Reconstruction vs. Amputation

Amputation remains the most common option presented to parents with children who are born with fibular hemimelia. We are frequently asked by both parents and surgeons why we think reconstruction is a better option for almost all patients with fibular hemimelia.

To start, let's explain why amputation is offered as the main alternative. Performing an amputation at the level of the ankle joint (Syme’s amputation) gives a nice round stump with the healed skin as a weight-bearing surface, which, combined with modern prosthetics leads to unrestricted excellent function. As we all saw demonstrated in the 2012 London Olympics, amputees and even bilateral below-the-knee amputees, such as Oscar Pistorius, fitted with advanced prosthetics, can compete at the highest level. There is no question that a patient with fibular hemimelia who undergoes a Syme’s amputation and good prosthetic fitting, and who has access to a technologically-advanced prosthesis and prosthetic care on a regular basis (most children need a new prosthesis each year) will function normally for almost any activity. Nevertheless, if an amputation could be avoided and the foot and ankle reconstructed to nearly normal function comparable to that afforded by a below-the-knee prosthetic, most parents and individuals will choose to have the reconstruction. I do not think anybody wants to give up their foot or ankle unless there are no good alternatives.

Two patients who have completed limb reconstruction and lengthening playing basketball with Dr. Paley

 

When pediatric orthopedic surgeons are asked “would you amputate the foot if all that was wrong with the leg was a foot or ankle deformity such as club foot or many other childhood foot deformities?” the answer is universally “no”. Despite this, the results of some club foot treatments leave the child with chronic pain and a stiff deformed foot that might be better treated by amputation and prosthetic fitting. When orthopedic surgeons are asked if they will amputate the leg of a child with no foot deformity and just a limb length discrepancy, the answer is almost universally “no”. When orthopedic surgeons are asked if they will amputate the leg of a child with a combination of foot deformity and limb length discrepancy, the answer is frequently “yes”. This doesn't follow, since, for a foot deformity our standard answer is to perform foot deformity correction surgery, and for a limb length discrepancy our answer is to perform a limb lengthening surgery. Therefore, it does not make sense that when there is a foot deformity combined with a limb length discrepancy, the answer is not a foot deformity correction surgery combined with a limb lengthening procedure. What Dr. Paley recommends is exactly that: foot deformity correction with the SUPERankle procedure combined with lengthening using an external fixator.

Dr. Paley has compared the results of the SUPERankle procedure with lengthening to the Syme’s amputation. He presented these findings at the 2011 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in San Diego. His findings were subsequently published by Orthopedics Today.

Twenty-two patients that Dr. Paley personally treated with the SUPERankle procedure were compared to an age-matched group of patients who underwent Syme’s amputation at the Texas Scottish Rite Hospital in Texas. The results of the two groups demonstrated no difference in function. Both groups were satisfied with their results and both groups were equally functionally active and both groups reported no pain. Both groups give compatible function to normal. 

The choice is therefore the parent’s and the family's as to which procedure they prefer for their child. With lengthening reconstruction surgery using the SUPERankle, the big advantage is that in addition to normal function, one retains a sensate foot that can feel the ground and has balance and proprioception (positional awareness). No prosthesis can provide sensibility or proprioception.

Furthermore, the child and later the adult with the prosthesis must get an expensive, high-quality, technically-advanced prosthesis made every year throughout childhood and frequently throughout adult life. This is an important economic consideration. The total cost to healthcare of that many prosthetic changes is much greater than all of the medical costs related to the surgery of lengthening reconstruction surgery. This does not even factor in the frequent adjustments and modifications to prosthesis that are required, nor the intermittent skin irritation of the stump to the prosthetic that causes some pain and suffering and sometimes interrupts prosthetic use. Another factor to consider is that children with fibular hemimelia who have missing knee ligaments will require a prosthesis with added stress to the knee, as well as children with valgus of the knee who will still require corrected surgery in addition to the amputation. Our study also could not quantify the psychological effects of going to the beach with prosthesis and having to take it off in order to swim in the water or walking on the sand one-legged, or the stress to the individual on having to wear shorts or a short skirt with prosthesis. With lengthening reconstruction surgery, these considerations do not apply.

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