12 THE STRAITS TIMES JUNE 2 2011
Saving
LIMBS
M
adam
Neo
Suzhen,
44,
suffered Hospital (NUH), said Associate Professor
a horrific James Hui, head and senior consultant at
worksite accident when
JOAN CHEW
her left leg was pinned
under the tyre of a
forklift, crushing her bones and muscles
and ripping off the skin.
For engineer Leong Fook Chuen, 55,
the aching pain in his left ankle turned out deformed leg successfully grown to a
to be a rare cancer of the bone.
A 20-year-old woman, who wanted to be
known only as Hazel, was born with a
deformed foot. As she grew up, it became
obvious that her right leg would be shorter more than half would end up with an
than the left.
All three patients suffered from
different medical conditions, but they had
something in common: They all faced the
grim prospect of an amputation of their
legs.
If they had lost their
limbs, they would have had
to be fitted with prostheses,
or artificial limbs, if they
wanted to get around
without a wheelchair.
However, all three
OUT OF 10 BONE CANCER
PATIENTS CAN HAVE
managed to keep their legs,
thanks to medical advances
which have made limb
salvage more feasible today.
HELP FROM MEDICAL ADVANCES
Bones can now be grown surgically,
harvested from one’s own body parts or
taken from dead bodies for transplant.
Complications during wound healing,
such as infections which could have
resulted in amputations in the past, can
be managed better with new devices.
Bigger teams of doctors with
microsurgery expertise and changes to
hospital protocol mean accident victims,
for whom time is of the essence, now wait
a shorter time for reconstruction to begin.
Six orthopaedic surgeons Mind Your
Body spoke to agreed that fewer
amputations are now being done on
patients with deformities, cancer or
injuries.
For instance, the most common
skeletal deformity in the leg, fibula
hememilia, can now almost always be
Amputation is no longer the
norm for patients with cancer,
accident victims and those
born with deformed limbs
successfully treated through procedures to
lengthen the bone.
Each year, a handful of children like
Hazel are seen at National University
the division of paediatric orthopaedics.
In the past, he said, these children
would have their abnormal limbs
amputated and the stump fitted with a
prosthesis.
But now, all of them can have their
normal length.
More than three in four accident victims
can have their crushed limbs salvaged
now, compared with a decade ago when
amputation, said Dr Peng Yeong Pin, head
and senior consultant at the department
of hand and reconstructive microsurgery at
NUH.
Last year, only one out of 14 accident
victims whose lower limbs
were injured ended up with
an amputation.
INSTEAD OF
Tan Tock Seng Hospital
AMPUTATION
(TTSH) carried out five leg
8
amputations on accident
victims last year, down from
about 10 in 2000, said Dr
THEIR LIMBS Winston Chew, head of its
SAVED NOW
hand and microsurgery
section.
Hospitals are able to
achieve this because they now dedicate
more resources to limb salvage
procedures.
Ten years ago, Dr Chew was the only
doctor in TTSH trained in microvascular
surgery techniques, such as flap
techniques, which limb salvage
procedures require. He was then
supported by visiting consultants from
Singapore General Hospital (SGH). Now,
there are three other experts in his
department.
These days, flaps – pieces of tissue
transplanted to repair wounds – can
minimise the need for amputations, said
Dr Tan Ter Chyan, a consultant at the
department of hand and reconstructive
crests
microsurgery at NUH.
In 2006, 54 flaps were done at NUH.
By 2009 and last year, this had risen to
70 flaps each year, suggesting that fewer
injured limbs were amputated.
In the past, it could take up to two
Reconstructing a leg
weeks after the initial emergency surgery
before an accident victim went into the
ALLOGRAFT operating theatre again to undergo limb
reconstruction.
AUTOGRAFT ■ A transplant can be This was because doctors had to wait
Recipient’s
■ Severe accident victims with tissue loss usually taken from a dead
tibia
for the wounds to heal on their own before
have an autograft done, where the muscles, bones donor and these tissues patients were deemed ready for the
and skin are transplanted from one part of the body to may be live or dead. reconstructive surgery, Dr Chew said.
Recipient’s But using skin and muscle flaps for
another. ■ Live allograft fibula
wound coverage has reduced the waiting
■ However, this creates a second surgical site which transplantation of bone time to an average of three to seven days,
the patient must recover from. Sometimes, this, in and soft tissue is not he explained.
turn, may need to be covered up. done in Singapore.
Such a transplant HELP FROM NEW PROTOCOL
requires immune Sugical advances are not the only thing
suppression therapy, saving accident victims from amputations.
Muscle which brings with it NUH has also put in place a new
Latissimus Head of many complications.
■ Muscles are often protocol in 2008 for patients who need
dorsi femur
harvested from the lattisimus (ball-and- ■ Dead allograft limb reconstruction to be operated on
dorsi, one of the biggest socket transplantation is within a week after the emergency surgery.
muscle flaps from the body joint with usually used for Now, most of their patients are
that covers the lower back. the pelvis) revision joint surgery operated within this time frame.
■ Other muscle flaps and not for trauma Steel
Previously, without this clear timeline,
used include the patients. These grafts many were operated on up to 14 days
gracilis muscle from plate with
act as a scaffolding for screws later.
the inner part of the Femur patient’s bone to grow If surgery is completed within a week,
thigh, the vastus
into, but do not have there is less chance of infection setting in,
lateralis from the
outer part of the live cells or proteins resulting in more of the patient’s own
quadriceps, and the which help in bone tissue being saved. This can bump up the
rectus abdominis healing. Dead success rate up to as high as 90 per cent,
where men often train These allografts are allograft NUH’s Dr Peng estimated.
for their six-packs. often imported from In the case of bone cancer, amputations
Gracilis ■ Calf muscles may overseas centres as were part and parcel of treatment, where
muscle also be used to cover Singapore’s bone the entire tumour could be removed along
wounds in the banks do not have a with the normal bone surrounding it to
shin area. good supply of reduce the chance of tumour recurrence.
Dead allograft done on bone cancer
Rectus ■ Removing these allograft bone. patient Leong Fook Chuen in January
In the 1970s, amputation would be the
abdominis muscles do not significantly There is no need for “first course of action” for bone cancer
at Singapore General Hospital.
affect a person’s movement bone matching. patients, said Associate Professor Tan
Vastus or function, though that part Mann Hong, senior consultant at the
lateralis of the body may be weaker as department of orthopaedic surgery and
a result.
director of the musculo-skeletal tumour
MEGA-PROSTHESES service at SGH.
But with more precise diagnoses – from
Skin ■ When a long length of bone more accurate imaging technology, like
■ The wound or muscle flap may be grafted with skin graft, together with a joint (such as a knee magnetic resonance imaging (MRI) and
usually from the thighs. joint) is removed, as in tumour positron emission tomography (PET) – as
■ There is no need to replace the skin at the donor site, as
only a thin layer is taken. The area where it is taken will
heal in two to three weeks’ time.
surgery, a large implant consisting of
the joint and adjacent segments of
bone is used to replace the missing
skeleton. Such an implant is called
well as surgical plans, most patients can
now avoid the radical procedure of an
amputation.
In the last five years, Prof Tan has done
Ribs Nerves a mega-prosthesis. fewer than five amputations on bone
■ Nerve injuries are repaired or
grafted. Nerve grafts are usually
■ But it has a limited lifespan of cancer patients, about half the number
10 to 15 years and needs to be done in the previous five years.
taken from the sensory nerves of Eight in 10 patients with bone cancer
the leg, known as the sural nerves. replaced in subsequent surgery.
can have their limbs preserved now, said
■ Nerves take a long time to grow, Tibia ■ Accident victims who have Dr Mark Edward Puhaindran, a consultant
about 1mm a day, so it will take a
Fibula
open wounds are not suitable at the division of musculoskeletal oncology
year to grow up to a foot length. for this, as their risk of at NUH’s department of hand and
infections with a large reconstructive microsurgery.
prosthesis is high. NUH sees about 10 to 15 bone cancer
■ Young patients and patients a year, compared with seven or
children who are still eight cases a decade ago.
growing are also not Of course, the complete removal of the
Blood vessels This is a proximal tumour usually takes precedence over
femoral mega-prosthesis recommended for
If injured, these such an implant. saving the limb and doctors will not
are repaired or in the upper part of the
thigh, including the hip and hesitate to recommend amputation if they
grafted with veins most of the thigh bone feel it is necessary, said Prof Tan.
in the leg to
called the femur. But many patients think otherwise.
re-establish blood
Recipient’s He said: “Patients can accept stiff limbs
circulation.
bone and certain morbidities, but the moment
you mention an amputation, they will not
Iliac Bones GRAPHICS: LIM YONG
agree to it.
■ The iliac crests, the curved ridge at the top of the pelvic bone, PHOTOS: ISTOCKPHOTO, TOP NEWS
“After all, it is a very final act.”
AND SINGAPORE GENERAL HOSPITAL
Femur has a large amount of bone which can be used as bone grafts.
■ The fibula and the ribs (up to two ribs) can also be used because SOURCE: DR WINSTON CHEW, HEAD OF THE HAND AND
MICROSURGERY SECTION AND SENIOR CONSULTANT AT THE
joanchew@sph.com.sg
they are not essential for weight-bearing or normal bodily functions. DEPARTMENT OF ORTHOPAEDIC SURGERY AT TAN TOCK SENG HOSPITAL
MORE STORIES ON PAGES 14-15
14 THE STRAITS TIMES JUNE 2 2011
Fixing crushed leg with her own body parts
Madam Neo Suzhen (right), 44, told her doctor
bluntly after being warned that her left leg might
be amputated: “I will commit suicide if my leg is
gone.”
Life without her limb never once crossed her
mind, not even when she saw “very bad, fleshy
things” sticking out of her crushed left leg.
Fortunately, doctors were able to save her
leg.
The nightmare began on the morning of July
21, 2009, when she was walking out of her
workplace, a factory that made wood flooring
products, to a hawker centre to get breakfast.
As she crossed the factory compound, a
forklift suddenly reversed from its stationary
position and hit her on her right side. She fell
and the forklift ran over her left leg, crushing it.
Madam Neo said she did not feel the pain
then and was conscious when she was whisked
to National University Hospital (NUH) in an
ambulance.
Dr Tan Ter Chyan, consultant at NUH’s
department of hand and reconstructive
microsurgery, said the friction from the tyre of
the forklift literally “skinned her” alive.
The skin covering her left shin, which was
about 8 per cent of her total body surface area
or seven palm sizes, came unfurled.
The bones of her lower left leg – the tibia and
fibula – were fractured. Her nerves, muscles and
arteries in that area “all got twisted along with
the skin”, partially cutting off oxygen and blood
supply to that area of the leg, said Dr Tan.
In an emergency surgery, all her dead tissue,
which would lead to infection, was removed.
Her fractures were temporarily repaired and
stabilised with an external fixator, a device
which supports the bone from outside the skin.
The torn skin was shorn of its fat, hence
requiring less blood to keep it alive, and stitched
back to the leg to cover the wound. A vacuum
sealing technique, also known as negative
pressure wound therapy, was used to keep
infection at bay.
A piece of foam and dressing with a drainage
tube was applied to the wound and sealed with
a piece of transparent film. A vacuum source
connected to the tube continuously sucked out
excess fluid from the wound to help the blood
circulation. This technique has been used on 80
to 90 per cent of trauma patients at NUH for the
last eight years, Dr Tan said.
In the operations which followed in the
following week, the external fixator was removed
and the fractures repaired with a nail inserted in
the tibia (the shin bone), and a plate in the
fibula, on the side of the tibia.
Once these bones were stabilised,
Madam Neo had autografts done, in which
tissues were grafted from other parts of her
body to reconstruct the crushed leg. A section of
her calf muscles, with its blood supply still
intact, was manoeuvred to the shin area just
below her knee, while the lattisimus dorsi, a big
muscle flap from her back, was taken to cover
the rest of her leg down to her ankle.
Half of the skin that had been torn off in the
accident died a week later. It was removed and
replaced with a layer of skin, less than 1mm
thick, grafted from her left inner thigh.
After being hospitalised for 18 days,
Madam Neo went home.
The cost of the procedures came up to
$100,000, which she hopes to claim from the
forklift driver’s company.
The road to recovery has been long and
arduous. At first, when she was on crutches and
later on a walking stick, she was conscious of
how others viewed her and stayed indoors
mostly.
Physiotherapy helped her to walk on her own
again, which she did eight months after the
accident, she said. But she now has to
consciously lift her left foot higher whenever she
walks on uneven terrain, such as when going up
and down stairs, as this leg reacts less quickly
to changes in her surroundings.
Her new leg also has no sensation in the
lower portion.
She said: “If I bathe with hot water, my feet
will turn red but my left leg can’t feel the heat at
all.”
This is because she had lost her sensory
nerves in that part of her body, explained
Dr Tan.
So she has to check her leg regularly to
ST PHOTO: WONG KWAI CHOW
ensure it has not been injured or infected
without her realising it.
Madam Neo also has to avoid weight-bearing
activities like running. The avid jogger, who used
to run three to four times a week at her
neighbourhood park, can no longer enjoy the
activity.
Even an hour of standing during shopping
tires her now. What used to be a five-minute
walk from her house to the bus stop now takes
15 minutes.
But beyond such inconveniences and the fact
that she no longer wears skirts and bermudas to
avoid exposing her legs, Madam Neo is just
happy she can still walk.
She said: “I’m lucky to be living at a time
when there are medical advancements that are
able to repair my leg. I’m an independent person
who will never accept having to depend on
others to get around.”
By Joan Chew
Bones from the dead save cancerous leg
For close to a year, engineer Leong Fook Chuen
(right), 55, put up with an aching pain in his left
ankle as he walked.
The father of three children, aged 12 to 23,
recalled: “It felt like something was pressing
against my bones and muscles.”
A trip to a general practitioner resulted in a
diagnosis of osteoarthritis, which occurs when
the cartilage in the joints degenerate.
But the pain was in fact from a tumour, and
worsened progressively until he was forced to
visit a specialist at Singapore General Hospital
(SGH) last December.
There, he was diagnosed with stage 1
leiomyosarcoma of the bone, a cancer confined
to the distal end of his left tibia (shin bone),
after some tissue was analysed in a biopsy.
He was told he might have to have his leg
amputated below the knee. His doctor,
Associate Professor Tan Mann Hong, senior
consultant at the department of orthopaedic
surgery and director of the musculo-skeletal
tumour service at SGH, said: “An amputation
was the surest way of removing the tumour, but
patients always ask for alternatives.”
Mr Leong was concerned, but was more glad
to be able to stay alive.
He said: “As long as I can live, I can accept
anything. An amputation to keep me alive was a
bonus, so a limb salvage procedure was an
Growing bones to lengthen a limb
When Hazel (right) was born, the only sign that
her right leg was abnormal were that three toes
were fused together.
But when she turned one, it became clear
that her legs were unequal in length, recalled
her mother, 50, who is self-employed.
Hazel, who did not want to give her full
name, is now 20 and awaiting entry to a local
university. She has a congenital condition where
her fibula – the outer smaller bone connecting
the knee to the ankle – is totally absent. Her
tibia, or shin bone, and femur, or thigh bone,
were also abnormally short. Fibular hemimemia,
also known as longitudinal fibular deficiency, is
the most common skeletal deformity in the leg.
But it is a very rare condition among children
here, said Hazel’s doctor, Associate Professor
James Hui, who heads the division of paediatric
orthopaedics at National University Hospital.
He sees about five such patients, mostly
foreigners, in a year.
They have two options: To go for an
amputation or a leg-lengthening procedure.
Hazel’s father, 53, who works in the service
industry, said he and his wife were initially
worried about Hazel’s mobility and how her
deformed leg would affect her life.
He said: “There is nothing like walking on
your own two feet.”
No parent will easily accept their child having
to go through an amputation, so fortunately, all
of such patients can now be successfully
treated by growing the bones surgically, said
Prof Hui.
When she was five years old, Hazel went for
even bigger bonus.”
In January this
year, Mr Leong
underwent surgery to
remove his tumour.
A 20cm-incision
was made in the front
of his shin down to
his ankle, and 14cm
of his left tibia,
including part of his
ankle joint, was
removed. Only 7cm of
this was cancerous,
while the rest was
healthy bone.
ST PHOTO: AZIZ HUSSIN Doing this offered
“a generous margin” to
ensure that no tumour cells were left behind,
said Prof Tan. To replace his lost bone, an
allograft using bones from a cadaver, which had
been frozen and stored in a tissue bank in
Germany, was flown in for the procedure.
These bones are donated by healthy people
who die unexpectedly and as there is no need
for tissue matching for bone transplants,
Mr Leong did not require anti-rejection drugs.
Mr Leong’s surgery came up to $28,000,
which was covered by both his own and his
company’s insurance.
ST PHOTO: LAU FOOK KONG
her first surgery, where the abnormal bone in
her lower right leg was cut into two segments
and attached to a device fitted outside of her
limb, known as an external fixator.
A screw on the device was turned four times
a day, over the next three months, to widen the
gap between the two bone segments.
This prompted the growth of new soft tissue
to fill the gap between the bone segments, and
lengthened the leg by 1mm per day.
Hazel made frequent trips to the hospital to
have X-rays taken to monitor the progress of her
bone growth, said her mother.
The device was removed a year later. When
Hazel was 14, she had surgery to slow down
the growth of her longer left leg, so that her
right leg could “play catch up”, said Prof Hui.
Then at the age of 17, she had another
surgery to attach an external fixator to her
upper right thigh to prompt its growth, in a
procedure identical to her first.
About 10 cancer patients receive an allograft
at SGH each year, said Prof Tan. They form
20 per cent of the bone cancer patients at SGH,
while the rest are fitted with a metal implant.
Such implants can replace bones in the
shoulders, hips, knees and upper tibia, but
there are currently none for the ankle, lower
tibia and foot, Prof Tan explained.
An autograft, where bones are grafted from
other parts of the patient’s body, could not be
performed for Mr Leong because each person
has only one tibia in each leg.
Prof Tan added that over the last 16 years,
up to 95 per cent of patients with cancer of the
limbs have had them salvaged through such
medical procedures. The remaining 5 per cent
could not avoid an amputation because the
cancer had spread too far.
Mr Leong, who has gone back to work in
April, is now getting around on crutches.
Prof Tan said it will take up to nine months
before the grafted bone will fuse together with
Mr Leong’s own bone. This is when he will be
deemed well enough to walk without aid.
Mr Leong said: “I thought amputation was the
only solution for me. I never thought there would
be another way to save my leg.”
By Joan Chew
The device was adjusted over three months
and it was removed 11/2 years later.
Hazel said that her junior college arranged for
her classroom to be located on the ground level
for her ease of access.
She wore a larger school skirt – nipped in at
the waist with pins– to accommodate the bulky
device at her thigh.
In January this year, she had her last
operation to attach an external fixator to her
lower limb. The last of her daily adjustments to
the device was done last month.
The cost of all her treatments is estimated to
be more than $20,000, partly paid for with her
parents’ Medisave.
Meanwhile, she is still wearing the device to
support the bone, and gets around on crutches.
Though her right foot, about the size of a fist,
is still abnormally small, Prof Hui said that it
can bear her weight as it is supple and she can
walk with the entire sole of the foot touching
the ground without pain.
Her parents have never kept her indoors, but
she avoids crowded places where she risks
people knocking into her.
In the shower, she takes care to keep the
device dry by wrapping it with plastic bags
secured with layers of masking tape, she said.
She does not wear mini-skirts or shorts so as
not to draw attention to her legs, she said,
preferring to hide them in flared jeans.
Asked what she would most like to do after
the device is removed for good, she replied
without skipping a beat: “To go shopping for
slim-fit jeans.”
By Joan Chew