Leprosy mailing
list – March 30th, 2005
Ccn: all.
Ref.: Indications
for amputation in complicated chronic ulcer.
From: G Warren,
Sidney
,
Australia
Dear
Salvatore,
I have just
read the reply by Mr Kingsley (LML March 26th, 2005)
suggesting that amputation is a treatment of choice for the patients
with a chronically deformed foot who do not want to have to tolerate
years of chronic ulcers which keep recurring.
I understand where he is coming from, but after over 45 years of
dealing with chronic ulceration in leprosy and other neuropathic feet
I will state emphatically that amputation is the choice of
the lazy doctors and staff. It is not the choice of the
patients. Yes it does get rid of the ulceration but it is really
more difficult to fit a prosthesis to an anaesthetic stump than to fit
a shoe to a deformed anaesthetic foot. And the artificial limbs need
constant replacement and repair which is often not practical, and is
expensive.
Older patient
may never learn to walk in an artificial limb. In many
patients it is merely a matter of
a '
Bump-ectomy"- removal of the bony spur or promontory that
produces the excessive pressure that creates the ulcer- yes, that can
be done in an OPD setting if needed! In the more severe cases it may
be desirable to do a wedge osteotomy to reshape the foot with
internal fixation. Yes, they will heal if immobilised adequately
for long enough-usually 9 months.
On those with
a very severe destruction of the fore or mid foot then a
Pirrigoffs or Boyd amputation which leaves the heel pad intact
provides a weight bearing stump that does not need a prosthesis and on
which the patient can wear a normal shoe!
All this is
dealt with in my book. “The care of neuropathic limbs” which is
available from T.A.L.C. in
UK-
email <talc@ltalcuk.org.>
Webpage www.talcuk.org.
I have
literally hundreds if not thousands of patients in whom we have saved
feet that were once condemned and the owners told "we cannot cure
you- have it off". In some the feet have survived for 30-40
years after that statement and still remain ulcer free and useful- but
if the patient will not do his part of daily care then! So training of
the patient in self care is an essential and I make the patient do
that before I will really attempt reconstructive surgery.
This is the
work that Dr Paul Brand pioneered in
India
in
the 1950s and, in the last decade or so, is being applied in the
developed countries for diabetic patients and others with neuropathy.
The third
world lead the way for the first world to follow. I hope,
for the sake of the patients, that everybody can catch up
too. A failed reconstruction can always go on to an amputation-
but once it is off it is rather final! Good salvaging-
Grace
Warren,
Previously
Leprosy Mission Advisor in Leprosy reconstructive Surgery in
Asia-
and still doing it.
