It might seem unthinkable, but this man is having his leg amputated... out of choice! How one sprained ankle led to a drastic decision - with the NHS's backing

Matthew Smith dreams of walking: striding through a park hand in hand with his wife Sarah, carrying their five-year-old daughter on his shoulders. Then he wakes up and remembers the years of pain that have meant that such a simple pleasure is out of reach.
Three years ago, Matthew, 37, sprained his left ankle after slipping on a cobblestone. What seemed an innocuous accident set in motion a chain of events that would mean he would be left permanently disabled.
An unsuccessful repair operation compounded his problems, and last year he faced a bleak set of options.

Big decision: Matthew Smith, pictured with his family, is preparing to undergo surgery to amputate his leg below his knee

The first was learning to live with the discomfort that means he is reliant on powerful medication, crutches, a wheelchair or mobility scooter.
Another choice was a further operation to permanently fuse his ankle joint and stop further deterioration. Finally, he could choose to have his leg amputated below the knee.
It seems unthinkable, but Matthew chose amputation – despite two surgeons trying to change his mind.

An NHS orthopaedic expert has backed his decision, and the amputation will be carried out next week. The case is extreme, yet Matthew wishes the decision could have been taken earlier.
‘Of course I am nervous,’ he says. ‘It’s a huge decision and not one I took lightly, but I am looking forward to being the fit, strong and able man my wife and daughter deserve.’
Both he and his consultant, Steve Mannion at Blackpool Victoria Hospital, feel that more patients should be aware that amputation is something to consider.
‘It’s seen as mutilating but despite the fact we now know more about joints than we did hundreds of years ago, there are limitations to what we can achieve in terms of fixing or replacing them,’ admits Mr Mannion. ‘For patients such as Matthew, chronic lower limb pain has an awful effect on quality of life.

Bionic man: Matthew hopes that by replacing his injured leg with a prosthetic he will be able to return to a normal life (file photo)

‘He is a man in the prime of his life with a family who is now essentially wheelchair-bound and unable to work. We could keep operating on him for years attempting to fix the problem, but I’m not convinced it would reduce his pain significantly or improve his mobility.’
Mr Mannion says this is not an isolated case, and he is now treating a handful of patients with similar chronic problems in the same way. He adds: ‘Prosthetic technology is advanced – we’re not talking about peg-legs now. In many cases you can’t tell by looking at a person walking that they have a prosthesis.’
Matthew’s ordeal began in February 2010 as he was arriving home from work. ‘It was icy and there was no street lighting around the back of my house,’ he remembers. ‘I was stepping out of the car with a shopping bag in one hand, and I didn’t see the edge of the cobblestones.
‘There was a sharp pain and a pop in my ankle, and then I was flat on my back. A neighbour was coming in at the same time, and once we’d stopped laughing – despite it being agony – he helped me up.’ Any amusement quickly dissipated when, a couple of hours and a few painkillers later, Matthew’s foot was severely swollen and couldn’t bear any weight. A hospital visit and  X-ray confirmed the ankle was not fractured and he was sent home with crutches, more painkillers and a set of physiotherapy exercises.
‘I played golf and walked a lot as well as working out in the gym, so I threw myself into the exercises. I was told that was the way to get my ankle strength back, so I assumed I’d be back to normal in no time.’
But after three months, the ankle still hadn’t improved. ‘The sharp pain when I walked was getting worse, and my foot would swell, so I knew something wasn’t right.’
An MRI scan revealed a tear to one of the four ankle ligaments, and damage to another. Over the next few months, he was given injections of steroids – a drug that reduces inflammation – referred to an orthopaedic surgeon and sent back to physiotherapy.
He says: ‘Nothing helped. I was now using crutches all the time and still needing painkillers. I was able to continue working at my telecoms business, but by the end of the day I was in so much pain I couldn’t help with the housework or the baby.’
In November 2010, Matthew was booked in for surgery. ‘The surgeon told me he would clear out any scar tissue and swelling from around the tendon and this would ease my discomfort. I was just happy that my ankle was finally going to be fixed.’ But, in the months following, his ankle pain spread from the front of his ankle across the whole joint. The tendon the surgeon had operated on had also started dislocating.
‘Usually, that tendon sits behind the bony protrusion on the outside of the ankle, but when I tried to turn while walking, it seemed to move out of position and you could see it appear at the front of the ankle,’ explains Matthew.
The surgeon assured him it would settle down. ‘I went home and tried to carry on as normal,’ says Matthew, ‘but the pain from within the joint continued to worsen.’
Matthew was referred for a second opinion and another MRI scan revealed a defect had developed on the end of Matthew’s tibia – the shin bone – which wasn’t present before the last surgery. He was given a second operation to clear the debris, and the surgeon also performed a microfracture procedure, in which tiny breaks are made in the bone to try to stimulate new healthy tissue growth, to no avail.
‘It was just a nightmare,’ says Matthew. ‘With every procedure I hoped my ankle would be fixed and I could start getting my life back to normal, but things just seemed to go from bad to worse.’
As many in his dire situation might do, Matthew researched his condition on the web. ‘I discovered just how complicated the ankle is – and that any alteration to the way the joint works can have big implications. I realised that the odds of it improving with minor procedures were slim.’
Throughout the next year, he was reliant on high doses of morphine. ‘It took the edge off, but not completely, and it stopped me sleeping so I was like a zombie during the day. I had to use a wheelchair whenever we left the house, so I couldn’t even push my little girl on the swings.’

ALMOST AS GOOD AS THE REAL THING

Once Matthew has undergone his amputation, he will be referred to an NHS prosthetic centre to have his new leg made. First, a cast is made of the residual limb.
Sue Walker, Prosthetic Rehabilitation Unit Manager at the Royal Orthopaedic Hospital in Stanmore, Middlesex, says: ‘Depending on patient condition and speed of wound-healing, this can be as little as a fortnight later. Each prosthetic is made individually and on-site.’

WHO NEEDS WHAT?
There is a great deal of choice in terms of limb replacements. ‘Joints can range from the purely aesthetic – dummy feet – all the way through to those with powered ankle joints that can flex,’ says

Replacement: A prosthetic foot from Elan

Professor Saeed Zahedi, Technical Director of Blatchford Clinical Services, which designs and manufactures limbs for the NHS along with such companies as Otto Bock, Opcare and RSL Steeper.
Some amputees are more concerned with function and others with appearance.
‘Carbon-fibre feet, with which you can run and which offer more springiness, are ideal for the more active. Older patients prefer good shock absorption so that the movement of the foot doesn’t stress joints,’ says Ken Hurst of Otto Bock.

WHAT ABOUT BLADES?
‘One limb per patient is standard – we’re looking to provide appropriate equipment for ordinary life and for patients to meet their goals,’ says Walker.
‘The NHS will consider providing another prosthetic, such as running blades, if you can demonstrate keenness for a specific activity.’
Ken Hurst estimates that 90 per cent of prosthetics are provided through the NHS.

WHAT’S THE FUTURE?
At present, limbs are mono-functional – running and walking usually require different prostheses. ‘We want a limb that can combine all activities in one go,’ says Prof Zahedi. ‘Electronic prosthetic lower limbs are privately available and becoming more advanced,’ says Hurst.
The Elan by Endolite prosthetic foot and ankle system, pictured, detects slopes, walking speed and uneven ground and automatically adjusts resistance within the ankle joint so that movement is smooth. It is available on the NHS.

CAN PROSTHETICS BE SUPERIOR  TO REAL LIMBS?
‘Prosthetics aren’t as good as a real ankle,’ says Kevin Warwick, Professor of Cybernetics at Reading University. ‘But prosthetics have advanced dramatically over the past few years. If orthopaedics cannot repair a limb completely, perhaps this is a preferable solution.’

Matthew and his wife Sarah, 29, had been in the process of buying a beachfront cafe to run. Unable to help renovate the bar as planned, and because Sarah was having to concentrate more of her time on caring for her husband and child, they pulled out.
‘Losing the business was not just a blow emotionally, but financially,’ says Matthew. ‘We had to sell our house. And all the time I was thinking ‘‘This is ludicrous, how can all this be happening because of a twisted ankle?’’ ’
In March 2012, Matthew sought advice from his GP, Dr Jerome Kerrane, who referred him to a third orthopaedic surgeon.
After numerous consultations, he began seriously to consider amputation. ‘The more I looked into it, the more I realised it could be the solution,’ he says. ‘Below-the-knee amputees lead fit and healthy lives: no drugs, no wheelchairs. That’s what I wanted.’
However, Matthew’s consultant was extremely negative.
‘I think he felt that it looked as if they’d failed. Another surgeon I was referred to said the same thing. It only made me more determined.
‘I began to approach anyone I thought could help me. My GP eventually secured me an appointment with Mr Mannion. I was told he would take me seriously, and he certainly did.’
Matthew underwent a psychological evaluation and was given the all-clear. ‘Sarah was supportive and our daughter thought it was cool, saying, “Daddy’s going to be a robot.” ’
Mr Mannion says: ‘Amputation isn’t without risks. Some patients continue to feel pain after the amputation. In their mind, it feels as if the limb is still there.
‘Approximately one in ten patients may experience other complications, such as infections or abnormal scarring, which may need further surgery. But in someone healthy like Matthew, this is unlikely.’
After his operation, Matthew will be given rehabilitation at a local centre. ‘The next couple of years are going to be a steep learning curve. I should get my first leg within three months, and after I’ve mastered that there’ll be no stopping me. I plan to be golfing in no time, and I’m organising a fund-raising cycling trip across the Alps next summer.’
Matthew hopes to launch a charity this year – The Fun Foundation, which will help families with a parent who is affected by long-term illness.
He says his experience has changed his perception of disability. ‘Too many orthopaedic surgeons see amputation as failure and I think that needs to change. When I think about walking, holding Sarah’s hand with my daughter on my shoulders, I know it’s the right decision for me.’

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