Amputation or Not, Depends on Who's Evaluating

The unfortunate truth about amputation prevention is that not everyone agrees on when a leg should or should not be amputated. There are a lot of factors that make the decision even more difficult, from patient's personal beliefs to insurance coverage to resource availability. This discussion is a very sensitive topic so an honest but thoughtful discussion should take place between the patient and their family with the surgeon in direct care with the patient.

With evolving technology and our advanced understanding of lower extremity biomechanics, below knee amputations have seen a significant reduction in the past decade. Podiatry training is exactly that, knowing when a foot/leg is salvageable and when it is not. 

Here's a case example of an almost amputation with graphic pictures to follow:

A female in her mid-50s presents to the emergency room with a sore on the back of her heel present for several months. She is diabetic with fair control and is active. She admitted to having gotten into an argument with her husband, who then pushed a shopping cart into her leg, creating a laceration. She is the primary caretaker for her family so was not able to seek medical attention at the time. She started feeling sick and wondered why the sore has not healed yet so went to the hospital for care. She did not have insurance so was not able to establish regular care with a primary doctor. 

 After several surgeries to clear the infection, a large wound remained

After several surgeries to clear the infection, a large wound remained

The primary team that was consulted to care for her recommended a below knee amputation, believing it would help her get back to normal activities sooner while removing the extensive infection that was climbing up her leg. However, the patient adamantly refused because she feared it would inhibit her from caring for her family and she did not have health insurance to help obtain a prosthetic leg, which would be needed after an amputation to stay active. When I was consulted for wound care, I saw a necrotic wound filled with dead tissue, an exposed Achilles tendon, with a swollen, red leg that screamed underlying infection. She was developing a fever, indicating the infection was getting worse, and so the patient consented to having an immediate incision and drainage with removal of any dead tissue/tendon/muscle involved. The patient was still at risk for an amputation but without knowing the exact extent of the damage, I was hopeful that I could help her prevent an amputation.

During surgery, there was dead tendon and muscle that infiltrated with infection extending throughout the gastroc and soleus muscle. I followed the track of the infection and it kept taking me up higher in the leg. Amputation always lurks in the back of my mind but I was really fighting for this patient.

POP QUIZ: The patient ended up... (guess)... A) with an amputation B) winning the lottery C) without an amputation.

Answer: C) no amputation and doing well (!) with no residual infection and was able to resume life as she knew it before the infection. It took several surgeries and IV antibiotics to finally clear her infection. A negative pressure wound therapy system was also applied to irrigate (rinse out) the wound and close down the empty space for eventual closure and split-thickness skin graft for the distal area that could not be reapproximated. 

Limb preservation is considered, by some, time consuming but I see it as an essential and expected process and something I truly enjoy doing. Gratification is not often immediate in these wound care cases but with patience and determination, the fruits of your labor will show.