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

THE BALTIMORE SUN

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."

Nobody keeps precise statistics on the number of limb-threatening injuries that occur each year in the United States. Experts estimate there are between 15,000 and 30,000, most involving legs and feet shattered in automobile and motorcycle accidents. Most of the victims are adolescents and young adults, says MacKenzie, with males outnumbering females.

Nobody disputes that surgeons have enabled thousands to walk again. But even as the success stories mounted, so did the cases of patients who endured repeated operations and never regained the use of their legs.

Burgess, 54, said doctors who served under the extreme conditions of World War II and Vietnam were often quicker to amputate. They criticized colleagues who, it seemed, were caught up in the high-tech wizardry of limb salvage.

'You're missing the obvious'

"They told all of us that we had gotten technically seduced by the '80s," Burgess said. "They were saying, 'You guys, you surgeons are missing the obvious. This boy needs an amputation. You've probably harmed him.' "

The critics were supported, in part, by studies that showed better results among patients who had early amputations than those who were pushed through months of surgery. "We looked ourselves in the mirror and asked whether our egos were driving our common sense," Burgess said.

Dr. Michael Bosse, a trauma surgeon at Carolinas Medical Center in Charlotte, N.C., said the trend is being led by surgeons who have practiced long enough to see the long-term results -- good and bad -- of extreme salvage efforts.

"When I first started out as a trauma surgeon and had all the new technology available, your reputation was based on your ability to salvage extremities," said Bosse, 46, a researcher in the study. "I was much more aggressive and less discriminating than I am now. My thought was, every patient with a severe injury wanted to maintain a leg."

The trend has also been pushed by advances in artificial-limb technology. The latest prosthetic legs are "engineering marvels" equipped with shock absorbers and tension springs that behave much like natural legs, said Dr. Carl Valenziano, president-elect of the American Trauma Society.

"Patients will often do much better with a prosthesis," said Valenziano, director of trauma at Morristown Memorial Hospital in New Jersey. "Socially, it is my sense that several of the patients I have, even high school and college students, can deal better with artificial limbs than if they had a really deformed limb that was both painful and didn't function as well."

Bosse said patients are desperate to keep an injured limb, but will accept a doctor's decision to amputate if honestly presented with the facts.

Such was the case with Langer.

He was driving to work before dawn when two motorcyclists riding toward him lost control and went off the road on either side of him. Langer stopped to help, kneeling by one and then the other injured cyclist. Suddenly, a car speeding down the road slammed into a second parked car, which struck Langer's midsection.

His pelvis was fractured down the middle, his right foot was dislocated and turned back on itself, and his left leg was shattered. Doctors stabilized his pelvis and right leg with fixators, then turned their attention to his left leg, which was missing much of the tissue above the ankle.

He was wheeled into the operating room every 48 hours. Surgeons spent much of their time removing dead muscle and bone. Langer hoped and prayed that doctors would save the limb. "But I never really saw how bad it was," he said. "There were eight inches of bone and muscle missing. It was barely attached."

His wife, Deborah, prayed too -- privately dreading the day when doctors might declare that their efforts had been in vain.

"Every time, they'd take him down to surgery, and they'd take him back up and we'd feel a little better," said Deborah. "But they never told us he was out of the woods. They never said, 'OK, we can save it now.' "

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'Like a living hell'

Langer was suffering.

"I was so weak and in so much pain when I came out of surgery it was like a living hell," said Langer, who has two sons. "The pain medication would only last so long. They couldn't give it to you fast enough. The only peace was when I was asleep."

Finally, doctors told him they would rather remove the leg than put him through 20 more salvage procedures. In a morphine haze, Langer signed a consent form but left the final decision to Deborah, who quickly agreed. She had seen enough.

"Even wrapped, his leg looked terrible," she said. "It was dragging him down." She spent the next two hours walking around the hospital in shock, thinking about what had happened. "I kind of came to terms with it. I really believed in my heart they knew what was best."

A few weeks later, Langer went home to a hospital bed that had been set up in his living room. There, he watched the autumn leaves accumulate in his backyard, knowing he could do nothing about them. As the holidays approached, he anguished over the fact that he would not be able to set up the Christmas tree or roughhouse with the kids.

But merely seeing his children -- watching their excitement over Christmas lights and presents -- was enough to buoy his spirits. So is the knowledge that in the next month or two, he will get fitted for a prosthesis, and begin the hard work of learning to walk again.

"My independence is based on getting that other leg," he said. "Being able to take care of myself. Completely."

Pub Date: 12/31/98

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