ahuka and Lusi  in 1996 Nyakunde had found 79% of major amputation against 21% of minor amputation. Richardson C et al. on the other hand found that minor amputations predominate, with 43%, mainly for the upper limbs  .
In our series, the amputation at the leg was more frequent with 52.7% of cases. Our transtibial rate amputation is similar to Mezghani et al.  and 47%, and Quesnel  .
It appears from our study that 17.8% died. These results are higher than those found by Bisseriex et al. who obtained a death rate of 12.5%  . Our results could be explained by the changed nature of the initial lesions. We must recognize here regarding diabetes, weak management capabilities associated with a prohibitive cost of treatment resulting frequencies very high complications  and emphasize that chronic diseases, including diabetes, are a threat serious due to their severity and prevalence  .
The amputation is a situation encountered in Kisangani. The adult male is most affected. Diabetic gangrene and open fractures are the most encountered causes. Mortality is high and due to the precariousness of the economic fabric as shown by the high rate of unemployment. The early management of diabetes can help lower amputations in our midst. Only a real political will of governments and medical and many other actors of the public and private sectors will be achieved.