Notable Cases Amputation of a useless limb Robert L Pearce and Jane Fraser emiplegia caused by a cerebrovascular accident is a major cause of paralysis of the upper limb . Although amputation of a flail upper limb has been considered by some as a treatment option after brachial plexus injuries, it is generally not contemplated in the management of stroke victims. We discuss the effect of a paralysed arm on quality of life in relation to an elderly man with hemiplegia who requested amputation of his paralysed "useless" upper limb. Clinical and ethical factors were taken into consideration, particularly the issue of informed consent. H Clinical record A 70-year-old man was referred for treatment of basal-cell carcinoma on his face. He had a left hemiparesis as a result of a cerebrovascular accident (right internal capsular haemorrhage with cortical involvement) at the age of 65. He was right-hand dominant. His hemiplegia did not affect his facial muscles and his speech was unimpaired. He walked with the aid of a stick. In the course of discussion, he sought advice regarding amputation of his paralysed arm. Although he was coping reasonably well after his stroke, he still occasionally became angry and frustrated with his paralysed arm, because it made dressing difficult. He lived with his wife and was fairly independent, but she often had to assist him with dressing, as it took a long time and he found it tiring. He had spastic paralysis in all muscles of the affected arm, with contractures in all joints distal to the elbow. There was no evidence of voluntary movement in the left upper limb. Marked spasticity in his left arm and leg was associated with left hyperreflexia and a left extensor plantar response. Sensation was present, although diminished, in the left hand. Because of contractures in the paralysed hand, he lived constantly with a bad odour from this hand, which was almost impossible to wash. A resting splint maintaining functional wrist extension, thumb abduction and metacarpophalangeal extension, to be used at night, had been tried previously but without success, as the contractures were too well established. He complained of a cold feeling in his left arm and also a dragging pain extending down the arm. The pain was relieved by supporting the arm in a sling, but using a sling added to discomfort across his neck and shoulders. The patient's medical history included increasing dyspnoea on exertion after the stroke and occasional angina, although a chest x-ray and electrocardiogram showed no significant abnormalities. He was mildly hypertensive and a prostatectomy for adenocarcinoma had been performed several years before the stroke. After this preliminary discussion, the advice of a gerontologist and opinions of surgical colleagues, especially orthopaedic surgeons, were sought. None had ever had a similar request for amputation of a limb after a stroke. Some considered that it was unnecessary and possibly unjustified. Despite these varied opinions the patient was still keen to proceed. Consultations for assessment were arranged. These included consultations with his general practitioner, a neurologist, a psychiatrist, an anaesthetist and a physiotherapist experienced in stroke rehabilitation. In each case the consultant was aware of the need to provide the patient with arguments to enable him to give fully informed consent. The most important preoperative (and postoperative) assessments were performed in the physiotherapy department at Hollywood Private Hospital, where gait, coordination and balance were recorded. Functional assessments Hollywood Private Hospital, Perth, WA. Robert L Pearce, FRCS, FRACS, Aesth etic and Reconstructive Plastic Surgeon. Jane Fraser, Manager, Physiotherapy Services . No reprints will be available. Correspondence: Dr R L Pearce, Hollywood Private Hospital, Monash Avenue, Nedlands, WA 6009 . MJA Vol 164 1 April 1996 of the contralateral and dominant upper and lower limbs were normal. A video recording of the patient's posture and gait was obtained for comparison after the operation (Figures 1 and 2). With the benefit of fully informed consent, we proceeded with a routine amputation of the paralysed left arm above the elbow, leaving a stump with about 20 ern of humerus and adequate anterior and posterior myocutaneous flaps for closure without tension. Despite these precautions, some superficial blistering appeared close to the wound during the early postoperative phase. This was associated with oedema in the skin flaps but no other evidence of infection, drainage or discharge. No fur ther deterioration occurred after hyperbaric oxygen treatment, and healing was then uncomplicated. Postoperative recovery and rehabilitation went according to plan, with the physiotherapist playing an integral role . Along with normal daily living and social skills, the patient's gait, coordination and balance were further assessed at one, three and six months after the operation. A further video recording to demonstrate posture and gait and his ability to stand unaided from a sitting position was obtained at 12 months. Results Objective assessment after three years found no significant change in his standing posture (Figures 1-3), which consists of a broad-base support, asymmetrical weightbearing (he stands on the unaffected leg), lateral flexion of the trunk with rotation to the left and flexion of the left hip, and head held in the midline. Similarly, after three years his gait remained unchanged, although it was observed that he appeared slower and had less exercise tolerance than at the time of operation. He remains mobile with the aid of a walking stick, circumducts the left leg with no heel strike, pivots around his rigid left leg and does not step through with the right leg. We used the Berg Balance Scale (a 407 Notable Cases Figure 1: Video imagBs of the 7a-year-old man with left hemiplegia. Front view sho wing broad路ba sed gait be fore operation, with marked lateral flexion and rotation of the trunk. Figure 2: Pos terior view showing trunk pos ture and the paralysed left arm before opera tion, with his affe<;ted leg flexed at the hip join t. Figur e 3: Three reafS after the ope ration, showing the upper-limb amputation and no significant po stura l impro vement. comprehensive test of mobility and balance, with a maximum score of 56)1 to test his balance. which gave the following results: Before operation (Oct 1992) 44/56 After operation (Nov 1992) 34/56 At 3-year follow-up (Nov 1995) 32/56 Shoulder posture on the side of the amputation ha s not been adversely affected and limb fun ction on his dominant side remains essentially unaffected . The pati ent's subjective assessment after three years is that having his arm amputated was the corr ect de cision. Dressing is now easier. There is no longer any odour, and no pain or discomfort from the need to wear a sling. He feels his ba lance has improved and he ha s not had a fall since me operation. He sleeps better at night and without sedation. He has not returned to playing bowls but continues to drive his own car. Discussion Amputation of a limb is a drastic measure under any circumstance. Nevertheless, it is the treatment of choice in a wide variety of conditions, including neoplastic disease, severe trauma and vascular complicati on s, and chronic lymphoedema, particularly when me distal part of th e limb is involved . Amputation is not usually con sidered in the management of stro ke victims. H owever, surgical procedures, including tenolysis, tendon transfers and tendon 408 lengthening, are occasionally performed on the non-functional upper limb after stroke to correc t spastic flexion con tra ctures of the joints, particularly to relieve pain or allow adequate hygiene.! The mental att itudes of stroke victims to their unresponsive limbs are well documented .t These can be expect ed to change over a period of months after a stroke from anxiety and disbelief to ang er or depression, fru stration and disownment. Finally, th e aver age patient demonstrates resignation and acceptance of the useless limb . Our patient, having reached the st age of acceptance of his disability, regarde d his left arm as a nu isance. Louis Pasteur is known to have exp ressed the agony of many such patients when he observed his useless arm and groaned " If only I could have it off" . 4 Informed consent was particularly important in thi s case be cause of the patient's medical history and the risk of postoperative complication s. Both subjective and objective assess ments were con sidered essential, the latter being reinforced by a com prehensive team approach .S,6 Assessment during the earl y postoperative pha se showed no evidence of significant improvement in th e pati ent's posture, gait or balance as measured on the Berg scale. The effect of a major anaesthet ic and surgical procedure was a degree of diminished incentive and physical activity which did not recover. Hi s measured deterio ration in ba lan ce and th e lack of improvement in po sture and gait are con sider ed to be the direct result of thi s relatively brief period of im mobilisation rather than a complication of the upper-limb amputation. H owever, we assessed his capaci ty for independence in self-care and daily living activiti es to be unaltered. Our patient maintains a positive and opt imistic outlook, ha ving su ccessfully di scarded what he regarded as an impediment. In conclusion, although the end result ha s pro ved successful and justified the pro cedure in this patient, amputat ion in the management of hemiplegia should never be performed routinely or without balanced conside ration of all the pertinent clinical factors and risks. References 1, Harada N, Chui V. Damron-Rod riguez J . et et. scre eoing lor balance and rnobilily impairment in el d e ~y individuais living in residential care taenues Phys The, t 995; 75 ; 462路469 2 Ryerson SO Hemiplegia resuning from vascular insuft or disease, In: Umphred DA, ed itor. Neurolog ical reneb,lrtat;on, 2nd eo . Chapter 22, St Louis; C V Mosby. 1990 657-658 3, Waters RL. Upper extremily surgery in stroke patients, Chn Orlhop Chn Res 1978; 131: 30路37 . 4 Val ~ ry.Ra dot R. The life of Pasteur. London : Archibald Constable, 1906: 160. 5 McNeill PM, Walters JD, Webster IW. Ethics decision making in Australian nosptels. Moo J Jws! 1994: 161 48 7路 488, 6 Hancock L. Defensive medicine aro inlormed consent. Canberra: AGPS. 1993: 31. (Received3 Jul 1995, arx:eptOO 8 Feb 1996) MJA Vol 164 Q 1 April 1996