Surgeons weigh loss of a limb Amputation: Doctors questioning benefits of reconstructing arms and legs for patients who may be better served by prostheses.

December 31, 1998|By Jonathan Bor | Jonathan Bor,SUN STAFF

Two weeks and seven operations into their fight to save Joseph Langer's shattered leg, surgeons at Maryland Shock Trauma Center decided they had tried long enough. A decade ago, they might have been reluctant to quit this soon -- but not now.

They told the 37-year-old Pasadena man, who was injured in September when he stopped to help two fallen motorcyclists, that he'd suffer less with a prosthesis than a reconstructed leg that would require years of additional surgery and, perhaps, never stop hurting or support his weight.

"He might have had a living leg, but the function would be quite doubtful," said Dr. Andrew Burgess, chief of orthopedic surgery at the regional trauma center. "In a medical context, we might have chalked it up as a success. In fact, he was going to do better without it."

In the 1970s and 1980s, surgeons made huge technical leaps that enabled them to reconstruct limbs that were once considered unsalvageable. They cured rampant infections with a new generation of antibiotics, grafted healthy muscle and bone into wounds, and repaired bones with external fixators composed of steel frames, pins and screws.

With new tricks of microsurgery, they learned to connect tiny blood vessels that had been sheared apart.

But more recently, some surgeons have begun to ask whether some of their successes were really in the best interests of patients.

"All of a sudden, a cloud of common sense came over us," said Burgess. "We had the technical ability to save legs, but many were not that functional. Some patients were, in fact, in constant pain. The bottom of the foot might be numb and people might constantly trip or burn themselves in the bathtub or stumble up steps."

The question -- to save or remove -- has become one of the most pressing issues in trauma surgery. Eight of the nation's emergency centers, including Shock Trauma, are examining the issue through a study of 600 severely injured patients who have gone through amputation or reconstruction.

At regular intervals, researchers are visiting the patients and assessing their pain, function and quality of life. Within a few years, they hope to develop a rating system that could be used to decide early which course should be followed.

"The underlying hypothesis is that there are certain types of injuries that might be better treated using an amputation rather than reconstruction," said Dr. Ellen MacKenzie, assistant dean of the Johns Hopkins School of Public Health and one of the study's coordinators. "This is a perfect example of a technology that has gotten ahead of itself."

Struggle to decide

Burgess says he is quicker to amputate in borderline cases than he was a decade ago, but still struggles to decide when is the right point to declare a limb unsalvageble. Though gratified by zxssmany patients who live happily with reconstructed limbs, he admits that some endure lengthy reconstructions without ever gaining mobility and freedom from pain.

Gary Chasles, a former carpenter from Prince George's County, said he wishes doctors had decided to amputate his right leg earlier than they did.

Ten years ago, Chasles was riding his motorcycle outside Ocean City late at night when he collided with a car that had swerved onto the highway from a side street. Chasles smashed his right foot through the car's headlight, ripping apart his arch and instep.

Surgeons tried to rebuild his foot by borrowing muscle from his thigh and from the area beneath his arm. They amputated a toe when gangrene had set in, and straightened a few others by breaking and resetting them. Over the next year, he endured about 12 operations.

He stayed out of work for several months, battling a deep pain that flared whenever he tried to walk or stand. He sought relief by wearing a high orthopedic boot with gel insoles, but the foot still couldn't bear any weight.

L "It looked like I was just dragging my foot along," he said.

After two years, doctors proposed more surgery but didn't argue when he declared that he'd rather lose the leg and learn to use an artificial one. Two weeks after they performed a below-the-knee amputation, he was back to work. Within six months, he was walking ably with a prosthesis that he considers an extension of himself.

"I can tell you when a pebble is underneath," said Chasles, who now works for a prosthetics maker and counsels patients facing amputation.

Chasles said he battled post-surgical pain, but nothing approaching the agony caused by the earlier salvage procedures. He also faced an emotional sense of loss, but that, too, faded.

"Initially, you feel you're not the same person, you're not whole. But the truth is, you are the same person. You're just missing a piece."

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