Amputation Versus Conservatism
Milton J. Wilder, M. D.
Historically, the approach to the treatment of patients with anomalous limbs has tended to be conservative. The typical practice has been to attempt to support and lengthen the limb segments with or without surgical reconstruction. Amputation of anomalous limb segments has been reserved as a procedure almost of last resort. This conservatism has stemmed, at least in part, from lack of certainty as to the treatment of choice in such cases, and in some instances from patient or parental resistance to amputation. To amputate or not to amputate is a question debated repeatedly at orthopedic conferences.
In the past decade, a gradual but definite firming of opinion on this subject has been apparent. This is primarily due to the considerable accumulation of experience in the treatment of children with congenital anomalies, and particularly the expansion of knowledge concerning the historical development of defects over five, ten or fifteen years of a child's life. Under certain conditions, where the life history is known and the effects of treatment with and without amputation well documented, amputation has emerged as the possible treatment of choice. Kruger and Talbott,(1) for example, recently reported the successful application of this method of management in cases of congenital absence of the fibula. earlier, Aitken (2) described the successful outcomes of amputation in the treatment of a variety of types of congenital abnormalities.
My contribution to this area of interest will consist of the presentation of four cases in which amputation appeared to provide the most satisfactory solution to specific problems. In all instances, amputation was accepted only after considerable delay or extensive reconstruction or both.
This case is representative of patients who resist amputation in spite of multiple problems. Three operations were performed and further surgery to the foot contemplated before the decision to amputate was accepted. The surgical history was as follows:
Transference of the fibula into the os calcis, 1/23/58.
Tibio-fibular fusion, right lower extremity (Figure 3 ), 5/8/58.
Transposition of the fibula to proximal tibia, 7/24/58.
Syme-type amputation at ankle level, right lower extremity, 6/7/60 (see Figure 4 ).
Revision of soft tissue of draining amputation stump, 7/8/60.
The problem of proximal femoral focal deficiencies has been discussed frequently Patient J.S. was seen in our clinic after fusion had been performed elsewhere. The surgeon was apparently unaware of the difficulty the patient would experience in attempting to sit while wearing a prosthesis. In order to solve the problem, the femur was excised so as to dissipate the fusion. Because of the apparent favorable result achieved in this case, excisions of the entire femur have been done in four other patients. This procedure has succeeded in eliminating the bulky mass at the thigh, in producing shortening of the affected side, and in creating stability through the removal of the unstable knee joint. The prostheses thereby become easier to fit and the knee centers are equalized. The history of J.S. reveals :
Insertion of Kirschner wire in upper tibia, 5/17/55.
Ilio-femoral fusion, 8/29/58.
Steinman pin inserted over proximal tibia under local, 4/4/59.
Patient S. W. - Proximal Femoral Focal Deficiency.
The problems presented by this patient were primarily difficulties in proper prosthetic restoration. The fitting problems include bulkiness in the thigh region and difficulty in obtaining a satisfactory knee center because of the extension of the foot below the normal knee center. Amputation was suggested to the parents prior to the patient's visits to our clinic, but was unacceptable to them. The patient himself has finally requested amputation, which should facilitate fitting of the prosthesis and, by effecting equalization of knee centers, improve the patient's gait. (Figure 12 , Figure 13 , and Figure 14 depict the deformity and the prosthesis.)
Patient R. B. - Poliomyelitis.
Cases of poliomyelitis with marked leg length discrepancies are commonly presented for analysis. When the inequality is considerable and there are associated problems, amputation is my choice of procedure. This patient presented three and one-half inches of shortening and a painful deformed foot, and was a picture of general despair. Amputation afforded him equality in leg length and elimination of the need for further procedures on the foot. The patient now states that he is happy for^ the first time in his life. (Figure 15 and Figure 16 depict the post-operative stump and P. T. B. type prosthesis now being worn.) Other poliomyelitis patients with above-knee or below-knee amputation* have also expressed satisfaction after amputation and fitting of prostheses,in spite of muscle weakness. R. B.'s surgical history was:
Stapling of proximal tibial epiphysis on the right, 1/20/50.
Dorso-lateral wedge osteotomy of left foot, 2/14/50.
Removal of staples from the proximal tibial epiphysis, 5/5/53.
Below-knee amputation, left leg, 10/25/61.
This report presents only a few of the problems that are universal in amputation clinics. The procedure of interchanging clinical information is to be highly commended, since the shared experi ence is of invaluable benefit to all concerned. This is particularly true of the subject matter in this report. It is ofte difficult to obtain adequate documentatic of indications or contraindications for amputation in specific instances. When clinic chiefs pool their experience, the information becomes available to all interested individuals, and general knowledge and understanding of the subject is great increased.
Milton Wilder is Clinic Chief, Amputation Clinic Kernan Hospital and University Hospital Baltimore, Maryland
Kruger, Leon M., M.D. and Talbott, Richard D., M.D., "Amputation and Prosthesis as Definitive Treatment in Congenital Absence of the Fibula", Journal of Bone and Joint Surgery, 43-A, 5, July 1961.
Aitken, George T., M.D., "Amputation as a Treatment for Certain Lower-Extremity Congenital Abnormalities", Journal of Bone and Joint Surgery, 41-A, 7, October 1959.