Ministerial Meandering

A tale of two knees - Part 2

(By inserting photographs of the operative procedure, I don’t want to spoil your breakfast - or whatever meal you are currently contemplating - but for those of you with a ghoulish disposition, these images could be made available to you - for an extortionate price!)

On removing the dressings, once our RSM was under anaesthesia, it was immediately obvious why he was in such trouble.  The incisions made by my Greek colleague were hopelessly inadequate, and could not possibly have relieved any tension in the muscular compartments in the leg.

Despite having left them open (as he should have) they were far too short, and blue, purplish muscle was bulging out from them. I rapidly opened the leg up with full four-compartment fasciotomies from knee to ankle - and sighed.  This looked too late to save.

There are several criteria that we use to assess the viability of muscle tissue; colour, consistency, contractility, and does it bleed when you cut it?

The colour was not the healthy, pink of happy muscle; instead, it was sad, swollen, and plum-coloured.  On palpation (feeling it), it did not have the ‘bounce’ of health, but the soggy consistency of over-ripe brinjal (eggplant).   A touch with the diathermy point (electric fire-stick) produced not a brisk reactive twitch, but - nothing at all, no reaction whatsoever.  A small cut with the scalpel was not rewarded by an exuberant squirt of bright red blood, but a slow persistent ooze of purple, deoxygenated death.  This leg had to go before it killed my patient.  I was only too aware that the coca-cola urine volume was diminishing in front of my eyes, despite the gas-man’s attempts to stimulate the kidneys by fluid infusions.

There are several options to amputation of legs, and the first is to determine at what level to take it.  Below the knee? - by far the best option if you can do that without leaving any dead tissue.  Through-the-knee? - good for those who have to lose both legs (e.g. mine injuries) to leave them with a long lever so they don’t tipple out of wheelchairs.  Or above-the-knee? - if you have to - but the hardest to rehabilitate from by far.

My decision had to made on the basis of how far the dead muscle extended.  I could see the whole of the lower leg and all four muscle compartments were dead - so that ruled out a below-knee, because you have to have healthy muscle to cover the bone ends.  I looked at the possibility of a through-knee, but as I extended my incision northwards up the leg, I found more and more dead muscle.  To cut a long story short - that is exactly what we did.  He ended up with an above-knee amputation, but with as long a stump as I could fashion, to enable a good fit for a future prosthesis.

The moment the leg and its owner were parted on the operating table, his urine output dramatically increased and the colour began to clear.  My anaesthetist and I breathed a sigh of relief over that, at least.

However,  when our RSM woke up, with his family all around him in the recovery bay, I had to face anger, bitterness - and even hatred.  Their man was alive - but in his and their eyes, I was definitely the ‘bad guy’.

I won’t go over the next few days of his early recovery with you, but it was stoked with mean looks and deep resentment from all his family, and a look of ‘you’ve failed me’ from the patient himself.

Curious end to this part of the story is that on his evacuation back to the UK Military Hospital, he was looked after by our eldest daughter, Ruth, who was his ward doctor doing her internship.

But there’s more to come - this is, after all, only our ‘first’ knee!

Philip+