On cutting off a man’s leg

It took us three hours and a half to cut off his leg. We fashioned flaps of skin first, tied down vessels and nerves, cut through muscle to bone, divided the femur with a saw, then detached the limb from its owner. All we needed to do now was remove the steel nail which protruded half a foot out from the stump. The Kuntcher nail had been implanted sixteen years ago and didn’t want to come out. We used a hack-saw blade on it finally, more a blacksmith’s job than a surgeon’s, and cut it level with bone. The flaps were sutured together to finish the above-knee amputation. Half our time had been spent with the nail, first trying to extricate it, then cutting it off.

Amputation is ancient. It was life saving in pre-modern days because most injuries became infected. There were no antibiotics.The surgeon’s job was to prevent the infection from spreading. Speed was crucial. There was no anesthesia. Strong men held the patient down as the surgeon worked. There was no blood transfusion either. The surgeon had to be fast, MGR with flashing sword, hand faster than the eye could see. Robert Liston, whose average time was two and a half minutes for an above knee amputation, holds the world record at twenty eight seconds. Incision to closure, skin to skin, twenty eight seconds.

At such speeds finer points are blurred, passing by in a flash of knife and scissors. Speed thrills but kills as the wise road signal says. Liston holds another record, that of the surgeon who has killed the most number of people in a single surgery. The patient died, a lot of them did then, but less commonly also the assistant whose finger Liston had cut off during the melee. The finger became infected and the assistant died of it later. The third to die was a spectator who collapsed watching the scene. Surgery was spectator sport and one could, if so inclined, go to the nearest operating theater and watch the great artists of the day at work.

Things are tamer today, thankfully. From spectator sport surgery has transformed into the most secret of performing arts, conducted within darkened rooms under overhead lamps, witnessed by no more than a few of the chosen. Complex procedures can be done with abundant time safely under anesthesia. We did our amputation at leisure, looking before we cut, instead of vice versa and tried not to cut off the patient’s testicles with his leg. Liston did that too once, another record. He was a force of nature.

Amputation is in disfavor now. Limb salvage is the flavor of the day and we rescue extremities which have gone through the worst travails of modern existence, trapped within cement mixers, shattered in high speed motorcycle accidents, run over by massive trucks. These are truly mangled extremities, with crushed bones, ripped off arteries and severed nerves. But we have technology today. We can salvage these limbs routinely with superb plastic surgery, often restoring near normal function, something unthinkable just half a century ago.

But some of these limbs survive only partially. Blood supply is restored but joints become fixed and immobile in abnormal positions. Nerve function may not recover and the limb may be insensate. In the worst cases bones become infected and do not unite, an infected non-union, and the patient carries his limb around like a ball and chain. We get to see such patients often, five, ten, fifteen years after injury and ten, twenty, thirty surgeries down the line, still in terrible pain, still unable to walk. Years after their injury these people remain wrecks, not just physically but mentally and financially as well.

Meanwhile technology has advanced such that artificial limb prostheses are better than normal limbs, look at Oscar Pistorius. One can get a patient to walk a week after amputation with one of these. But it is a difficult call, advising amputation to a patient who has invested ten years and a fortune into the project of saving his limb. There was a recent patient with an infected non-union of many years who became extremely angry, almost violent, when I told him that the best treatment was an amputation. He wheeled off in a huff, leaking pus all the way, and never came back. He must still be spending money on that leg now, no doubt firmly attached to it until death does them apart.

There is considerable stigma about being one-legged in our parts, something which, I’m told, is not so much of a problem in the west. We once had a patient who came with a neuropathic ankle joint, a complication of diabetes. This is a flail joint which is useless for normal function. He walked with his leg in a metal and leather contraption devised by a local shoe smith. He insisted that we somehow stabilize his joint and my boss, always ready for a challenge put an enormous steel construct in the leg guaranteed, we thought, to fuse any joint in the world, neuropathic or not. It failed of course, neuropathic joints do not usually fuse, and in a month half his protein had gone out of the wound as pus. He was a tall broad shouldered man when he came, terribly fit except for the ankle. Six months after surgery he looked like an inmate of Auschwitz to whose leg a mad surgeon had attached a cluster of steel rungs and wires in an orgasm of medical experimentation. My boss had had enough by now and he told him that an amputation was the only way out. The patient refused. He was a big man in his home town, he said, and would lose all prestige if he had only one leg. I don’t know what became of him.

These stories are legion. We have good scoring systems now which can guide us to an amputation immediately after an injury, but it would be difficult to convince people. Doc Cuts Off Accident Victim’s Legs As Soon As He Came In, would scream the news channels and social media. Many doctors are wisely more circumspect and give the patient a chance to keep his limb. Six months and six surgeries later the patient and his surgeon has put in too much time and effort into the limb. We will give it one more try, they decide, and carry on with the same weary rituals. Not an easy decision, for the patient or the surgeon.

Our patient had injured his limb in a road accident sixteen years ago. He had fractures all over his right lower limb. The femur had broken, the tibia had come out through his skin and a piece of the fibula had been left behind on the road. He had had thirty surgeries in sixteen years. The femur had united with the K nail. The tibia had given up the ghost after a while and the leg was a mess now, scarred with incisions, pus pouring from multiple sinuses. He had arrived with a high grade fever and was in so much pain he couldn’t lie down in bed. He spent three days and nights on a wheelchair before agreeing to an amputation. The infection was spreading now, pus threatening to burst out through pockets in his tibia, and he was in danger of developing a septicemia.

I saw our amputation patient the evening after we removed his limb, lying in a festoon of tubings and leads and monitor beeps. He was smiling. It feels good now, doctor, he said, that leg was a prison, I spent years in it. I can’t thank you enough for cutting it off.