Errors in health care : never back on his feet despite prosthesis

They are now peppered with AI and deceptively real: artificial legs are supposed to help amputees, but for many they quickly end up in the closet. For reasons.

Petra W. Is a woman with finely polished nails and accurately coiffed ash blond hair. One who is happy to be told she looks 50. But she is 87 and sits in a wheelchair with only one leg, the left one. When asked about how she feels, she says: "It’s not so nice anymore," or "if you leave out the bad, it somehow goes well." Their optimism is extinguished. After her amputation two years ago, she had every intention of learning to walk again.

Waiting until the leg comes – often too late

But no sooner had she returned home from surgery than hurdles upon hurdles loomed before her. Their statutory health insurance did not want to pay for artificial legs at first. months passed. Her husband fought, with success. With her leg wrapped in a blue sack, Petra W. to the physiotherapist. But she had no idea about artificial legs, was more helpless in putting them on than Petra W. itself. Later it was said that the leg did not fit at all. In the meantime, the operation was already more than a year ago. Again her husband fought with the health insurance, again came a leg. But to learn how it could become her leg suddenly lacked support: Petra’s husband became demented, had to go to a nursing home. Today, Petra W.s cabinet two blue bags.

Bad luck? Destiny? The exception to the Hollywood happy ending narrative, according to which a dramatically injured person soon goes through life smiling again thanks to a prosthesis and an iron will? "There is no systematic data on the number of amputees who make it onto a prosthesis," says Melissa Beirau, a trauma surgery physician at the Berlin Trauma Center. "And no one is interested." Only one study by nursing scientist Uta Gaidys from the University of Applied Sciences in Hamburg exists. In 2013, with the help of two statutory health insurers, she surveyed 515 amputees up to four years after the amputation. The vast majority, 87.1 percent, had a prosthesis. But less than half – 41.4 percent – could walk well enough with it to cope with everyday life. Many could hardly walk more than a few minutes despite the prosthesis. Two thirds are therefore dependent on the help of relatives or strangers after the operation. Cooking, washing, doing errands outside the home – from then on, they can no longer manage many things on their own. As the most important cause of their need for care, they complain that they can walk too little.

Great prosthesis, but many don’t get far with it

Yet many would even have two different artificial legs for the amputated limb, says Andrea Vogt-Bolm, head of the independent association Ampu Vita. Gaidys’ study shows that a large proportion, 87 percent, even put on the prosthesis two to six times a week. But then they obviously do not get far. "Most people only wear them for a few minutes. Otherwise they lie around in the said blue bag," says Vogt-Bolm.

Surgeon Bernhard Greitemann removes patients’ limbs himself, and he runs a rehabilitation clinic near Osnabruck. He dislikes the story of useless prosthetics: A good 80 percent of amputees left his clinic on the prosthesis. They could walk and climb stairs. But how far they really get on the artificial leg in everyday life, and how far it will take them years later, he doesn’t know, he admits.

The medical technology company Ottobock in Duderstadt was shocked when Gaidys presented her study there in person, she reports. The visit also came as a shock to herself, "I walked into this lobby and thought, this is where we go on the space shuttle. That was incredible."There would be prostheses, which bend and stretch by Smartphone. Those who walk faster than normal, those who actively help themselves to sit down and stand up. Medical device manufacturer advertising shows amputees in suits, on the sunny side of their careers, dynamic, smiling.

Often the strongest will is not enough

Petra W. do not smile. "Surgeons don’t like to hear it, but a big reason is that amputations are done too late and then in slices. Big toe, forefoot, lower leg, thigh, then the other leg," says Gaidys. The operated ones are then weakened and unfit by the long Siechtum and the constant interferences. When they need a prosthesis, they often can no longer manage it, despite their best efforts, and end up in a wheelchair. The typical sufferer has had dozens of procedures, says Vogt-Bolm.

The accusation of too hesitant amputations contradicts the pronouncements of the professional societies: The German Society of Internal Medicine writes that most amputations in diabetics could be averted with vascular conservation measures. This is also the case for patients with circulatory disorders, says the German Society for Angiology for its patient clientele. Both diseases are by far the most important causes of amputations.

Removing a limb has long been considered a physician’s failure. However, other motives also come into question for (too) late amputations. Leg-preserving treatments and subsequent slice amputations bring in by far the most money in the reimbursement system. And because there is sometimes more salary for chief physicians, the more they treat, they also have an interest in the profitable tactics.

"There is always talk of salami tactics," says trauma surgeon Bernhard Greitemann. "But this criticism does not apply so. Of course there are revisions after amputations. But the primary goal must be the preservation of the limbs, also for reasons of mobility. You can walk without a forefoot prosthesis, but you can’t walk without a thigh prosthesis."

Two-class society of amputees

In the case of Petra W. the answer to the question why she is no longer running is probably different anyway. This is due to the fact that there are two classes of amputees: those with statutory insurance and victims of occupational accidents. If someone has an accident on the way to work and loses a leg, everything is done to help them get back on their feet. The Employer’s Liability Insurance Association does not want to pay for expensive disability and usually reimburses prostheses and rehabilitation without any problems. "These people almost always learn to walk on a prosthesis," Beirau says.

But most amputees are not among the lucky ones. They have lost their leg due to diabetes or a circulatory disorder, more rarely as a result of a tumor, for which the statutory health insurance has to pay. "The standard is that the reimbursement of the prosthesis is then first refused, especially for those over 60 years old," says Beirau. "Then you have to initiate an appeal procedure." It drags on. Meanwhile, the amputee patient is already squatting in a wheelchair in his home. The few existing muscles dwindle. He begins to go about his daily life in a wheelchair with the help of others. Then, after months, the health insurance company may approve an artificial leg, which first has to be made by an orthopedic technician. Again, months pass from the cost estimate until the "blue bag" arrives. But who then shows the legally insured amputees how to walk with an artificial leg?? Locally based physiotherapists often don’t know about prostheses, Beirau says. And rehabilitation is rarely approved in the first place. Once again, those with statutory health insurance have to fight. If they ever end up in a rehab facility, the body has already degraded so much that three weeks of cure – that’s how much is usually granted – will never be enough to get from a wheelchair to standing freely. "Learning to walk on a prosthesis is bone-deep work, even for a newly operated competitive athlete, for which he needs strong will," says Beirau. "Cancer patients are often amputated very high," says Greitemann. They are usually young, but with a transfemoral amputation it is difficult to learn to walk on a prosthesis."

Only accident victims receive the intensive program after the amputation without being asked. At the Unfallklinikum Berlin, each patient even has his or her own therapist. The training takes place in small groups of three to five people. "It’s a luxury. If the legally insured received this, many more amputees would be able to walk better," says Beirau. The injured exercise their arm and leg muscles in the gym. They receive daily physiotherapy and learn to walk on special equipment in the walking school. "The crowning glory is falling onto a mat with the prosthesis and standing up again on his own. Many are afraid of this in everyday life," explains Greitemann.

Even with optimal support, half of the success depends on motivation

Two-class rehab is a self-perpetuating system. Many an occupational accident victim gets a cure for the umpteenth time, like Jorg P. (67). Since a motorcycle accident in training, he has been a transfemoral amputee. With his new prosthesis, the Employer’s Liability Insurance Association sent him to the Berlin Accident Clinic for a cure. P. wobbles, dragging the left leg as if it were made of wood, rigid and immobile. Actually, with his modern prosthesis even climbing stairs should not be a problem – provided the wearer knows how to release the knee joint. "Step with the heel and then push off with force from the ball of the foot," says orthopedic technician Christian Hartz. But Jorg P. places the healthy foot on the step with silent fear in the face and rigidly moves the artificial leg to the side. "He’s gotten into a different habit," says Hartz. At home, he can get "a few meters" with a prosthesis, says P. While he certainly wants to learn to walk better, "I have my doubts," he says."

This is also part of the truth: Even with optimal support, 50 percent of success depends on attitude, says Hartz. Whether you call it motivation, courage or willpower – without it no one makes it on the legs.

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Lucrative prostheses Kneel before business

After Petra W. After losing her husband to dementia, her will was also broken. When the neighbors ring her doorbell, she can usually only push the heavy apartment door open a crack. Visitors better not talk about the artificial leg anymore. Otherwise the tears come.

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