Leprosy
mailing list – September 18th, 2005
Ccn: all.
From: A Salafia, Mumbai, India.
Dear
Salvatore,
Allow
me a few words about plantar ulcers and amputations which was a hot
topic a couple of months ago. I
just relate one experience which should make every surgeon ponder
before deciding whether to amputate or not.
An
old patient of mine came to me about 6-8 months ago with extensive and
very much infected left foot; the infection was on both malleoli; each
wound was about 10 cms. radius, which left very little soft tissue
apparently healthy; the bones were exposed, most of the soft tissues
necrotic, the only good thing, the plantar aspect of the foot was
unaffected, but then the plantar area received its blood supply by two
narrow strips of soft tissue.
I
asked my colleague, Dr. Chauhan (an orthopaedic) for an opinion; it
was a clear case of Charcot as the foot was ‘floating’; the
extensive damage to bones and soft tissue made us conclude that the
only possible solutions was amputation below knee (BK).
I
explained in details to the patient why the foot could not be saved
and why BK amputation was the only solution. The patient was not ready for
amputation; further he reminded me that 15 years early he had come to
me with a similar problem on the right foot; every orthopaedic doctor
in town had told him that amputation was the only solution, yet I
tried to realign the foot because the plantar skin was good. I did
align the foot; put it in POP for 4 months; later made him walk
–gradually- on his foot.
I
told him that this time there was a great difference: the infection
and the extensive tissue damage, which was not there on the right foot
15 years ago. The patient
asked for ‘one more chance’. I told him that I could not offer him
any other choice and I concluded “if you believe in GOD, pray for a
miracle’; the reply “Yes sir, I will do what you say”. He went to his native place.
Came
back after too months: the wounds had closed, except for a tiny
discharge; the bony damage was still –apparently – unchanged and
the foot was ‘floating’ as before.
What next? I told him I was impressed with the results but
asked to wait for two more months, so that the inflammations would
settle down. He did attend the ulcer-clinic regularly, after two
months a series of X-ray showed that there was a certain amount of
bone – impossible to make out which bone – in the foot; in this
circumstances I suggested - Dr. Chauhan agreed – that we do a
thorough surgical cleaning and try to put the Charnley clamps through
the tibia and the bones on the foot; “if the bones on the foot hold
well, then we can go ahead, but if the bones are ‘like butter’
than we have to do a BK amputation”. The patient agreed to this
plan. We did have to do a lot of cleaning, but when we passed the
Steinman pins, we found the bones to be ‘osteopetrotic’ and hence
went ahead with Charnley clamps. We kept them for two months, then
applied POP and asked the patient to start walking for a few minutes
at a time. Today he is
walking on his feet!
I relate this
because I too am surprised at the capacity of recovery some patients
have; and I conclude saying “do not give up too soon on your
patients, do not choose the easy path of amputation.”
Antonio
Salafia
