Amputation

            Nobody wants to live with an incomplete body. When it comes to amputation of a body part, every one is equally worried. Even I have imagined so many times what will happen if some mishap occurs and I have to get my finger, hand or any other appendage amputated. Amputation of upper limbs can result in end of my career, while amputation of the lower limbs can cause me life style problems. 

            There are situations in which there is no way other than cutting the diseased part. The classical textbook description of amputation includes ‘dead, deadly and dead loss’. It is difficult for a surgeon to decide on major thing like amputation. Even with the same patient, 5 surgeons will have five different opinions on management. Each one forms their decision from their clinical experience and judgment.

           There is a patient currently admitted in our ward with a large wound on right lower limb. It started as a necrotizing fasciitis and underwent multiple debridements. He is not a diabetic, but had jaundice, probable as a result of sepsis. His septic symptoms started resolving after the first debridement. Almost two months have passed and there are no signs of granulation of the wound. Amputation of the limb was advised, but the patient and relatives were not willing. Today one of our consultants commented that, there is still hope and debriding with dressing should help in healing of that wound. The senior consultant replied ‘I can give in writing, that wound is not going to heal and the patient is not going to get a functional limb back even if you wait for long.’

      

           There was a patient post renal transplant, a chronic diabetic and near blind as a squeal of diabetic retinopathy, presented to Out patient department with a small foci of infection at 2^nd space of right foot. There was no underlying bone infection and he was treated with incision drainage and antibiotics according to culture reports. The lesion never healed well, it remained dormant. After 2-3 months, he presented with infection involving forefoot. At that stage it warranted a forefoot amputation. On imaging the blood flow to the limb was present although decreased. The patient was a well-educated man, with an equally educated wife. It was difficult convincing them for a below knee amputation at the first instance. The same time it was not possible to substantiate on the available reports that, there was no chance of healing. The treating doctor did not want to put pressure on the patient or relatives and the patient and relatives did not want to give up hope. The wound was treated with serial debridement and dressing for a period of two months. Finally he started having fever and increasing pain, the decision was made and he underwent a below knee amputation. Even after that it took around 4 weeks for the stump to heal properly.

          There was another patient I met in Trauma Center. He was a young man recently married and had a small child. He had polio during child hood and had left lower limb residual paralysis. He was travelling on a scooter and got hit by a car, resulting in an open fracture of the paralyzed lower limb. There was a major tissue loss, and the fracture was fixed with external fixators. I did his wound dressing. There was little muscle tissue on that limb. Most of the muscles were atrophied and replaced by fat as a result of the paralysis. But the interesting thing was that the patient looked extremely sad and irritated. He wanted to have that limb amputated. He had even requested the surgeon in charge to amputate that limb. He said ‘All the life, I was carrying this limb like a burden, It was of no use and now I am in hospital just because I have a wound on this limb which is giving me pain. Even if the fracture and wound heal, I am not going to get any advantage of it. Why can’t you just amputate it? I will be happy with prosthesis.’ Well, the surgeons point was that, the limb was salvageable according to the grade of injury and we should do whatever that takes to save that limb.

            It is not just about the limbs, breast is another important organ, which needs to be removed as a part of cancer treatment. In India for the less educated population coming from rural area, their only condition is to get the whole disease removed. They are not worried about cosmetic outcome. They often express a feeling as if some dangerous animal or thing is attached to their body and they want to get rid of it. They come to surgeon just because they cannot remove if by themselves. On the other hand the educated, urban ladies often want to do a procedure that retains the breast.

              Many breast conservation surgeries are done now days. But radiotherapy is an inevitable part when you do breast conservation surgery. Often the radiotherapy leaves persistent skin color changes, thickening of skin, and local reaction. I cannot think from a female point of view, but I often feel, removing the whole breast and going for a reconstruction gives a better cosmetic outcome than the ‘different’ looking deformed residual breast.

        One has to take in account of everything before deciding on amputation. The decision for amputation will be painful for the patient and family. The patient and family will always turn their head to the side where they see some hope. Medicine is a subject where no one can give hundred percent guarantee on anything. But once the decision is made, it is better to stay with it than giving multiple options and adding confusion to the already perplexed patient.