Notes From the Medical Director: Choosing Amputation

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Volume 11 · Issue 4 · July/August 2004 | Download PDF

by Doug Smith, MD, ACA Medical Director

Life is full of wonderful moments – and difficult ones. We eagerly anticipate and cherish the wonderful times. It is human nature to try to avoid the difficult ones; however, the difficult choices are the ones that can open the doors to finding out about our inner strengths. As Sir Edmund Hillary, the first person to climb to the top of the world, said after he scaled Mount Everest: “It’s not the mountain we conquer, but ourselves.”

I noted in my last column that doctors instinctively want to save an injured or diseased limb, rather than amputate it. Nevertheless, occasionally amputation can be the most direct route to renewed health and a better life.

Whenever I talk with patients during the process of reaching a decision to amputate, I tell them, “You’re making a decision that nobody should ever have to make.” Nevertheless, that decision must be made and sometimes the wisest course is to choose amputation. Why is this? Shouldn’t the goal be to save the limb? Unfortunately, that is not always possible. Sometimes, it is not even desirable. For instance, in cases of a traumatic injury, toxins released by the severely damaged tissue can lead to kidney failure, respiratory problems and even death. Saving the limb actually could threaten the person’s life.

In congenital deformities, the issues become extremely complex. A study by James McCarthy and associates in the December 2000 issue of The Journal of Bone and Joint Surgery compares two groups of children with fibular hemimelia, a congenital defect of the lower leg. One group was treated with amputation. The other participants underwent a process of lengthening one of the leg bones.

The study concluded that those children who experienced early amputation were more active and had less pain and fewer complications. They also experienced fewer surgeries and were more satisfied than those who underwent the lengthening procedure. To me, that would seem to indicate that those children who experienced amputation might well be “happier” in the end than those with salvaged limbs. Even with this type of outcome data, the decisions facing the family and the surgeon are excruciatingly difficult.

Further study is needed to examine quality of life issues for people who must choose limb salvage or amputation. Such choices are commonly required for a variety of conditions, including congenital defect, trauma, tumor, diabetes, vascular disease, and pain.

There are no guarantees that a person suffering pain in a limb will enjoy improved comfort following amputation surgery and recovery. Amputation can and does have issues of discomfort and pain. But it’s very interesting to note that McCarthy’s study spotlights those whose lives seem improved after limb loss, rehabilitation and adjustment to a prosthesis.

A prosthetic device that is well designed can be comfortable, durable and able to bear weight for walking. Some salvaged legs will not function as well as a modern prosthetic replacement if the salvaged limb cannot bear weight, causes severe pain or lacks sensation. Saving that limb could limit the person’s mobility because it cannot bear up during activities.

Emotionally, attempting to save a limb may not be the wisest course. It can put a person on a “salvage” roller coaster. There are no guarantees that this process, which takes time and often subjects patients to issues concerning skin graft, muscle flaps or bone grafts, will produce the desired results. Patients may experience highs and lows and spend a considerable amount of emotional energy. They may also feel that they have “failed” if the lengthy process does not produce the hoped-for result.

I try to counsel patients that sometimes amputation can put them on the path leading to a better life. The goal in life is not to finish with 10 fingers and 10 toes – but to be active, enjoy life, and be able to do the things that are important to you. Of course, amputation is a very difficult decision to make. I have found that peer visitor-support programs can be very helpful. Those considering limb loss can meet others who made the decision to choose amputation and can discuss the effect it had on their lives. This enables them to obtain information and gain realistic insights into what they will experience.

While losing a limb certainly is a major setback in the beginning, in time the person may again lead a full, active life. “Amputation may be permanent, but defeat need not be,” said journalist and magazine publisher C.B. Forbes. “History has demonstrated that the most notable winners usually encountered heartbreaking obstacles before they triumphed. They won because they refused to become discouraged by their defeats.”

Choosing amputation can be that difficult, but wise, first step toward triumphing over adversity.