Are Orthopedic Surgeons Leaving the Amputation Healthcare Team?
Some Say Yes, Others Say It's a Shift in Care
According to the Center for International Rehabilitation Research Information and Exchange (CIRRIE) at the University at Buffalo, The State University of New York, while "worldwide prevalence estimates of amputation are difficult to obtain...the World Health Organization (WHO) estimates that in Latin America, Africa, and Asia combined, almost 30 million people require prosthetic limbs, braces, or other devices, up from 24 million in 2006."
Though the overall rates of amputations due to trauma or malignancy are decreasing, the incidence of dysvascular amputations are on the rise, thanks in part to increases in diabetes and obesity as well as an overall increase in life expectancy. In the United States alone, amputations due to dysvascular disease account for roughly 54 percent of amputations. Trauma, cancer, and congenital amputations make up the remaining percentages, according to WHO.
"In the industrial and developing worlds, causes for amputations are dominated by vascular disease," says Dan Blocka, BSc(Hons), CO(c), FCBC, immediate past president of the International Society for Prosthetics and Orthotics (ISPO) and faculty member for the O&P educational programs at George Brown College, Toronto, Ontario, Canada.
While the prevalence of amputations continues to rise worldwide, fewer new orthopedic surgeons are interested in learning about therapeutic amputations as a subspecialty and working as a member of the amputee rehabilitation team, according to several experts interviewed for this article. For example, orthopedic surgeons starting out in the United States today are turning their attention and skills to more lucrative markets—namely knee and hip replacements—and prefer to perform amputations on wounded soldiers from Iraq and Afghanistan, our experts say. This is in part because these types of high-profile procedures are more interesting and bring significant media attention, as compared to an elderly patient or a patient with diabetes who has to have a lower limb amputated, according to Blocka.
"Young surgeons are not that interested in the older amputee population," he says. "They like the high-profile cases with a lot of publicity. The older patient who has diabetes just is not that interesting to them." Of course, there will always be a handful of orthopedic surgeons who will be interested in the care of elderly patients and the conditions that lead to amputations for that population. The majority, however, will become increasingly hard to recruit, Blocka maintains. "What's the incentive for them?" Blocka asks. "They'd rather look for another area to make their mark." In the future, Blocka predicts that most orthopedic surgeons' interest in performing necessary amputation surgery on such a population will be "more on a humanitarian basis."
Marcos Guedes, MD, an orthopedic surgeon and prosthetist who has been practicing in Brazil, South America, since the mid 1970s, agrees.
"I am afraid that Blocka is correct," says Guedes, who now operates a facility in Sao Paulo, Centro Marian Weiss, Brazil, where he has a multidisciplinary team of physicians, prosthetists, technicians, and physical and occupational therapists and an infrastructure that includes a fabrication lab and physical therapy facilities to help those with amputations in his care. He says he no longer makes prostheses but has "good prosthetists working for me."
Guedes, who had a left transtibial amputation due to a motorcycle accident that he was involved in just before he graduated medical school in 1975, says that amputation surgeries today are reserved for surgical fellows. In addition, the surgeon who assists the fellow learned about amputation surgery the same way.
Guedes notes that chapters relating to amputation surgeries are in the back of medical textbooks, and these chapters are seldom read. "Very few times the fellow came to the book to study the procedure," he says.
The location of such pages in a medical textbook, however, doesn't lessen their importance, according to Douglas Lundy, MD, who has been a practicing orthopedic surgeon in Marietta, Georgia, since 2006. The fact that these chapters are located in the back of medical textbooks "is not wrong," Lundy says. "It just fits into the miscellaneous group [of] the hand, foot, ankle, or sports medicine."
Subspecialty training is often not necessary, particularly when it comes to transtibial amputation surgery, which is among the common procedures performed by orthopedic surgeons, says Lundy, who has extensive experience in trauma care resulting in amputations. "These types of surgeries [are] done so often that you don't have to review the procedure every time. It's like knowing how to drive a car—you don't have to consult a textbook every time you get behind the wheel."
Surgical residents are never left alone in the operating room when a patient requires an amputation, he adds. "They can't do anything without you [the board-certified orthopedic surgeon] there. Residents are taught by board-certified experts," Lundy says.
John Fisk, MD, an orthopedic surgeon who was a resident in the early 1970s, says that while it was "customary practice" to take one- to two-week courses in orthotics and a one-week course in prosthetics as introductory background, "it wasn't a requirement." Fisk is a past director of the children's amputee clinic for Shriners Hospitals for Children—Chicago, Illinois, past vice president of ISPO, and past president of the Association of Children's Prosthetic-Orthotic Clinics (ACPOC). He retired in 2007.
According to Fisk, today's orthopedic surgical residents receive two hours of O&P instruction for each year of their training, and that amount of instruction is "hardly anything by contrast," he says. Attempts to get these requirements changed through the American Academy of Orthopaedic Surgeons (AAOS) have been unsuccessful, he adds.
Different Points of View
The orthopedic surgeons interviewed for this article have mixed opinions about the premise that they are purposefully leaving the amputation rehabilitation team and that the education specific to amputation surgery is lacking. Lundy says that O&P training for orthopedic surgeons is built into a resident's medical training. Shepard R. Hurwitz, MD, an orthopedic surgeon who has been practicing since 1976, concurs. "It's more than minimal," says Hurwitz, a professor in the Department of Orthopaedics, University of North Carolina, Chapel Hills, and director of the American Board of Orthopaedic Surgery. "It's part of the fabric of your training, particularly in your fellowship years."
Amputation surgeries have been "pretty well studied," over time, Hurwitz says. "There's a lot of [online] information available. You can read a digital text right there in the operating room."
Surgeons understand that some amputation surgeries aren't as common as a transtibial procedure, Hurwitz adds. When such a case presents itself, surgeons will review reference materials beforehand. A good combination, he says, is when the surgeon has quality reference material, a lot of experience, and his or her mind is sharp and focused.
Douglas G. Smith, MD, began his career as an orthopedic surgeon at Harborview Medical Center, Seattle, Washington, in 1989, where he now directs the surgery side of the hospital's amputation program. He says that the current model of amputee rehabilitation is different today, but when viewed through the eyes of those who have been in the field for many years, the perception that orthopedic surgeons are leaving the rehab team has some validity. It depends on the point of view and geographic location of the healthcare professional, says Smith, who also serves as professor of orthopedic surgery at the University of Washington Medical Center, Seattle, was the medical director for the Amputee Coalition from 2000 to 2008, and has served as a consultant to the United States Military Amputee Centers since 2002.
In addition to performing amputation surgery from severe trauma on loggers, construction workers, fishermen, and motorcyclists in the Pacific Northwest (the highest number are the result of motorcycle accidents), Smith has been performing amputation surgery on Iraq and Afghanistan war veterans since about 2002. He says the team approach to amputation rehabilitation is still happening; however, "it's just happening differently."
The former model of a patient's multidisciplinary team of healthcare providers—often made up of the patient's family members, physicians, nurses, occupational and physical therapists, prosthetist, social worker, and nutritionist—sitting in a room with the patient and brainstorming about what's best to do in terms of his or her rehabilitative care has gone by the wayside, says Smith, who performs between 150 and 175 amputations per year, about 30 percent more than he did a decade ago.
"The older system was much kinder to the patient, but it is increasingly difficult," he says. "It is considered inefficient to have all the different healthcare providers physically be in the same room with one individual patient at the same time. Today, it's much more frustrating for the patient to have to see each provider separately.
"In the current system, a surgeon usually directs the care around the time of surgery, requesting more or less input from rehabilitation physicians, therapists, and prosthetists as needed and as they are available," he continues. "After surgery, a rehabilitation physician will often manage the care, also seeking input from other team members as needed...."
The historical model was wonderful for the patient and for instant information exchange, but very few patients were seen per day, according to Smith. "There is no doubt that physicians, therapists, prosthetists, and counselors are being asked to see more patients in a given day," he says, "and it is much less common to have all the providers present at one time."
The ability to obtain information regarding the patient's medical situation through electronic medical records, e-mail messages, and telephone communication has allowed the multidisciplinary team model to continue, albeit on a more limited scale. "The current system is not better," Smith admits, "but it is what has evolved for many reasons."
Far From Failure
While orthopedic surgeons may not all agree that the number of those choosing amputation as one of their subspecialties is dwindling, all of the surgeons interviewed for this article agree that amputation does not have to be viewed as a failure by the physician and his patient.
"I try to remind my patients that amputation isn't necessarily a failure," Smith says. Without doubt, it is a painful, emotional surgery that involves cutting and removing everything from tissue and bone to muscle and nerves, but it doesn't have to be viewed as an end.
When Guedes has to perform an amputation on one of his patients, he tells them that although the procedure may appear to be the final act of losing a limb, it can be a new beginning. "I let them know that we are starting something new, not just losing the limb," says Guedes, who estimates that he has performed more than 1,500 amputations (primarily lower limb) during his 30 years as an orthopedic surgeon.
Fisk agrees, saying that although many vascular surgeons view amputation as a final step because the patient's circulation is unable to be improved, the procedure is not failure. "It's a part of the rehabilitation process," he says.
"Amputation has this terrifying association with disfigurement and impairment," Hurwitz says. "It doesn't have to be that way. Every reconstructive procedure is not a failure. It's a new beginning if the limb can't be salvaged. Many can do much better with an amputation. Once the pain is gone and they start using the limb, they can see benefits quickly."
Guedes says he follows his patients' rehabilitation process and discusses the case with other members of the rehab team—communication that is "crucial" for patient success.
Though prosthetic device technology has advanced significantly over the years, basic amputation surgical procedures have remained about the same, according to Guedes. However, "amputation is a very creative surgery," he adds. "When we have to construct a new limb that will receive a prosthesis, it turns into a real challenge. Surgeons love this."
Betta Ferrendelli is a freelance writer based in Denver, Colorado.