02 Jun 2011
By: JOAN CHEW
Madam Neo Suzhen, 44, suffered a horrific worksite accident when her left leg was pinned under the tyre of a forklift, crushing her bones and muscles and ripping off the skin.
For engineer Leong Fook Chuen, 55, the aching pain in his left ankle turned out to be a rare cancer of the bone.
A 20-year-old woman, who wanted to be known only as Hazel, was born with a deformed foot. As she grew up, it became obvious that her right leg would be shorter than the left.
All three patients suffered from different medical conditions, but they had something in common: They all faced the grim prospect of an amputation of their legs.
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If they had lost their limbs, they would have had to be fitted with prostheses, or artificial limbs, if they wanted to get around without a wheelchair.
However, all three managed to keep their legs, thanks to medical advances which have made limb salvage more feasible today.
HELP FROM MEDICAL ADVANCES
Bones can now be grown surgically, harvested from one’s own body parts or taken from dead bodies for transplant.
Complications during wound healing, such as infections which could have resulted in amputations in the past, can be managed better with new devices.
Bigger teams of doctors with microsurgery expertise and changes to hospital protocol mean accident victims, for whom time is of the essence, now wait a shorter time for reconstruction to begin.
Six orthopaedic surgeons Mind Your Body spoke to agreed that fewer amputations are now being done on patients with deformities, cancer or injuries.
For instance, the most common skeletal deformity in the leg, fibula hememilia, can now almost always be successfully treated through procedures to lengthen the bone.
Each year, a handful of children like Hazel are seen at National University Hospital (NUH), said Associate Professor James Hui, head and senior consultant at the division of paediatric orthopaedics.
In the past, he said, these children would have their abnormal limbs amputated and the stump fitted with a prosthesis.
But now, all of them can have their deformed leg successfully grown to a normal length.
More than three in four accident victims can have their crushed limbs salvaged now, compared with a decade ago when more than half would end up with an amputation, said Dr Peng Yeong Pin, head and senior consultant at the department of hand and reconstructive microsurgery at NUH.
Last year, only one out of 14 accident victims whose lower limbs were injured ended up with an amputation.
Tan Tock Seng Hospital (TTSH) carried out five leg amputations on accident victims last year, down from about 10 in 2000, said Dr Winston Chew, head of its hand and microsurgery section.
Hospitals are able to achieve this because they now dedicate more resources to limb salvage procedures.
Ten years ago, Dr Chew was the only doctor in TTSH trained in microvascular surgery techniques, such as flap techniques, which limb salvage procedures require. He was then supported by visiting consultants from Singapore General Hospital (SGH). Now, there are three other experts in his department.
These days, flaps – pieces of tissue transplanted to repair wounds – can minimise the need for amputations, said Dr Tan Ter Chyan, a consultant at the department of hand and reconstructive microsurgery at NUH.
In 2006, 54 flaps were done at NUH.
By 2009 and last year, this had risen to 70 flaps each year, suggesting that fewer injured limbs were amputated.
In the past, it could take up to two weeks after the initial emergency surgery before an accident victim went into the operating theatre again to undergo limb reconstruction.
This was because doctors had to wait for the wounds to heal on their own before patients were deemed ready for the reconstructive surgery, Dr Chew said.
But using skin and muscle flaps for wound coverage has reduced the waiting time to an average of three to seven days, he explained.
HELP FROM NEW PROTOCOL
Sugical advances are not the only thing saving accident victims from amputations.
NUH has also put in place a new protocol in 2008 for patients who need limb reconstruction to be operated on within a week after the emergency surgery.
Now, most of their patients are operated within this time frame.
Previously, without this clear timeline, many were operated on up to 14 days later.
If surgery is completed within a week, there is less chance of infection setting in, resulting in more of the patient’s own tissue being saved. This can bump up the success rate up to as high as 90 per cent, NUH’s Dr Peng estimated.
In the case of bone cancer, amputations were part and parcel of treatment, where the entire tumour could be removed along with the normal bone surrounding it to reduce the chance of tumour recurrence.
In the 1970s, amputation would be the “first course of action” for bone cancer patients, said Associate Professor Tan Mann Hong, senior consultant at the department of orthopaedic surgery and director of the musculo-skeletal tumour service at SGH.
But with more precise diagnoses – from more accurate imaging technology, like magnetic resonance imaging (MRI) and positron emission tomography (PET) – as well as surgical plans, most patients can now avoid the radical procedure of an amputation.
In the last five years, Prof Tan has done fewer than five amputations on bone cancer patients, about half the number done in the previous five years.
Eight in 10 patients with bone cancer can have their limbs preserved now, said Dr Mark Edward Puhaindran, a consultant at the division of musculoskeletal oncology at NUH’s department of hand and reconstructive microsurgery.
NUH sees about 10 to 15 bone cancer patients a year, compared with seven or eight cases a decade ago.
Of course, the complete removal of the tumour usually takes precedence over saving the limb and doctors will not hesitate to recommend amputation if they feel it is necessary, said Prof Tan.
But many patients think otherwise.
He said: “Patients can accept stiff limbs and certain morbidities, but the moment you mention an amputation, they will not agree to it.
“After all, it is a very final act.”
Email: joanchew@sph.com.sg
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