Loss of Limb also called Limb Amputation is a major health burden on the families, society, and on medical services as well. Limb amputation is a catastrophic event and an irreversible act which is sudden and emotionally devastating for the victims. Limb amputation is one of the most ancient of all surgical procedures with a history of more than 2500 years dating back to the time of Hippocrates. Amputation is the last resort when limb salvage is impossible or when the limb is dead or dying, viable but non-functional or when it is threatening the patient’s life.
It has been estimated that there are roughly 0.62 amputees in India per thousand population. This translates to close to one million individuals with amputations in the country. According to NSSO Report on patients with amputations in 1982 Jammu and Kashmir had 3000 amputees, prevalence rate of 50-75 per lac population.
The incidences of different pathologies leading to limb amputation have been reported to vary in different populations. In developed countries peripheral vascular disease is the major cause; whereas, trauma, infections, and malignancies are the leading causes for amputation in developing countries. While in rest of the India the main causes of traumatic amputations were road traffic accidents, railway accidents, agricultural accidents and burns due to fire, electrocution, and chemical injuries.
A study was performed based on patient records data in artificial limb centre (ALC) at Bone and Joints Hospital Barzulla a major centre providing prosthetic limbs to amputees in Kashmir. The records of patients from Janurary 2006 to December 2018 were reviewed, and data including geographical distribution, sex, amputated limb, the level, and the cause of amputation was obtained. Total number of newly registered patients at the ALC was 504.
In contrast to rest of world and India in our valley out of all the causes of amputations Fire arm injury (FAI), gangrene, mines and blasts, road traffic accidents (RTA) and tumour were the major causes of maiming.
Fire arm injury in 44 patients mostly happened 1989-2008. For amputations due to FAI Srinagar topped followed by Baramulla. This high prevalence in two districts was due to high militancy in these areas during this period.
Mines and Blasts 73 patients took a higher toll from 1999-2008 but now the trend is decreasing. Blasts caused 4% upper limb amputations and 96% lower limb amputations. Baramulla and Kupwara had many victims where mine blast accidents are common along the border areas, while Srinagar and Sopore had highest number of bomb blast victims due to high militant activity.
These two causes are common in areas where there is a situation of law and order as was seen in America during its civil war. These two preventable causes could be brought down if the political turmoil comes to an end.
Of the 70 patients undergoing amputations due to gangrene only 1.4% had upper limb amputation rest has lower limb amputation at various levels. Srinagar , Kupwara, Anantnag and Baramulla were the main districts to this category. Gangrene in our study was attributed to diabetes and chronic vascular impairments. What is of concern for us is this rising number of amputations due to diabetes and dysvascular disorders. This rising trend is due to life style modifications, change in dietary habits and increased tobacco smoking. These are one of the preventable causes of amputation if awareness of the complication of diabetes and cardiovascular diseases is increased in public.
Total number of amputations due to Road Traffic Accidents (RTA)are 160. Baramulla and Srinagar 17.5% each, Budgam 14.4%, and Pulwama 11.25% patients. RTA are due to reckless driving, no traffic regulations and bad roads.
Another cause of concern is rising trend of amputations due to various cancers. Total number of patients 38. Anantnag topped with 8 patients, followed by Baramulla and Kupwara with 6 each and Srinagar had 5 patients. This increase in trend could be due to improvement of diagnostic modalities by which we diagnose these tumours early and with timely interventions save the lives. We still need to take a leap into the limb salvage (saving) operations, which are costly due to modular implants to restore the function of the limb involved. . It is worth a topic of research why the bone tumors are more common in Anantnag.
Two other less frequent causes with definitive trends are Machine cut Injury and Leprosy. Machine cut injury due to Band saw was most frequent in Baramulla , in this district which is producing boxes for apple packaging. Out of 11 cases of amputation due to leprosy 9 were from Srinagar, these patients were residents of Leper Hospital situated in Srinagar.
The loss of a limb has severe implications for a person’s mobility, and ability to perform activities of daily living. Rehabilitation is very important in these patients to restore normal lifestyle, restoration of their dignity and integration in society. This is done by prescribing an ideal prosthesis and to return them to the highest level of activity. Prosthetic rehabilitation is a complex task that ideally requires input from a transdisciplinary rehabilitation team.
While the world is making Robotic Arm/Bionic arm light in weight, with sensory feedback system with such precision and control that it can peel a grape, making a person highly functional. However the prosthesis used in ALC is very basic for upper limb it is mostly for cosmetic purposes. Similarly the lower limb prosthesis provided in ALC has very basic components just enough for activities of basic daily living. If a person is highly competitive and needs better joints and sockets which would enable him to follow his instincts then he has to buy them from market costing him thousands of rupees or even lacs.
Technologies are flooding our markets and with ever reduced prices it is unfortunate that these rehabilitation equipments are still costly or unavailable in Kashmir. Thus making our main emphasis on the indigenously made low cost rehabilitation equipments even if they are functionally very basic.
Recommendation for Government is that all our plannings should work on every step keeping specially abled persons as an integral part of our society. So, that we have a barrier free environment for the disabled; with no attitudinal bias. Data on the needs – both met and unmet – are important for policy and programmes. These will facilitate the identification of cost-effective environmental interventions.
Acknowledgements
We are grateful to the staff of the Artificial Limb Center (ALC) for the wonderful work they did in caring for these patients. We are also thankful to ICRC for providing the logistic support to run the centre.
Dr Tufail Muzaffar is Consultant Physical Medicine and Rehabilitation, Government Medical College Srinagar.