Amputations in leprosy.

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EDITORIAL
Amputations in leprosy
MARCOS VIRMOND
Instiuto Lauro de Souza Lima, Bauru, Brazil
Accepted for publication 30 April 2007
Removal of an anatomical segment is not pleasant for anyone; perhaps even more so in
leprosy patients because of disease stigma. Amputation has an immediate relation to social
dependence and handicap. The loss of a once normal part of the body is regarded by both the
person and society as a detrimental event. In contrast, children with some upper limb
congenital anomalies do not regard this as ‘abnormal’ until later in life when society,
sometimes even parents, impose on them the concept that they are ‘different’. Amputation
may have a very negative impact on someone’s life as well as carry many symbolic
representations, from pity to repulsion, encompassing guilt and resignation, both from the
amputee and their social partners. However, amputations are valuable surgical procedures,
life-preserving and, strange as it sounds, a choice for certain rehabilitation processes.
Amputation has a place in the management of disability in leprosy. Amazingly, it can be the
bridge from dependence and depression to full social integration including economical
participation. To have these positive results, it should be properly indicated, carefully
performed and, most importantly, adequately managed and supported by competent
prosthetic services.
Indications for amputation in leprosy are few and very specific. They are mostly restricted
to the lower limbs, as in the general population, in whom over 85% of amputations occur in
this part of the body. Primary indications for amputation are long-standing consequences of
plantar ulcers and severe bone/joint disintegration.
Although infrequent, malignant transformation in plantar ulcers1,2is a mandatory
indication. It should also be considered in severe bone/joint disorganisation due to
neuropathic disintegration associated with plantar ulcers and contractures. The patient should
be fully and explicitly involved in the decision for amputation since it is their limb that will be
removed. Furthermore, a patient’s participation in the post-surgical fitting period is even
more important than the surgeon’s skill in performing the amputation. The indications for
amputation vary with the surgeon’s personal preference and the cultural and technological
surroundings, the latter in respect of prosthetic services and long-term maintenance of
prosthesis.3One should remember that fitting a shoe on an insensitive foot is far easier than
fitting a prosthesis on an anaesthetic amputated leg4and not the reverse as some unmindful
Correspondence to: Marcos Virmond (email: mvirmond@ilsl.br)
Lepr Rev (2007) 78, 85–87
0305-7518/07/064053+03 $1.00
q Lepra
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surgeons believe. Patients know which institutions have amputation as an immediate first
choice, rather than using the lengthy and demanding conservative treatments. They flee from
these hospitals and crowd those who offer a more individual-oriented approach.
Amputation is the oldest surgical technique, dating far back and developing in the middle-
ages with Ambroise Pare ´’s techniques and his advanced prosthetic devices. Improvements in
amputations paralleled wars. The Second World War saw a marked advance in surgical
techniques and in the modern principles of the post-amputation care of the patient. It is worth
highlighting that surgery in leprosy is dependent on advances in the surgical treatment of
trauma and other diseases and that leprosy cases in need of amputation can be treated in any
general hospital dealing with other trauma or orthopaedic conditions. Surgeons should
remember that amputation is not only to remove the limb but, more importantly, to prepare a
good stump for the prosthesis5Selection of techniques depends most on the specific clinical
condition, expertise of the surgeon and, to some extent, availability of prosthetic services.
However, Boyd, Pyrogoff, Syme and below-knee amputations are still the preferred choices
for selected situations. It is vital that patients agree to the selected procedure. Anaesthetic
limbs usually are regarded as accessory tools; this has been made clear particularly in leprosy
cases where the sensory loss is not abrupt as it is in trauma. However, patients can be very
conservative in preserving their parts when facing amputation. Toes, especially, are requested
to be preserved. In these cases surgeons must consider alternative techniques. A sound
example is the selection of a sub-total metatarsectomy instead of a transmetatarsal
amputation for treating extensive and unstable scars in the forepart of the sole.6This
alternative will comply with both demands: the surgeon will do his job properly and the
patient will keep his toes for social and emotional purposes. Therefore, in amputation
procedures, proper communication and adjustment to medical and patient’s needs is
mandatory. Stanley G. Browne long ago wisely warned that surgical skill is unavailing in the
absence of patient cooperation.7
The provision of good prosthetic services is critical to successful amputation. Materials
and techniques have improved tremendously over the last 50 years. Now, cosmetic
appearance, ergonomic features, and the mechanical quality of lower limb prostheses are
striking and even include special designs to practice specific sports. However, it seems that
leprosy patients are out of the reach of these innovative technologies. Three points should be
discussed here: cost, properness and availability. The cost of prosthetics, as a whole service,
should be taken into consideration and the provision of services should be adapted to the local
conditions, provided basic quality, durability and acceptability are maintained. A study from
the early 1970’s has removed some of the prejudices about the financial costs of orthopaedic
aids8, proving that, in financial terms, it is possible to provide good prosthetic services for
leprosy patients in developing countries. Sometimes novel, albeit costly material is cheaper in
the long run. Furthermore, prostheses for leprosy patients should not become additional
stigmatising factors. Proper materials and good design can prevent this added burden.
Another important point is that amputations in leprosy lead in most cases, to anaesthetic
limbs. This is a unique condition that most general prosthetists are not aware of, nor do they
have enough skill to cope with the challenges of providing a prosthesis for an anaesthetic
stump. Prosthetic workers in leprosy institutions should have the expertise to correctly adjust
the socket, to align the prosthesis avoiding pressure and friction and so preventing ulceration
in the stump. These special skills are needed if health managers make prosthetic services
available to leprosy patients in the general health services. Indeed, these general prosthetic
clinics rarely deal with insensitive stumps and often have no expertise in preparing adequate
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sockets. Finally, if controversially, leprosy patients have the right to access good quality
prosthetic services. This seems to have been neglected for years. Leprosy has always been
considered as a treatable bacterial disease, and not as a treatable bacterial disease with a high
potential to generate severe deformities. Budget shortages and the ample scope of control
measures have been the common explanation for this, inhibiting the one-patient focused
approach of rehabilitation measures, such as prosthetic services. There is an amazing array of
adaptative prosthetics that can make amputees fully economically and socially integrated.
A properly designed and fitted prosthesis can open a whole new world of activities for these
patients, restoring both their place in society as economically active persons, and as family
members. Health policy makers should seriously address the accessibility of prosthetic
services to leprosy patients. If budgetary constraints do not permit a wide range then at least a
basic package of good quality prosthetics should be provided. Funds should also be
guaranteed to train prosthetists in the management of the insensitive stumps of leprosy
patients, as well as maintaining a continuous supply of materials to prosthetic workshops. If
there are too few leprosy patients to maintain special services, let us remember that diabetes is
the leading cause of foot and leg amputation.9The possibility of merging activities between
prosthetic services for diabetics and leprosy patients should be explored. Leprosy patients’
needs for prosthetic aids should no longer be neglected nor their other basic needs – the
provision of adequate footwear, which would help prevent the need for later prostheses.
References
1Schwarz R. Squamous Cell Carcinoma and Amputations. In: Schwarz R, Brandsma W (eds) Surgical
Reconstruction and Rehabilitation in Leprosy and other Neuropathies. Ekta Books, Katmandu 2004, p 251.
2Fleury RN, Opromolla DVA. Carcinoma in plantar ulcers in leprosy. Lep Rev, 1884; 55: 368–378.
3Fritschi EP. Surgical reconstruction and rehabilitation in leprosy. The Leprosy Mission. New Delhi. 1984.
4Warren G, Nade S, The Care of Neuropathic Limbs – a practical manual. Parthenon Publishing, London, 1999.
p 130.
5Arvelo JJ. Amputations and prostheses for the lower limb. In: McDowel F, Enna CD (eds) Surgical Rehabilitation
in Leprosy. The Williams & Wilkins Co. Baltimore, 1974, p 383.
6Srinivasan H, Palande DD Essential Surgery in Leprosy. Techniques for District Hospitals. WHO, Geneva,
Switzerland, 1997, p 24.
7Browne SG. Foreword. In: McDowel F, Enna CD (eds) Surgical Rehabilitation in Leprosy. The Williams &
Wilkins Co. Baltimore, 1974, p vi.
8Wollstein L. The Economics of Orthopaedic Technical Aids in Leprosy. In: Proceedings of the First All-India
Workshop on Deformities in Leprosy, Implications, Prevention and Management. Karigiri, 1970. p 51.
9Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet –
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