Comment on: ‘Post Amputation Syndrome’

Sir: Dr J. Kulkarni¹ gives a good list of lower limb amputation sequelae with comprehensive information on frequency. However in a clinical setting we suggest that it might be more helpful to classify amputation sequelae by their presentations:

1. Observed at physical examination;

2. Expected to be reported by the patient;

3. Normally hidden, such as loss of morale and determination in constructing a new and fulfilling life.

We feel that the use of the word ‘syndrome’ in the context appears inappropriate. The Oxford Concise Medical Dictionary defines syndrome as ‘a combination of signs and/or symptoms that forms a distinct clinical picture indicative of a particular disorder’. 2

In clinical practice, syndrome assumes a common causative factor, e.g., Horner's syndrome, with eye signs and lack of sweating on the side of the face due to pathology in the cervical sympathetic ganglion, or Down's syndrome, with clearly associated genetic factors. Following lower limb amputations many of the conditions described by Dr Kulkarni 1 could have different aetiologies, for example, altered mechanics of gait for back pain, local pathology for wound and skin problems, vascular pathology for the increased vulnerability of the surviving leg and co-morbidities for decreased life expectancy. Some of the sequelae may be iatrogenic. There is no clear precise clinical pattern in the three suggested categories that has a strong association with a particular aetiology or level of amputation. If this were to be called a Syndrome, there would be several other post-operative syndrome complexes, e.g., Post Coronary Bypass Syndrome to describe local problems in the chest wound, leg problems from the graft donor site, cardiac complications and recognized psychological problems.

Some surgical procedures do have specific post-operative syndromes. Thus post-gastrectomy syndrome is a condition where a patient may have abdominal cramps, diarrhoea, light headedness along with increased heart rate and a drop in blood sugar levels. This is specifically due to a lowered tolerance for large meals and rapid emptying of the stomach. It does not include other sequelae of this operation such as wound problems, abdominal hernia and peritoneal adhesions.

Use of the word syndrome in this context could mislead practising clinicians into considering the listed entities are expected sequelae in all amputees. It may also dishearten patients undergoing planned amputation and could result in confusion by patients applying for benefits. It is of course important that clinicians should recognize all symptoms following amputation, some of which may be post-operative complications or due to the original pathology or co-morbidities.