More on Amputations

Post provided by Barbara Bergin, MD

We’ve all been talking a lot about amputations. It’s an operation that doesn’t get much attention in this country. It’s not very glamorous and it’s certainly not cutting-edge technology. We’ve been doing amputations pretty much the same way for a hundred years. In the United States about 40,000 below knee amputations (BKA) and 35,000 above knee amputations (AKA) are done every year! About 70% of those amputations are due to disease, the main culprit being diabetes. About 20% are due to trauma. Those statistics have been gradually changing over the past several decades because of advanced technology with regard to treatment of traumatic injuries of the lower extremities. We learned a lot about the importance of cleaning contaminated wounds in Viet Nam. Just getting a contaminated broken bone cleaned and temporarily stabilized with an external fixator (like the ones you see in the pictures from Haiti) has made dramatic increases in the number of limbs we save here in the U.S. and in other industrialized countries. But again, in Third World countries, amputation remains the mainstay of treatment for these kinds of injuries.

Now an amputation isn’t a simple operation. If not done properly, with adequate bone coverage and just the right amount of muscle padding, fitting and ultimate use of a prosthetic limb can be a problem. So a lot of planning goes into the performance of this operation. And when there is adequate, healthy skin and muscle, this can be done with a relatively predictable outcome.
But traumatic amputations are a whole different ball game. A limb smashing into pavement from a motorcycle accident or being crushed by a collapsed building, such as thousands suffered in Haiti, almost never gives the surgeon an opportunity to perform a textbook amputation. There is always some degree of contamination, torn muscle, stripped skin and exposed bone. This can leave the patient with thin skin and a poorly padded stump, which then can be difficult to fit into a prosthesis and will almost always result in some functional disability and pain. Surgeons want to make every effort to give a patient a BKA because of the energy requirements it takes to function with an AKA (see Dr. DeHart’s blog from 2/22/10). We will often do skin grafts and muscle transfers to cover a little stump of bone in order to give a patient a BKA.

This is doubly important in Haiti, where a BKA instead of an AKA could make the difference in a patient’s ability to work and support him/herself. Many patients are refusing to have second and third operations in order to make improvements to their stump. I can’t blame them. It’s a huge pill to swallow even under ideal circumstances.

Barbara Bergin, MD
Texas Orthopedics