An occupational therapist helps a young double amputee fit his legs during rehabilitation. File photo: SOWETAN/VATHISWA RUSELO.
An occupational therapist helps a young double amputee fit his legs during rehabilitation. File photo: SOWETAN/VATHISWA RUSELO.

“Up, up, up, come on! Now balance! Hold … and down.” Raising a serious sweat, six patients are undergoing physiotherapy at Cape Town’s Groote Schuur Hospital. It’s a session with more meaning than most: these are lower-limb amputees, striving either to maintain muscle strength after having recently been fitted with a prosthetic leg, or in training to receive one as soon as the state’s resources allow.

Supervising the session is Ruth Siebritz, who is tiny, but — like most physiotherapists — tough and demanding, which her charges clearly appreciate. Siebritz’s equipment is sparse, indicative that even in the country’s preeminent tertiary hospital, the budget is tight. This also translates, tragically, into the reality that more patients want a prosthesis than can be supplied.

Groote Schuur assists predominantly with leg prosthetics, fitting only about 10 arm units annually. The need is lower because there are fewer arm amputations; major causes, such as diabetes and vascular diseases, affect the lower limbs foremost, being further from the heart. “And the functional gains of an arm prosthetic are just not as good as for lower limbs,” explains Siebritz. 

In October 2017 Christopher Martin, 56, sought medical attention for a small but persistent and oddly expanding sore on a toe. He’d never been ill before, let alone gone to a hospital. A few hours later he was diagnosed as diabetic and informed that his foot was gangrenous and required immediate amputation. Two days later, he was advised to undergo another, higher amputation, to facilitate and better adapt to a prosthetic leg. “Yes, I cried. I realised I was going to be disabled. But I made peace.” He believes his state of mind has helped with the commitment to qualify and train for a prosthetic, and the rehab he is undergoing. 

Adapting to amputation

Coming to terms with the loss of a limb is a long journey that requires a lifelong change in mindset and daily routine. After amputation, the stump is a bloated, rounded lollipop, requiring practised technical bandaging to “cone” it for prosthetic fitment. Diligent maintenance is necessary to retain the form, prevent atrophying of the remaining muscles causing a regression to an incompatible shape, and minimise chaffing sores, which, if infection occurs, can even require a subsequent, higher amputation.

Occupational therapist Jomaine Strydom plays a key role at the “acute” phase, the first days and weeks after an amputation, to quickly get the patient as independent as possible. “One of the first things we teach an amputee is balance. With only one leg, it’s surprisingly easy to topple over.” It’s a long road: retraining in basic daily activities can take three months, requiring dedicated involvement by therapists like Strydom to adapt mind-body co-ordination, enable the relearning of muscle memory, and assist with coping techniques to manage their condition.

An amputee also faces an arduous process to qualify for, and then obtain, a prosthetic. Candidates are rigorously assessed for weight ratios, basic body strength, and attitude. In state hospitals there is no guarantee, but once a candidate has qualified, medical specialists work closely with the patient to prepare them for the prosthetic.

Strydom’s occupational therapy colleague, Ayesha Noordien, is responsible for the later stages of rehabilitation, getting the patient back to work. This often involves assessing working conditions and counselling or imploring employers to make adjustments in basic areas such as physical accessibility and safeguards to prevent falls. Sometimes, sadly, she can do little, given SA’s employment statistics and the fact that many of Groote Schuur’s patients are manual labourers. Retraining patients in new skills isn’t supposed to be part of her remit, but her empathetic eyes convey that she goes beyond the job description. 

Technological advances

Reality bites, too, in the availability of technological advances in SA’s public hospitals. Maritz Laubscher is an orthopaedic surgeon specialising in complex trauma. He provides a peek into newer biomedical technologies, as well as cutting-edge prosthetic programmes that combine myo-electric sensors, robotics and algorithms in neural-integration implants. These hold huge promise of significant improvements in comfort, control, safety, and functional capabilities such as a more natural walking speed. But they cost millions of rand and are currently unavailable at public hospitals.

More realistically, orthopaedic and prosthetic specialists in SA are increasingly exploring osseo-integration, the implantation of a protruding metal peg into the femur. This enables a clip-on, bone-anchored leg prosthetic, which improves overall function for above-knee amputees — if a patient can afford it. Sadly, for most SA amputees, even osseo-integration is decades away.

Laubscher is more upbeat about 3D printing, believing that cost savings should soon enable public hospitals to help more people, albeit with a basic prosthetic. He concludes our conversation with a surprisingly upbeat remark: “Amputees are often very motivated people and they can be more rewarding to treat than other orthopaedic cases.”

I witness this in 34-year-old single mother Lenise Japtha. Like Martin, she tells a story of abrupt disruption to her life. Three years ago an aggressive leukemia made her rapidly, dreadfully ill. Suffering bleeding and clotting thromboses in both lower limbs, she underwent below-knee amputations within days of diagnosis. “I’m going to be normal again,” she swore to her two young children. She received two prosthetic legs a year later and has nothing but praise for the Groote Schuur team. “They motivated and pushed me, gave me strength to fight. I just wanted to walk.”

It’s a wish felt acutely, personally, by the hospital’s head of orthotics and prosthetics department, Andrew Byett, himself an amputee due to a motorcycle accident when he was 20. He shows me his prosthetic leg, 3D-printed in an Iron Man motif. He had been studying engineering, but after recovering he switched career path. “I wanted to help people in similar situations.”

“At the moment [in state facilities] we have resources to make very basic legs, to get people walking. Sure, they would function better on better technology, but funds aren’t available. For example, one of the best prosthetic knee-joint and leg units costs about R800,000. For that amount, I could make over 100 basic legs.”  

Which is precisely what they do at Groote Schuur: Byett’s department made 308 prosthetics in 2018.

Byett is often the final arbiter of the decision to allocate a state-funded prosthetic. “The hardest part of my job is telling someone they don’t qualify. Basically, I’m telling them that they’ll never walk again.” But he feels immense reward when his job enables people to get moving again. “It gives me a kick.” 

The inadvertent pun makes us both smile, and the end of my visit to Groote Schuur feels like a beginning. Martin tells me he lost his job as an appliance repairman, but his customers have followed him and he is now able to earn a living from home. Japtha, meanwhile, is grateful for many things: “My future is bright. And I think my kids are proud of me.”