Amputations in leprosy.

Removal of an anatomical segment is not pleasant for anyone; perhaps even more so in leprosy patients because of disease stigma. Amputation has an immediate relation to social dependence and handicap. The loss of a once normal part of the body is regarded by both the person and society as a detrimental event. In contrast, children with some upper limb congenital anomalies do not regard this as ‘abnormal’ until later in life when society, sometimes even parents, impose on them the concept that they are ‘different’. Amputation may have a very negative impact on someone’s life as well as carry many symbolic representations, from pity to repulsion, encompassing guilt and resignation, both from the amputee and their social partners. However, amputations are valuable surgical procedures, life-preserving and, strange as it sounds, a choice for certain rehabilitation processes. Amputation has a place in the management of disability in leprosy. Amazingly, it can be the bridge from dependence and depression to full social integration including economical participation. To have these positive results, it should be properly indicated, carefully performed and, most importantly, adequately managed and supported by competent prosthetic services. Indications for amputation in leprosy are few and very specific. They are mostly restricted to the lower limbs, as in the general population, in whom over 85% of amputations occur in this part of the body. Primary indications for amputation are long-standing consequences of plantar ulcers and severe bone/joint disintegration. Although infrequent, malignant transformation in plantar ulcers is a mandatory indication. It should also be considered in severe bone/joint disorganisation due to neuropathic disintegration associated with plantar ulcers and contractures. The patient should be fully and explicitly involved in the decision for amputation since it is their limb that will be removed. Furthermore, a patient’s participation in the post-surgical fitting period is even more important than the surgeon’s skill in performing the amputation. The indications for amputation vary with the surgeon’s personal preference and the cultural and technological surroundings, the latter in respect of prosthetic services and long-term maintenance of prosthesis. One should remember that fitting a shoe on an insensitive foot is far easier than fitting a prosthesis on an anaesthetic amputated leg and not the reverse as some unmindful