Primary Care Diabetes xxx (xxxx) xxx Contents lists available at ScienceDirect Primary Care Diabetes journal homepage: www.journals.elsevier.com/primary-care-diabetes Review Contribution of diabetes to amputations in sub-Sahara Africa: A systematic review and meta-analysis Daniel Boateng a,b,1,*, Bernard Bless Ayellah c,1, David Nana Adjei d, Charles Agyemang e a Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands b Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana c Public Health Nurses’ School, Korle Bu, Accra, Ghana d Department of Medical Laboratory Sciences, School of Biomedical and Allied Health Sciences, College of Health Sciences, University of Ghana, Korle-Bu, Accra, Ghana e Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, Netherlands A R T I C L E I N F O A B S T R A C T Keywords: Diabetes related amputations remain a major global problem, with devastating complications. We critically Diabetes appraised relevant literature to quantify the prevalence of diabetes related amputations in sub-Saharan Africa Amputations (SSA). An electronic search was performed using the EMBASE and PubMed databases until 2020. Twenty-four Sub-Saharan Africa out of 834 studies retrieved were included. The pooled prevalence of diabetic-related amputations was 36.9% Systematic Review Meta-analysis (95%CI: 32.9%–40.8%). Complications of diabetes related amputations included infection, anaemia, foot deformity and mortality. The study revealed a substantial contribution of diabetes to the burden of amputations in SSA and suggests the need for further studies to assess how to reduce the incidence of diabetes, reduce the incidence of and or delay the progression of macro and microvascular complications of diabetes in SSA. 1. Introduction prevalent and feared complications [5,6]. A South African study, for instance, reported an alarming burden of LEAs due to DM in the public Diabetes mellitus (DM) is a growing global health emergency and sector in Cape Town [6]. A report by the Centers for Disease Control and one of the most challenging health problems in the 21st century [1]. In Prevention (CDC) also revealed about 15–40 times higher burden of 2019, it was estimated that 463 million people have diabetes globally, amputations among DM patients than among non-DM patient [10]. and this number is projected to reach 578 million by 2030, with over Aside the obvious associated morbidity, diabetes patients with LEA have four million people estimated to die from diabetes-related causes [2]. an increased risk of complications and reduced quality of life [11]. DM is one of the most common non-communicable disease, contributing Specifically, 70% of patients who undergo LEA die within their first five to premature disability and the leading cause of death in most low-and years [6]. Even in high-income countries such as the UK, there is high middle-income countries (LMICs) [1,3]. In sub-Saharan Africa (SSA), mortality following amputation, ranging from 39% to 80% [12]. 15.5 million people were estimated to be living with DM in 2017 [4]. The indications for amputations, prevalence of diabetes related The complications of DM are common and devastating, leading to amputations and complications of diabetes related amputations in SSA is blindness and organ damage such as renal failure [5,6]. Major compli- needed. This information will provide a basis for planning locally cations such as amputations are also high among patients with DM [7,8]. appropriate interventions. A few reviews have been done on amputa- The increased burden of amputations among people living with diabetes tions in Africa: for instance, Thanni and Tade, reviewed the indications is parallel to the exponential increase in the incidence of DM [9]. Dia- and mortality of lower extremity amputations in Nigeria [13] and betes foot and lower extremity amputations (LEAs) are the most Limakatso et al. assessed the incidence of phantom limb pain among Abbreviations: AKA, above knee amputation; BKA, below knee amputation; CDC, centers for disease control and prevention; DM, diabetes mellitus; LEA, lower extremity amputations; LMIC, low- and middle-income countries; NCD, non-communicable disease; NIH, National Institute for Health; SSA, sub-Saharan Africa; UEA, upper extremity amputation. * Corresponding author at: Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands. E-mail address: d.boateng-2@umcutrecht.nl (D. Boateng). 1 Joint first authors. https://doi.org/10.1016/j.pcd.2022.01.011 Received 29 October 2021; Received in revised form 27 January 2022; Accepted 28 January 2022 1751-9918/© 2022 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe. Please cite this article as: Daniel Boateng, Primary Care Diabetes, https://doi.org/10.1016/j.pcd.2022.01.011 D. Boateng et al. P r i m a r y C a r e D ia betes xxx (xxxx) xxx amputation population [14]. The critical questions are what is the platform software for advanced meta-analysis [17]. Heterogeneity test contribution of diabetes to the burden of amputations in SSA? What are for all the proportions were assessed with recourse to the Cochran’s the complications associated with diabetes related amputations? heterogeneity statistic (Q) and degree of inconsistency, 12, using the Currently, information on the above questions is either scanty or absent random effect model [18]. The robustness of the pooled estimates was in SSA and have not yet been systematically assessed. Therefore, this assessed by conducting a leave-one-out sensitivity analysis [19]. These systematic review aimed to assess the contributions of diabetes to am- assessed the impact of each of the included studies on the pooled esti- putations in SSA and to determine the complications associated with mate [19]. Statistical significance was considered at a P-value of <0.05. diabetes-related amputations. 3. Results 2. Methods 3.1. Study characteristics This proposed review protocol was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis A total of 830 titles and published studies were identified as per the (PRISMA) for protocol extension guidelines [15]. above-mentioned search criteria (Fig. 1). A total of 743 studies were excluded for being irrelevant to the review question, and 89 full text 2.1. Search strategy articles were assessed for inclusion. In addition, 61 articles were excluded due to various reasons such as wrong outcome or exposure and A customized search strategy containing appropriate words and published in other languages other than English. Eventually, 24 full text terms were used to search MEDLINE/PubMed and Embase databases. papers were reviewed as detailed in Fig. 1. The search strategy is provided as a Supplemental File A. All the included studies involved patients who had undergone ex- tremity amputations. With regards to the outcomes, 18 studies investi- 2.2. Inclusion and exclusion of studies gated the indications and distribution of amputations. Twelve studies reported on the complications and mortalities post amputations. All We included studies that were done in SSA and were (i) published in studies were conducted in public hospitals, with the exception of one English in peer-reviewed journals between 1988–2020, (ii) reported study, which was conducted in a private hospital [20]. All studies were original research on diabetes related amputations in SSA, (iii) conducted retrospective except three studies; of which one was cross-sectional and in any of these study settings; community, residential care homes, pri- two were prospective [11,21,22]. Countries where the studies were mary care, secondary care, tertiary care and specialized care centers/ conducted also varied; half of the studies were conducted in Nigeria institutions; or at the regional level using data from primary research, whereas 2 each of the studies were conducted in Ghana, Tanzania and demographic and health surveys, or demographic and health surveil- Kenya. La Cote D’Ivoire, Rwanda. All the studies were consistent in lance systems. Papers were primarily from research of quantitative defining their inclusion criteria with their outcomes as indications, design. complications, and the contribution of diabetes to amputations. All Studies that were conducted among SSA populations living outside studies included at least 44 patients and the total sample size for all SSA were excluded. Two reviewers (BBA and DB) screened the studies included studies was 3478 (Table 1). The age of patients in the studies titles and abstract against the pre-defined study inclusion criteria. In ranged from 2 months to 96 years. case of divergent opinions, DNA and CA were consulted. Full texts were also independently screened by BBA and DB for eligibility. Information 3.2. Quality assessment was extracted on: authors, year of publication, study design and popu- lation, research methods, indications and mortality burden of amputa- The quality of studies were assessed based on the National Institute tions. Contact was made to authors for full text if the full text was of Health (NIH) Quality Assessment Tool for Observation Cohort and otherwise not available. Cross-sectional Studies [23]. This assessment tool appraises the reli- ability, validity and generalization of quantitative studies. Most of the 2.3. Definition of terms/concepts studies were rated to be good or of high quality (n = 17). They described in detail the design and methodology used, the process of recruiting Diabetes-related complications are defined as amputations per- participants, justification and methods of arriving at required sample formed because of complications primarily due to uncontrolled diabetes size, study setting, clear and detailed presentation of findings. Studies only. Diabetes related amputations refers to clinically diagnosed persons that were rated to be of fair or poor quality (n = 7) were papers that with diabetes who had gone through amputations. Extremity amputa- failed to describe details of subject recruitment process including in- tions are amputations involving the upper and lower limbs. Upper ex- clusion and exclusion criteria and sampling strategies and lacked justi- tremity amputations involve amputations affecting the upper fication of sample size and other issues that could lead to higher risk of extremities such as the shoulder, elbow and fingers etc., whiles lower bias and undermine generalizability of the study (Supplementary File B). extremity amputations involve amputations of the lower limb such as the ankle, thigh, legs and toes. Indications of amputations are the causal 3.3. Distribution of amputations factors or the factors contributing to amputations. Infection in this study refers to gangrene. This article focused on gangrene and peripheral The levels of extremity amputations were reported as upper ex- arterial disease secondary to diabetes leading to amputations. The SSA tremity and lower extremity amputations (Table 2). The lower extremity region was classified based on the United Nations classification of amputations were further categorized as above knee or below knee countries [16]. amputations. Most (60.9%) of the studies reported on lower extremity amputations. Information on the number of amputees per specific age 2.4. Data analysis group was, however, limited in the included studies. Findings from the studies were narratively summarized. Absolute 3.4. Indications of amputations in sub-Saharan Africa number and prevalence of amputations were included, for both men and women. The indications for amputations were summarized as pro- Table 2 shows results of the indications of amputations among the portions. The pooled prevalence of diabetes related amputations were included studies. The reported indications of amputations included estimated using Open Meta (analyst) software, an open-source, cross- trauma, tumours, infections, diabetes, gangrene and complications of 2 D. Boateng et al. P r i m a r y C a r e D ia betes xxx (xxxx) xxx Fig. 1. Flow chart for study inclusion and exclusion steps. The flowchart illustrates the process of arriving at final articles included in the study, from identification of records (n = 834) to final inclusion in meta-analysis (n = 24). bone setting. In Nigeria, the six most common indications of amputation 3.5. Complications of diabetes related amputations were trauma, malignant tumours, diabetic gangrene, infections, pe- ripheral artery disease and burns. Specifically, a hospital-based study by Fourteen included studies reported on the complications associated Ogundele (2015) identified trauma and diabetes as the leading causes of with amputations, which included infection, foot deformity and mor- amputations [24]. Studies from the southern and northern parts of tality. Two of the studies reported mortality rates, without indicating the Nigeria showed that complications of traditional bone setting and proportions attributed to diabetes. There was marked variation in the trauma were the leading causes of amputations [25,26]. Murwana- overall burden of post-operative complications in SSA with mortality shyaka et al. in Rwanda also identified traumatic gangrene and other associated with amputations ranging from 4.7% in a study conducted in trauma-related limb conditions as the leading indications for amputa- Rwanda to 62.5% in a study conducted in La Cote D’Ivoire [28]. In a tion [27]. Essoh et al., in their study among adults in Ivorian Teaching study by Dakbana and Nyaku in Nigeria, complicated diabetes accoun- hospital found trauma, diabetic foot, and peripheral artery disease as the ted for 57% of indications [25]. Foot deformity was 16.7% in a study leading causes of amputations [28]. conducted in Ghana by Atosona [11]. The data revealed a significant contribution of diabetes to the burden of amputations in SSA. Specifically, the overall pooled prevalence of 4. Discussion diabetes related amputations was 36.8% (95% CI: 32.9%–40.1%) as shown in Fig. 2. A leave-one-out sensitivity analysis revealed that the 4.1. Key findings pooled prevalence was most impacted by prevalence data from Sarfo- Kantanka et al. [9] and Manickum et al. [29] (Supplemental Fig. E.1). The review revealed a substantial contribution of diabetes to am- However, there was no significant difference in the pooled prevalence putations in SSA. Other indications of amputations include trauma, tu- when these studies were left out, indicating that the pooled estimate was mours, infection, gangrene, and complications of bone setting with not driven by these studies. much variability among countries, regions, and particular health in- The estimated overall prevalence for other indications of amputa- stitutions. Complications of amputations identified in the review tions were trauma: 39.1% (95% CI: 30.4%–47.7%) (Supplemental included infections, gangrene and mortality with diabetes contributing Fig. A), tumour 14.5% (95% CI: 9.8%–19.2%) (Supplemental Fig. B), substantially to mortalities among post operation amputations. infections 4.1% (95% CI: 2.2%–5.9%) (Supplemental Fig. C) and pe- ripheral vascular disease (PVD) 8.8% (95% CI: 5.6%–14.4%) (Supple- 4.2. Discussion of key findings mental Fig. D). The results of the leave-one-out sensitivity analyses for the pooled prevalence are presented as Supplemental Fig. E (1–5). The 4.2.1. Contribution of diabetes to amputations leave-one-out analyses showed no marked difference in results, sug- The significant contribution of diabetes to the burden of amputations gesting that they were not driven by one single study. in SSA corroborates the results of a systematic review that compared the incidence of lower extremity amputations in the diabetic compared with 3 D. Boateng et al. P r i m a r y C a r e D ia betes xxx (xxxx) xxx Table 1 Characteristics of included studies. Study and year Study design Data collection instrument Sample Sex distribution size Country Data source Study setting Male % Female % Age of participants Akiode et al. (2015) [55] Retrospective study Case notes of all major amputations 69 75.4 24.6 Nigeria Hospital records 1998–2003 Olabisi Onabanjo Hospital in Sagamu, Nigeria 10 months–80 years Awori and Atinga (2007) [64] Retrospective study from Questionnaires 74 59.0 41.0 Kenya Hospital records 2003–2004 Kenyatta National Hospital, Kenya 7 months–96 years Chayla et al. (2012) [65] Retrospective study Questionnaire 167 71.0 29.0 Tanzania Hospital records March 2008–February 2010 Buganda Medical Centre 2 months–70 years Agu and Ojiaku (2016) [20] Retrospective study Data Extraction form 67 91.0 9.0 Nigeria Hospital records 2007–2015 South-western hospital in Nigeria 9 months–89 years Dabkana et al. (2018) [25] Retrospective Data Extraction form 163 75.0 25.0 Nigeria Hospital records 2010–2016. University of Maiduguri Teaching Hospital in Nigeria 2 months–70 years Kidmas et al. (2004) [66] Retrospective study. Amputation data sheet 87 57.0 43.0 Nigeria Hospital data 1992–1997. University of Jos Teaching Hospital, Nigeria 3–83 years Nwosu et al. (2017) [26] Retrospective design Case notes on amputations between 2008–2014 116 67.0 33.0 Nigeria Hospital records 2008–2014 Federal Medical Centre, Benin Kebbi, Kebbi State, Nigeria 3–89 years Ogengo et al. 2009 [67] Retrospective study Case notes on amputations 120 72.0 28.0 Nigeria Hospital records 99–200 Kikuyu Hospital, Kenya 10–90 years Odatuwa-Omagbemi and Vadiki Retrospective study Case notes on age, sex, 44 61.0 39.0 (2012) [68] Nigeria Hospital records 2009–2011 Central Warri Hospital, Nigeria 8–88 years Edonwonyi and Onuminya, Retrospective study Case notes on amputations 53 68.0 32.0 (2016) [69] Nigeria Hospital records 2005–2010 Irrua Specialist University Teaching Hospital, Irrua, Edo state, Nigeria 14–86 years Loro and Francschi (1999) [70] Retrospective, quantitative study, Case papers 241 71.4 28.6 Tanzania Hospital records 1983–1992 Dodoma Hospital, Tanzania 9–89 years Berhe et al. (2017) [71] Retrospective review A pretested questionnaire 87 78.0 22.0 Ethiopia Hospital records January 2011–December Ayder referral hospital, Mekelle, Ethiopia 2013 3–95 years Omoke et al. (2012) [72] Retrospective study Data extraction sheet 58 77.0 23.0 Nigeria Hospital data 2001–2010 Ebonyi State University Teaching Hospital, Nigeria 7–90 years Ogundele et al. (2015) [24] Retrospective study A questionnaire 158 70.0 30.0 Nigeria Hospital records 2006–2013. Nigerian teaching hospital, Nigeria 1–91 years. Olasisinde et al. (2002) [73] Retrospective study Case notes 82 83.0 17.0 Nigeria Hospital records 1987–1999 Nigerian teaching hospital 2–85 years Atosona and Larbie (2019) [11] Cross sectional study Questionnaires and Biomedical information sheet 100 69.0 31.0 Ghana Surveyed information from diabetic patients KBTH, KATH and TTH from June to July 2015 18–80 Alegbeleye (2020) [21] Retrospective study Data collected sheet 132 79.0 21.0 Nigeria Surveyed information from patients National Othorpaedic Centre, Kano, Nigeria 2006− 2010 18–90 years Baidoo and Debrah (2016) [54] Retrospective study Information sheet 94 61.0 39.0 Ghana Medical records on amputations 2010–2013 St. Joseph’s Orthopedic hospital, Ghana Not given Essoh et al. (2009) [28] Retrospective study Data extracted sheet 156 69.0 31.0 La Cote D’voire. Patients records 1998–1999 Yopougon Teaching Hospital, Abidjan 15–85 years Manickum et al. (2019) [74] Retrospective study Information sheet 941 71.0 29.0 South Africa Hospital records 2010–2014 Four public sector hospitals in South Africa 10–90 years Ndukwu and Muoneme (2015) Retrospective study Case notes 90 60.0 40.0 [75] Nigeria Case notes of patients 2011–2012 NAUTH, Nigeria (continued on next page) 4 D. Boateng et al. P r i m a r y C a r e D ia betes xxx (xxxx) xxx Table 1 (continued ) Study and year Study design Data collection instrument Sample Sex distribution size Country Data source Study setting Male % Female % Age of participants 17–89 years Murwananshyaka et al. (2013) Retrospective study Questionnaire 107 70.1 29.9 [27] Rwanda Medical records 2009–2012 University Teaching Hospital in Butare, Rwanda 1–93 years, median age: 44 years Ahmed (2009) [22] Prospective analytic Questionnaire 100 Not Not stated stated Sudan Hospital based study, 2002–2003 Khartoum Teaching Hospital and JADC 35–92 years Alegbeleye (2020) [21] Observational prospective Pretested proforma 172 72.4 27.6 Cameroun Hospital-based study 2018–2019 St Elizabeth Catholic General Hospital, Shisong, Northwestern region, Cameroon. 1–84 years. KBTH = Korle-Bu Teaching Hospital; KATH = Komfo Anokye Teaching Hospital; TTH = Tamale Teaching Hospital; NAUTH = Nnamdi Azikiwe University Teachng Hospital; JADC = Jabir Abu El Iz diabetes center. the non-diabetic population, where the proportion of LEA among dia- been reducing significantly over the past decade [50]. These achieve- betic persons ranged from 27% to 75.5% [30]. A study among the ments were mostly through a campaign of increased screening, wide- Caribbean population in Barbados, also revealed a high contribution of spread adoption of multidisciplinary foot management clinics, stringent diabetes to amputations [31]. With SSA predicted to be one of the re- vascular risk factor management and improved patient education [51]. gions of the world with the highest burden of diabetes, its contribution This review provides evidence of the increased burden of diabetes to the burden of amputations cannot be overemphasized. The Global coupled with LEA and serve to reinforce that diabetes and its compli- Lower Extremity Amputation Study demonstrated high levels of asso- cations pose an ever-present danger to both current and future genera- ciation between diabetes and amputation worldwide [32]. In the USA, tions. Of critical importance is the religious and cultural belief of what diabetes accounts for 65% of non-traumatic lower-extremity amputa- diabetes is, its cause cure etc. which leads to late presentation in SSA tions performed [33]. In the UK, almost one in three (33%) amputees has [52,53]. diabetes [34], whilst almost half of all Australian amputees are affected by diabetes [35]. 4.2.2. Complications of diabetes related amputations Diabetes foot disorders is one of the most prevalent diabetes related Our systematic review also showed an increase mortality rate among complications [36]. With a significantly higher risk of LEA and mortality diabetes related amputations [25,54,55]. High mortality rate from dia- [37]. LEA in diabetes patients often arise as a result of poorly managed betes related amputations is almost universal. A study in the UK for diabetes (poor glycemic control) and/or peripheral neuropathy, infec- instance revealed that, up to 80% of diabetes patients die of LEA within tion and peripheral arterial disease [37]. The reasons for the increase 5 years [37]. Gunney et al. found that 18% of major amputations result burden of diabetes related amputations in SSA could be attributed to in mortality within the first 90 days post operatively [56]. Other evi- sub-optimal diabetes care, control and management [37,38]. Clinical dence shows that patients with diabetes who undergo LEA have a high outcomes of diabetic foot ulcers could be improved through prompt mortality rate [57]. Although this rate of postoperative mortality is referral for specialized assessment and treatment [39]. A recent sys- substantial, it is consistent with other diabetes literature from a sys- tematic review and meta-analysis found a positive impact of structured tematic review of mortality after LEA [58]. However most of these diabetic foot care services on preventing overall and major LEA [40]. mortalities are hardly reported in SSA due to lack of access to healthcare Also, in SSA, health systems are more focused on infectious diseases and [41]. Even though co-morbidities of cardiovascular and renal compli- are not well equipped to provide care for NCDs such as diabetes. Further, cations may account for mortality in diabetes related amputations, there the general lack of access to foot screening services and specialist is no published work on this. podiatrist within the public health space could account for the problem of diabetes related amputations in SSA [41]. Many other factors 4.2.3. Other indications of amputations including limited resource allocation, lack of training among health This study identified gangrene aside diabetes as one of the leading professionals and low health literacy contribute to the high rates of causes of amputations. The occurrence of gangrene in some of the pa- complications of diabetes foot and amputations in SSA [42]. For instance tients who sustained trauma could be attributed to initial mismanage- in Ghana, as in most other countries in SSA with a rising trend of ment by traditional bonesetters, which alludes to their inadequacies diabetes-related, lack of resources, high patient load, absence of suitable with majority of them in LMIC’s [59,60]. The role of diabetes in foot facilities and trained personnel have been identified as major contrib- gangrene cannot also be over emphasized as foot gangrene is reported to utors [43]. Furthermore, illiteracy, poverty, shortage of nursing staff, be 50 times more common in diabetes patients over the age of 40 than in lack of diabetes policies/guidelines, and inadequate medical resources non-diabetes patients of the same age [61]. Access, culture and poverty impede the management of diabetes in the sub-region [44]. could contribute to the patronage of traditional medications especially The increased burden of diabetes related amputations could also be in the management of diabetes in some countries in SSA [62], resulting due to late presentations at the health facilities. Several studies from SSA in later presentation at the health facility. There is an undeniable role of indicated that people living with diabetes report late to hospital or only medical plurality in diabetes self-management in some countries in SSA after the onset of gangrene or late sepsis that might be resistant to an- for instance among the Swahili of Lamu town, Kenya and in Guinea, tibiotics, fluids and insulin, culminating in systemic infection, which diabetes patients use herbal and traditional management approach in increases the risk of amputation [45–47]. addition to orthodox [63]. Contrary to the finding of this review, a decline in incidence of LEA has been reported in many high-income countries over the past three decades [48,49]. For example, in the UK, the rate of amputations has 5 D. Boateng et al. P r i m a r y C a r e D ia betes xxx (xxxx) xxx Table 2 Outcome of assessment of included studies. Study and year Indications for amputations Levels of amputations Complications % Country DM, % Trauma Tumours Infections PVD Others % UEA LEA/ BKA % Others % % (Cancer) % % % AKA % % Akiode et al. (2005) 14.1 76.1 8.5 Not 1.4 31 Not 42 28.9 Mortality rate was [55] Not given given given 7.2% 50% due to Nigeria diabetes. Awori and Atinga (2007) [64] 17.5 18.9 24.4 1.4 37.8 Not given Not 55 31 14 Not given Kenya given Chalya et al. (2012) Mortality rate was 41.9 38.4 7.4 8.6 3.7 13.6 39.5 46.3 0.6 [65] Not given 16%, 42.0% was Tanzania due to diabetes. Agu and Ojiaku 22.3 70 Not Not 43.3 37.2 19.4 Mortality was 9%; (2016) [20] Not given Not given Not given 50% was due to Nigeria given given diabetes Dabkana et al. Not Not Mortality rate was (2018) [25] 57 13.3 7.3 4.3 5.5 17.6 given given 76 Not given 55.6% 22% was due to peripheral artery disease. Nigeria Complicated diabetes accounted for 57% of indications Kidmas et al. Mortality rate was 26.4 29.9 23 9.2 11.3 Not 49.9 37.2 13.9 (2004) [66] Not given given 12.6%, 34% due to Nigeria diabetes. Ogeng’o et al. 2009 11.4 35.7 12.9 14.3 Not 25.7 24 31 45 [67] Not given Not given Kenya given Odatuwa- Omagbemi and Vadiki (2012) 63.6 20.5 Not given Not given Not Not given 9 37.5 62.5 17.4 Mortality rate was given 6.5% [68] Nigeria Edonwonyi and Onuminya 40.6 35.9 6.3 7.8 9.4 6.3 32.1 53.1 9.4 (2016) [69] Not given Not given Nigeria Loro and Franceschi Not 15 40 10 20 15 Not Not given Not given Not given Not given (1999) [70] given given Tanzania Gebreslassie et al. 8 37.7 24.1 9.8 20.7 Not 23 36.5 (2018) [71] Not given Not given Not given Ethiopia given Ogundele et al. (2015) [24] 30.4 48.1 2.5 Not given 3.8 Not given 24 31 45 Not given Mortality rate was 0.2% Nigeria Nwosu et al. (2017) Diabetic 24.1 19.6 8.9a 8.0 Sequel of 24.2 45.5 39.3 [26] foot tradition bone Not given Nigeria -23.2 setter (16.1) Olasinde et al. (2002) [73] 13.4 65.9 8.7 Not given Not 9.8 15 Not 42.9 37 Not given Nigeria given given Atosona and Larbie Foot deformity: 23.2 51 19.6 46 (2019) [11] Not given Not Not Not Not given Not given present vrs absent Ghana given given given – 16.7% vrs 2.1%; p = 0.043 Omoke et al. (2012) [72] Not Not Not given Not given Not Not given Not Not Not given Not given Not given Nigeria given given given given given Ajibade et al. (2013) [76] 4.5 42.4 12.1 3.8 Not Gangrene 31.8 27.8 31.1 36.4 6.8 Mortality rate was given 2.3% Nigeria Baidoo and Debrah 27.4 46.3 27.4 11 21.7 45 55 Mortality rate was (2016) [54] Not Congenital 6.4% Not given 53.8% due to Ghana given malformation, 3 diabetesto diabetes Essoh et al. (2009) Mortality rate was 31.4 49.9 3.2 13 2.5 27.4 11.9 46.9 11 [28] Not given 16.5%, 62.5% to La Cote D’Ivoire due to diabetes and Septicemia (continued on next page) 6 D. Boateng et al. P r i m a r y C a r e D ia betes xxx (xxxx) xxx Table 2 (continued ) Study and year Indications for amputations Levels of amputations Complications % Country DM, % Trauma Tumours Infections PVD Others % UEA LEA/ BKA % Others % % (Cancer) % % % AKA % % Manickum et al. 55 (2019) [29] Not Not given Not given Not Not given Not Not 37.3 Not given Not given South Africa given given given given Murwananshyaka 1.9 13.1 29 2.8 0.9 14 35.5 37.4 8.3 Mortality due to et al. (2013) [27] Gangrene, 43.9 diabetes was 4.7%. Rwanda Ahmed (2009) [22] 70 18 patients (74) had Mortality rate due Not Not given Not given Not Not given Not Not (26%) had transtibial to diabetes was Sudan given given given given trans femoral amputation amputation 20%. Alegbeleye (2020) [21] 22.9 60.4 2.6 3.49 Not 12.21 42.3 Not (57.7) Not given Mortality due to given given DM was 9.30%. Cameroun PVD = peripheral vascular disease; DM = diabetes mellitus; UEA = upper extremity amputations; LEA = lower extremity amputations; AKA = above knee amputations; BKA = below knee amputations; DFG = diabetic foot gangrene. a Post infective gangrene. Fig. 2. Forest plot of the pooled prevalence of diabetic-related amputations in sub-Saharan Africa. The forest plot shows the prevalence and 95% CI as well as the pooled prevalence from meta-analysis of 22 included studies that reported on the prevalence of diabetes related amputations. 4.3. Strengths and limitations implementation of strategies to ameliorate the increasing incidence and complications of diabetes and its related amputations. Furthermore, The strength of this review is the fact that it is the first review that enhanced health education and special diabetes care (foot care) must be assesses the contributions of diabetes to amputations in SSA and to given to the individuals living with diabetes to reduce the complications determine the complications associated with diabetes-related amputa- and the mortalities associated with diabetes. tions. Unfortunately, we were unable to include other studies conducted in other languages due to language barriers. English as an inclusion Funding criterion might have excluded some advanced research result from other countries. Our study was limited to only some few African countries and This research did not receive any specific grant from funding therefore does not represent all the countries in SSA. agencies in the public, commercial, or not-for-profit sectors. 5. Conclusion Conflict of interest The review findings demonstrate a substantial contribution of dia- None declared. betes to the burden of amputations in SSA with its associated compli- cations of infections and high mortality rates. However, the factors responsible for this contribution in SSA are not very clear. This suggests Author contributions the need for further studies to assess how to reduce the incidence of diabetes, reduce the incidence of and or delay the progression of mac- Bernard Bless Ayellah: Conceptualization, Original draft prepara- rovascular and microvascular complications of diabetes in SSA. In tion. Daniel Boateng: Methodology, Formal analysis, Reviewing and addition, there is the need for countries to invest in planning and editing. David Nana Adjei: Supervision, Reviewing and editing. Prof Charles Agyemang: Supervision, Reviewing and editing. 7 D. Boateng et al. 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