Although trauma is recognized to be the most common cause of amputation among applying amputees, we think that those amputees do not reflect the general profile in our country. It is known that the most common cause of lower extremity amputation is peripheral vascular diseases and/or diabetes mellitus (DM) 3
Vaz et al. determined the mean age of the patients as 67.6±12.7 years 8. AlSofyani et al. 9 found the mean age as 63.3±17.4 years. In the study of Kauzlaric et al. 10 they determined that mean age was 62 years. Mean ages of these studies seem consistent. Mean age of our patients was 36.12±11.69 years, and it can be explained by the fact that our patients are younger, the demand of younger patients for new technology prosthesis, and the fact that the Social Security Institution pays the new technology prosthesis depending on many conditions such as age, no complications, active employee and student.
In a socio-demographic study with 1538 amputees by Pezzin et. al., 935 amputees between ages 18-86 years old were searched for prosthesis satisfaction 11. The mean age was 50 years in that study whereas in our study the mean age was 36. Note that our youngest patients age was 9. Another reason for the discrepancy may be the maximum life span differences between the two countries.
Aydemir et al. 12 has assessed 147 amputees at Armed Force Rehabilitation Center in Turkey. They determined the mean age of the patients as 32.0±6.4 years. Yaşar et al. 13 determined that the mean age was 23.48±6.04 years. They had assessed 382 soldier and 17 civilian amputees. These studies are similar to ours as the age group is young. However, we think that this is due to the fact that these two studies were carried out at Armed Forces Rehabilitation Center.
Vaz et al. 8 has assessed 39 amputees in Portugal in which there were, 7 (17.9%) female and 32 (82.1%) male patients. AlSofyani et al. 9 has assessed 121 patients in Saudi Arabia. There were 37 (30.6%) female and 86 (69.4%) male patients in this study. Raichle et al. (14) has evaluated 752 amputees and there were 210 (27.9%) female and 542 (72.1%) male patients. We determined 107 (12.8%) female and 729 (87.2%) male patients in our study. Our percentages are closer to the percentages of Vaz et al 8. We think that the rate of amputation in males is higher because of both traffic and work accidents are more frequent in males. In our opinion, due to the low level of economic independence and education in female, the rate of work accidents and traffic accidents is low and therefore amputation rate is low. However, we should keep in mind that these ratios may not reflect the general average of society.
Aydemir et al. 12 determined that 2 (1.4%) female and 145 (98.6%) male patients in their study. There were 1 (0.3%) female and 398 (99.75) male patients in the study of Yaşar et al 13. We think that the number of female is very small due to the fact that these two studies were carried out in military hospitals.
Vaz et al. 8 examined the amputation etiology and determined that there were 92.3% vascular disease, 5.1% bone tumor, 2.6% enfection. When AlSofyani et al. 9 evaluated the patients etiology, they found that 63.6% DM, 16.5% periferal vascular disease, 7.4% trauma, 7.4% lower extremity cancer, 1.7% cronic osteomyelitis, 1.7% skin breakdown, 0.8% sistemic sepsis, 0.8% local important enfection 9. Kauzlaric et al. 10 detected that there were 48.9% DM, 27.1% periferal vascular disease, 11.3% trauma, 7.3% DM + periferal vascular disease, 3.2% osteomyelitis, 2.3% tumor in etiology, respectively. Raichle et al. 14 determined that 4.3% tumor, 16.1% DM, 22.3% vascular disease (non-DM), 53.5% injury, 3.1% congenital, 20.9% gangrene 14. We found that the etiology 44.6% traffic accidents, 12.2% occupational accidents, 9.1% malignancy, 8.5% congenital defects, 6.1% gunshot wounds, 3.3% electrical contact injury, 3.1% peripheral vascular disease, 3.0% explosion of mines, 1.9% Infection, 1.7% earthquake, 1.0% DM, 1.7% falling, gas explosion 0.7%. In our study, the percentage of DM and peripheral vascular disease was found to be very low in the etiology. However, traffic accidents and occupational accidents constitute the greatest percentage of amputation etiology in our study. This suggests that occupational safety and traffic safety system is not sufficient, but it is not a prevalence study related to occupational accident and traffic accidents. We believe that multicentre prevalence study should be conducted in this regard and that necessary precautions should be taken.
Aydemir et al. 12 they determined that 68% mine, 19% gunshot, 4.1% rocket, 4.1% road traffic accident, 2.7% electrical injury, 1.4% pedestrian vs. car accident, 0.7% railway accident in the amputation etiology. Yaşar et al. 13 found that 92.7% mine, 4.5% trafik accident, 1.5% electrical burn, 0.8% freezing, 0.5% earthquake. As the rate of mine explosion is high, the results of the two studies are similar. And we think it's about having military hospital data.
Aydemir et al. 12 found 91.2% unilateral and 8.8% bilateral amputees 12. Yaşar et al. 13 determined 86.7% unilateral, 13.0% bilateral amputees 13. We encountered 92.3% unilateral and 7.1% bilateral amputees, and our findings seem consistent.
In the study of Vaz et al. 8, the amputation levels of the patients were 59% above-knee, 25.6% below-knee and 15.4% foot amputation. Alsofyani et al. 9 determined the amputation level as 49.6% above-knee, 50.4% below-knee. Aydemir et al. 12 found that 21.8% above-knee, 59.3% below-knee, 9.3% knee, 5.6% hip, 3.7% ankle(syme) amputation 12. Yaşar et al. 13 detected amputation level as 14.6% above-knee, 50.77% below knee, 11.25% chopart amputation, 4.6% syme, 4.4% knee disarticulation, 1.1% hip disarticulation, 0.2% hemipelviectomy. Our findings are 54.5% unilateral above-knee, 28.3% unilateral below-knee, 10.0% unilateral knee disarticulation, 2.8% unilateral hip disarticulation, 1.2% bilateral below-knee, 1.7% above-knee/knee disarticulation and contralateral below-knee, 1% bilateral knee disarticulation and foot/ankle disarticulation 0.5%. Our findings seem similar with the study of Vaz et al. 8.
In comparison with the studies of Aydemir et al. 12 and Yaşar et al. 13 in our country; the high rate of below-knee and foot/ankle amputees in their study may still be related to military hospital characteristics. Mine explosion injuries in soldiers cause more below-knee and foot/ankle amputation. The high rate of above-knee amputees in our study may be related to the development of high technology micro-processor controlled knee jointed prosthesis and the fact that our patients are mostly younger and active patients and therefore more likely to have applied for this prosthesis. Our hospital is a national rehabilitation center and the referee hospital status where the prosthesis approval. We think that the prosthesis with micro-processor controlled knee joint of patients who are coming our hospital for approval explain to the percentage of patients with above-knee amputation and knee disarticulation is high.
The incidence of lower limb amputation depends partially on age distribution and geography. In a prospective study from Netherlands including 191 lower limb amputees by Pernot et al. 15, they found that 13.1% of the amputee patients were above 65 years old and the major cause of amputation was vascular diseases. The transtibial level was the most common injury level. In another study with one-year follow up with amputees by Kauzlaric et al. 10, the mean age of the patients was 62, DM and obstructive vascular diseases were the most common causes of amputation, trauma was the second cause. In our study, traffic accidents were the main cause of amputation for patients above 65 years and disvascular causes like DM were the next cause. Besides, we also found that transtibial amputation was the most common injury level in this age group, which was in concordance with the study by Pernot et al. 15 (Figure-1).
In the study of Pezzin et al. 11, the etiologic factors of amputation according to ages were as follows: Malighnancy for patients younger than 18 years old, trauma for patients between ages 19-44, vascular problems for patients between ages 45-64, and also for patients above 65 years old 11. In our study, congenital defects were the major cause for patients under 18 years (39.6%) and traffic accidents were the second most common cause. For patients between 19-44 years old, traffic accidents were the most common cause for amputation (45.3%) and secondly occupational accidents (12.1%). For patients between 45-64 years old, traffic accidents were the major cause of amputation (48.1%), and then occupational accidents (17.6%). For patients older than 65 years old, traffic accidents (42.9%), DM (28.6%) and infection (28.6%) were the major causes of amputation respectively (Figure-2). In our study, traffic accidents were the most common etiology except patients under the age of 18 years old. Therefore, development of the traffic and road safety system is extremely important in our country.