For Richard Blalock, a lifelong runner, removing his arthritic right foot and replacing it with a prosthetic was the only option he had for continuing to live doing what he loved.
Elective amputation, he said, is a misnomer.
“You wouldn’t want to have it done if there was some way to avoid it,” said Blalock, 61, of South Carolina. And he didn’t see that there was.
But, for his doctor, Charleston-based foot and ankle surgeon Blake Ohlson, Blalock’s surgery does fall into the category of amputations he considers elective. It’s a small category. Every year, he does such operations for about three or four patients whose limb function would otherwise never return to what they want it to be. This year, that included Elisha Morgan of Gorham, who found Ohlson by reading Blalock’s blog, after eight orthopedic surgeons in southern Maine refused to do the operation.
Ohlson said Blalock, who developed arthritis decades after his foot was run over by a school bus, could have had his ankle fused or the joint replaced and probably wouldn’t have had pain or a detectable limp. But he wouldn’t have been able to run marathons.
“It’s the level of activity that he wanted,” said Ohlson.
The recent advancement of prosthetics, which can enable amputees to run, swim and rock-climb, has a lot do with why Ohlson performs elective amputations for people who want them.
“Prosthetics have jumped way ahead of our current treatment methods,” he said.
Although the tendency of surgeons has been to save as much of a limb as possible, more patients, including the young veterans of wars in Iraq and Afghanistan, are opting to amputate or take off more of a limb to better fit a prosthetic, sacrificing a part of their body to be able to have a more active life.
“The current methods of treatment do not allow young individuals to return to the level of function they’re accustomed to,” Ohlson said. “To them, it’s not weird at all.”
Aside from anecdotal indications of that trend, there’s little information about it.
The only data the American Academy of Orthopedic Surgeons could provide is a breakdown of types of amputations between 2001 and 2009 from the National Hospital Discharge Survey, which is conducted by the U.S. Centers for Disease Control and Prevention.
The study showed that, on average, just over a quarter of amputations every year are considered elective, which it defines broadly as a patient having time to schedule the operation – as opposed to an emergency or urgent procedure.
Blalock’s case seems to be in a subset of that, because he had other treatment options – and Morgan’s maybe in an even smaller one.
“It’s a lot rarer to find someone who has no deformity,” Ohlson said. “Hers is pretty uncommon.”
Morgan decided to amputate her foot to rid herself of chronic pain caused by Ehlers-Danlos syndrome, a genetic connective tissue disorder, in which collagen – the body’s glue – doesn’t work properly, making joints hypermobile or loose.
Representatives of the Ehlers-Danlos National Foundation, the American Pain Society, the Amputee Coalition and the American Orthotic and Prothestic Association all said they had no information about amputation used as a method of pain management.
In 2001, The Journal of Bone and Joint Surgery published a study of 18 patients who had below-the-knee amputations for treatment of severe chronic, or intractable, pain.
“Amputations are rarely performed solely for pain relief because of concerns regarding the persistence of pain and disability after the procedure,” the report read.
Yet two years after their amputations, 16 patients were satisfied with the outcome and said they would have the operations done again in the same circumstances. One patient was unsure, and one was not satisfied and would not have done it again.
Seventeen of the patients decreased or stopped their use of narcotics after the amputations. Their average walking distance increased from 0.3 mile to 0.8 mile without having to stop. Eight held jobs after the amputations, whereas only three of the patients worked before.
“In selected patients, a below-the-knee amputation may be a good salvage procedure for intractable foot and ankle pain that is unresponsive to all medical and local surgical reconstructive techniques,” the study concluded.
Dr. Stephen Hull, medical director of the Mercy Pain Center in Portland, said he would not support amputation as a solution for pain because of the likelihood of continued pain.
After an amputation, a patient may continue to feel as if pain is coming from the missing limb when signals between the nerve endings and the brain get confused. As many as 80 percent of amputees experience phantom pain, though the frequency, duration and even feeling – from burning to twisting – varies greatly among patients, according to the Amputee Coalition.
Ohlson understands that many doctors have that fear.
“It takes a little bit of a leap of faith,” he said about the procedure. But he takes steps to cut down the risk of the nerve signals getting mixed up.
One way is to give his patients, including Morgan, a local anesthetic before the operation to “essentially fake the residual limb out so it doesn’t know that it had an amputation,” he said.
He also requires patients to get a second opinion and a psychological evaluation to make sure the patient “doesn’t have a secondary gain,” like Body Integrity Identity Disorder, a mental illness in which people feel an overwhelming desire to be an amputee.
If patients are still tearing up at the thought of losing their limbs or have other issues going on, like a struggling marriage, Ohlson might make them wait to amputate.
It’s also important that patients are committed to taking care of the residual limb, he said.
Ohlson said he has suggested amputation to patients, but most often, they come to him asking for it. The people who are really ready, he said, have no emotional attachment to their limb, but want it gone so they can get on with their lives.
“It’s impressive because there’s a stigma associated with it,” he said of missing a limb. But, he added, “you live like that person has for the past 10, 15 years, you’re going to have the same attitude.”