The New York Times

Friday, September 22, 2000

Mutilation Victims Aided by Swiss Surgical Team

By DENISE GRADY

A little-known operation developed by a German Army surgeon during World War I has been used to restore some grasping ability to people whose hands were chopped off with machetes in terrorist attacks during the civil war in Sierra Leone, doctors are reporting today.

In the British medical journal The Lancet, the doctors, a Swiss team working for the International Committee of the Red Cross, say that the operation restored a measure of independence to 11 people, including 8 who had both hands amputated and could not eat, dress or use the toilet by themselves.

But in telephone interviews, the doctors said that the operation was used in Sierra Leone for only a few months and is no longer being done there, even though the country has hundreds of amputees. Several reasons have been given. Proponents of the surgery said they may have been thwarted by advocates for prostheses. Those who favor prostheses said that the patients themselves had rejected the surgery because they found its results to be ugly.

Both sides agree that no one knows how well most of the dozen or so people who already had the surgery are faring, because they are now scattered about Sierra Leone and no one has kept track of them.

The country, on the coast of West Africa, has suffered from nine years of civil war.

Rebels carried out hundreds of machete attacks and amputations of hands in 1998 and 1999 as a means of terrorizing civilians. They were members of the military junta that was ousted after briefly taking over the country.

The operation described in the Lancet, called the Krukenberg procedure, divides an amputee's stump into a pair of pincers. Though unsightly, they are functional and can be used for basic tasks like eating and getting dressed. Some doctors say that for people who have lost both hands, the operation works better than a prosthesis because it provides more dexterity and a sense of touch.

Dr. Francois Irmay, a surgeon at Geneva University Hospital and an author of the article, said he and his colleagues went to Sierra Leone in July 1998 on a wartime surgical mission.

The doctors, expecting to encounter many amputees, had studied the problem before leaving Switzerland, and concluded that for people who still had one hand a simple hooklike prosthesis would suffice.

"But with a double amputation, even with a hook, you don't do a lot," he said. Thinking the Krukenberg procedure might be a good option for some patients, the team practiced it on two cadavers in Switzerland. Performing the operation on two hands takes about seven hours and is not difficult, Dr. Irmay said.

He said that after operating on several patients in Sierra Leone, he visited a refugee camp run by Handicap International, a French group that offers prostheses, and found 38 more double amputees. "We decided we would come back with one of our Krukenberg patients so people could understand what we were talking about," Dr. Irmay said. But when he returned with the patient, the 38 amputees were gone.

Kombah Pessima, program director for Handicap International in Freetown, Sierra Leone, said he did not know about the 38 people Dr. Irmay described. But the story, he said, "just confirms the fact that they would not prefer it, would not like it that well."

He said people feared the operation because the results were so unsightly. "I remember one said it resembles a crab," he said. "And one patient told our psychologist that when he went back home, the wife was not able to come near the husband and the children were afraid."

Mr. Pessima said the Red Cross and Handicap International had agreed that the operation should be suspended in Sierra Leone. He said patients preferred prostheses, which consist of hooks with cosmetic artificial hands. He said his organization offers the prostheses, as well as counseling and physical therapy to teach patients how to use them.

The Red Cross did not return telephone calls for comment.

Dr. Hugh G. Watts, an orthopedic surgeon with the Shriners Hospitals for Children, Los Angeles, who visited Sierra Leone in January on behalf of the United States Agency for International Development, said that he considered the Krukenberg procedure to be a good operation, and performs it himself on some children in this country.

"It's confused because of the cosmetic parts of it, and as with anything cosmetic it's in the eyes of the beholder," Dr. Watts said.

Dr. Irmay said that he and other members of the medical team thought patients were so relieved to be able to care for themselves that it made up for their unsightly limbs. "We really had the feeling that these people had a second birth," he said. "We had the sense that they were happy. But happy, unhappy. What does it mean in this context?"