THE topic of amputation comes up a lot when people visit my surgery. If a patient has an ingrown toenail, a swollen ankle, is diabetic, or has a corn, one of the first fearful questions is: “Will I have to get my foot chopped off?”

It is the biggest anxiety people have regarding their feet and this is because it is such a common procedure in Jamaica.

Throughout the world, the vast majority of amputations are due to diabetic toe, foot or leg complications — the most common of which is nerve damage. Other causes of amputation can be trauma, ischaemic disease, deformity, persistent pain that renders the limb useless, and diseases which may be life threatening such as cancer.

In the case of diabetes, most amputations are preceded by foot ulceration. The development of an ulcer is considered to result from a combination of peripheral vascular disease (poor foot circulation), peripheral neuropathy (nerve damage), infection, and poor foot care.

RISK FACTORS FOR DIABETIC AMPUTATION

1. Elevated blood glucose levels

2. Retinopathy (eye disease due to diabetes)

3. Neuropathy

4. Ischaemia (reduced circulation)

5. Osteomyelitis (bone infection)

6. Soft tissue infection

7. Septic gangrene

8. History of previous ulceration

9. Non-healing ulceration

Before an amputation is carried out, the surgeon will ensure that the patient’s medical circumstances have been optimised and that nothing else can be done to save the limb. The amputation of the great toe is thought to be the most important of the toes if removed. However, most people are able to function quite well after surgery and physiotherapy. Prosthetic limbs can be very expensive and are not suitable for everyone, nevertheless, they can be extremely useful in aiding normal gait.

COMPLICATIONS OF AMPUTATION

As in any surgical procedure, amputations carry risks. A patient’s age, their general health and the type of amputation being done all have to be taken into consideration. Complications include blood clots, post-operative infections, pneumonia, and heart attack.

Phantom limb pain is a common phenomenon among people who have had a limb removed. In this situation patients experience sensations or pain that seem to be coming from the amputated limb. The symptoms can range from mild to severe. The cause is unclear, but there are three theories. The first is that the pain is the result of nerve endings around the stump forming clusters called neuromes. It is thought that neuromes generate abnormal electrical impulses to the brain that are interpreted as pain. The second theory is that the lack of sensory input from the amputated limb causes chemical changes in the central nervous system leading to confusion in the brain and triggering pain symptoms. The last theory suggests the brain has a “memory” of the amputated limb and associated nerve signals. It is thought that the brain tries to recreate this memory.

Amputations also affect the psychological state of the patient. Many patients report feelings of grief and bereavement similar to the death of a loved one. The financial burdens of hospital and doctor’s bills can also be overwhelming.

It is imperative that if we wish to reduce the rate of diabetic amputations in Jamaica, that foot health is made a priority. Health education, and good glycemic control are also essential. Remember, most amputations begin with a foot ulcer. With regular care from a podiatrist and multidisciplinary diabetic care team, these sores can be prevented. This has been statistically proven in many countries around the world and it is time we had it in Jamaica.

Angela Davis BSc (Hons) DPodM MChS is a podiatrist with offices in Montego Bay (293-7119), Mandeville (962-2100), Ocho Rios (974-6339), and Savanna-la-Mar (955-3154). She is a member of the Health and Care Professions Council in the United Kingdom.