All he did was step off the curb. There wasn't anything particularly unusual about the stride, but his barefoot heel caught the cement and began to bleed. That was more than two years ago. Today, after a series of life-threatening infections and failed skin grafts, our group at the hospital was scheduled to exercise the last option on the list: a "BKA" - below-knee amputation.
We stopped by during morning rounds to check in before the operation. "Well, I was thinking, maybe you could just cut off the heel or part of the foot, not the whole thing," he suggested, "Or maybe just the foot, not up the leg." It was his decision, we explained, whether to have the operation, but this surgery was the right one medically - it provided the best chance for healing and the proper mechanics for prosthesis.
Under general anesthesia the leg is prepped and draped in sterile fashion. A horizontal line is drawn on the front half of the shin, four finger-breadths below the tibial tuberosity, the bony prominence below the knee cap. This line is extended at right angles down each side of the calf, then wrapped around the back and connected a few inches above the ankle. An elastic band is wrapped tightly around the leg from the toes to the knee to wring out the blood, and a tourniquet is inflated around the thigh. A scalpel then is used to cut through the skin along the drawn line, where possible, down to the bone. Once the tibia, the larger bone, is exposed, the soft tissue is scraped off the upper portion. A high-speed saw, wetted to control bone dust, is used to cut through the tibia. Most dust is contained; the smell is not. The smaller bone, the fibula, is easily dispatched with heavy shears. With the bones bisected, a 10-inch-long steel blade - a carving knife on any other day - is used to slice down the calf along the back of the bones, leaving an attached "posterior flap" of skin and soft tissue. All blood vessels are then tied off, one by one, until the tourniquet can be removed without bleeding. The posterior flap is folded forward, trimmed to fit and sewed in place, forming the "stump."
This life-altering and disfiguring procedure is often the result, as was the case here, of decades of peripheral vascular disease and neurological complications. Among the underlying causes of PVD are smoking, uncontrolled diabetes, high cholesterol and high blood pressure. These diseases cause a narrowing of the blood vessels and decreased blood flow known as ischemia, leading to tissue damage and impaired healing. This process is similar to that which causes heart attacks and strokes. Diabetes also causes degeneration of the leg nerves, which impairs sensation, leading to more frequent injury.
Importantly, all of these diseases can be controlled at least partially through lifestyle modification. Quitting smoking, maintaining a healthy diet and exercising are the best prescriptions, yet they are some of the most difficult to fill. The BKA is the result of not one, but a series of missteps - made not only by patients who can't or won't modify habits but also by physicians who don't take the time to motivate their patients, guiding them toward positive lifestyle changes. We often think of heart attacks, strokes and death as the end of this road. "Well, you've got to die of something," as many of my patients put it. True. But do you have to lose your leg?
Jeffrey is a University Medical student. He can be reached at j.sturek@cavalierdaily.com.
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