Programmed amputation on a teenager: What kind of preparation for what outcome?

OBJECTIVE: Traumatic lower limb amputation is rare in pediatric population, and surgeons always try limb salvage. But rarely, later amputation occurred when the traumatic limb is painful. It is a difficult and irreversible decision needed a multidisciplinary approach. We report how we managed a programmed trans-tibial amputation on 13-years-old boy, 20 months after a foot trauma.

OBSERVATIONS: Our patient is an adolescent victim of a left foot crash. The first checkup showed a degloving injury, dislocation of the interphalangeal joints and of all toes. Foot salvage was decided, but necrotic evolution required minor distal amputation and frequent dressings and skin grafts. Despite physiotherapy, orthosis (anti-equinus orthosis, orthopedics sole, orthopedics shoes) an equinus appeared. Moreover, he presented intense neuropathic foot pain, which required drugs, TENS and psychologic counseling. The foot presented secondary ulcerations requiring surgical cushioning. Seventeen months after trauma, the boy presented a painful, non-functional and ulcerative foot with important impact on quality of life (QOL). After multidisciplinary consultations, the boy and his parents decided a trans-tibial left amputation. A specific multidisciplinary preparation lasted 3 months: he met amputees, psychologist with and without his mother, certified prosthetist orthoptist, specialists of physical and functional rehabilitation, pediatric surgeon. Twenty months after trauma, trans-tibial amputation was carried out. One month after amputation: he walked with crutches, 3 months after: walked and could walks up and down the stairs. One year after: he had no pain, took no drug, got a satisfied gait on quantitative 3D gait analysis (3D GA), practices several sports, says that he has a "normal" teenager life, has an objective "normal" participation.

DISCUSSION/CONCLUSION: There is no case on literature reported on late amputation on child after a trauma. So, there is no recommendations to prepare amputation or to know what can we expected from it. We report a specific preparation and objective results (QGA, participation, QOL). This experience can be useful for team facing this particular and difficult situation.