Amputation for uncontrolled pain and coming to terms with limitations

An 83-year-old woman with type 2 diabetes of 14 years' duration with a previous history of stroke, who was

Fig. 7.8 Ischaemic ulceration in a foot with severe rest pain which led to above-knee amputation.

already wheelchair bound, presented with ischaemic ulceration and severe rest pain (Fig. 7.8). She had had transfemoral angiography and this had shown severe infrapopliteal disease with no recognizable main artery below the knee. Furthermore the arterial circulation of the foot was extremely poor with no plantar arch present. Neither angioplasty nor bypass was possible. She did not want an amputation and her ischaemic ulceration was treated conservatively. However, despite opiate analgesia it was not possible to control her pain and for this reason she underwent above-knee amputation.

Postoperatively, she was happy that she no longer had pain, and she was rehabilitated to return to her wheelchair lifestyle. She attended the diabetic foot clinic for care of the remaining foot. Three months later we noticed that she was depressed and she confided that she would have liked to have tried a prosthesis. The physiotherapists agreed to see her in the rehabilitation gym, and to let her try a pneumatic postamputation walking aid (PPAM aid) and discuss having a cosmetic prosthesis. After two sessions she came to terms with the fact that a prosthesis would not help her and declined further treatment. However, she said that she felt much happier because, as she told us, 'I was allowed to try instead of being written off'.

Key points

• Uncontrolled rest pain in the presence of unrecon-structable arterial disease is an important reason for a major amputation

• Patients may resent not being offered the chance to try a prosthesis

• Help and advice on all aspects of living with an amputation are available from national organizations such as the Disabled Living Foundation in the UK and the Amputee Coalition of America.

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