Leprosy mailing list – April 16th, 2005
Ccn: all.
Ref.: Indications for
amputation in complicated chronic ulcer in leprosy.
From: S
Kingsley,
Mumbai
,
India
.
Dear Dr Noto,
I thank Dr
Grace Warren
(LML - March 30th 2005) for the useful comments on the traditional
core values and principles of interventions (palliative and surgical)
to manage an ulcerated leprous foot.
As regards
“amputation” (lml – March 26th 2005), I proposed this as an
“inappropriate assumption”; in the context of treating chronic
ulcers with malignant change [A feature of Marjolin's ulcer]. In
such cases the “amputation” (followed by adaptation of prosthesis)
is inevitable, which allows the patient to have physical autonomy as
well as helps to limit morbidity due to disseminated disease.
Apparently, I did not refer that “amputation” means only
“below-knee amputation”. The amputation may range from
“Sesamoidectomy” to “Lisfranc's or Pirrigoffs amputation”
taking into account the extent of neuromuscular and skeletal damage as
well as several other factors such as patient's age, nature of
occupation and psycho-social implications. All these are
considered as a general rule before subjecting the leprosy patients
for any “amputation” procedure. Most leprosy patients with chronic
ulcer would expect that the surgical treatment must provide them a
functional and a trouble-free limb [But not a care-free limb]. As the
‘consumer culture’ is changing, we must help the leprosy patients
to make the best decision based on their own values and preferences.
Rightly, Dr
Grace Warren
has emphasized on the need for ‘self-care training’ to keep the
insensitive foot free of ulcers for a pretty long period.
Nevertheless, the impact of “self-care” have not made any
significant change in reducing the recurrence, as the routine “lip
service” given to a leprosy patient with anaesthetic feet had least
effect in preventing recurrent ulcerations. Still it is not
common to see a leprosy patient with chronic ulcer occupying hospital
beds intermittently for several years. Moreover poor compliance
to regular protective micro-cellular-rubber (MCR) footwear has been
observed by many leprosy workers. Therefore, it is necessary to
plan a “targeted prevention strategy” that would be required to
arrest the morbidity associated with recurrent plantar ulcers.
It is well acknowledged that this is a stupendous task and just leaves
it alone.
Rapid developments in medical technology have dramatically increased
the benefits of modern medical care for treating wounds and ulcers due
to variety of aetiology. The use of many wound healing agents (skin
transplantation as mentioned by Dr PK Das - lml April 2nd 2004 -),
phototherapy (pulsating magnetic field and laser beams) and
hydrocolloid occlusive dressing have shown only a short-term effect in
healing burn wounds and other type of ulcers like stasis ulcers and
post operative wounds. However these sophisticated technologies
are heavily biased towards hospital-based curative care and not
percolated to the leprosy services due to economic reasons.
Compared to the cost of maintaining hospital beds, loss of wages, cost
of dressing materials and the cost of conventional MCR footwear, which
are required in multi-fold for a leprosy patient with chronic ulcer,
the cost of a well fit prosthesis, - including repairs and
replacements – I am sure the latter, would work out to be cheaper.
I think these
are the fundamental problems which many leprosy workers are facing
today in preventing recurrent ulcerations and we simply lack an ideal
intervention protocol to confront this challenge. With these
explicit practical concerns, I once again state that “amputation”
is just one of the management for chronic plantar ulcers in leprosy
patients and definitely not the choice of professional workers.
Best regards,
S. Kingsley
