Early Prosthetic Management Can Lead to Better Outcomes
30 Jan 2017
Few topics in rehabilitation elicit more debate and exhibit less consensus than the management of patients in the first days after lower-extremity amputation surgery and the timing and method of their transition into a prosthetic limb.
This important decision is impacted by (1) the surgeon’s natural desire to closely monitor the new amputee’s recovery by regularly examining the progress of wound healing; (2) rehabilitation practitioners’ preference for resuming exercise and initiating weight-bearing and prosthetic intervention as soon as practicable; and (3) reimbursement realities.
Certainly, the age and health of the patient affect the decision. A young, traumatic amputee may be capable of taking his first steps a few days after surgery, while an elderly, dysvascular patient may take weeks or months before the clinical team feels comfortable initiating prosthetic care. In some instances, of course, the amputee’s general state of health rules out prosthetic intervention altogether.
In 2003, the American Academy of Orthotists and Prosthetists funded a Clinical Standards of Practice (CSOP) consensus conference on lower-limb post-amputation management. The CSOP concept is used by various medical professionals to examine practice concepts that are poorly or under-reported in the literature.
In an intensive two-day process, the assembled multidisciplinary team of experts reviewed and compared the five predominant post-amputation management strategies:
• Soft dressings
• Non-removable rigid dressings
• Non-removable rigid dressings with an immediate post-operative prosthesis (IPOP)
• Removable rigid plaster dressings (RRDs), and
• Prefabricated post-operative prosthetic systems.
The participants concluded that the current level of research does not make possible evidence-based protocols or recommendations favoring one approach over another. However, the CSOP literature review did confirm that rigid dressings do produce significantly accelerated rehabilitation periods and considerably less edema than soft dressings, and that significantly fewer post-operative complications are experienced with prefabricated postoperative prosthetic systems than with soft dressings. Other definitive comparisons are lacking at present.
This CSOP has focused new attention on the benefits and drawbacks of the various approaches and accentuated the need for future research comparing all types of dressings within one study.
Moving from Amputation to Ambulation
Examining amputation dressing alternatives in more detail:
• A soft dressing – soft gauze used alone or in conjunction with a device such as an ACE wrap, shrinker sock, or gel liner to achieve compression and perhaps some form of a knee immobilizer to counter contractures – can be easily removed for wound inspection.
However, potential drawbacks impacting early prosthetic intervention are significant: reduced edema control, increased risk of contractures, extended inactivity and depression from being confined to bed for a long period.
Prosthetic management may not begin until the third or fourth month after surgery, by which time the patient’s motivation to ambulate may have waned.
• A rigid dressing can prevent most of these problems. This dressing is usually constructed of plaster, fiberglass or a combination, and if it is to serve as the foundation of an IPOP incorporates an attachment for the prosthetic components. In addition to controlling edema and preventing contractures, a rigid dressing helps reduce pain and guards against wound contamination.
• By allowing frequent inspection of the amputation site but retaining many benefits of a rigid cast, the removable rigid dressing (RRD) offers a compromise between soft and rigid dressings. The RRD is fabricated of plaster or fiberglass and suspended by stockinette and supracondylar suspension cuff or sleeve; residual limb socks are added as needed to maintain a close fit. The RRD has lower trimlines than a non-removable rigid dressing and thus permits knee range of motion exercises.
Care must be taken not to leave the wound exposed for lengthy periods as edema build-up can begin within 20 minutes. While exercise and weight-bearing can be initiated with the RRD, it is not normally used as the basis for an IPOP.
• The polyethylene semi-rigid dressing (PSRD) has been applied in place of an initial dressing as early as five days postop… with staples/sutures still in place. Used in conjunction with a shrinker, it has been shown to provide better edema control than either an RRD or shrinker alone. Moreover, the PSRD’s flexibility enables a new amputee to apply and remove the dressing, which is similar in assembly to a prosthetic socket. To keep weight to a minimum, no pylon or foot is added; however, partial-weight bearing can be initiated by positioning the distal end in a wheelchair seat or other appropriate surface under qualified supervision.
What About IPOPs?
The immediate post-operative prosthesis is usually a simple, relatively inexpensive device that gives the new amputee an immediate reason to begin using his or her amputated limb. The therapeutic objective becomes one of rehabilitation rather than simply recovering from surgery.
The rigid dressing applied in the operating room serves as the IPOP “socket,” to which are attached a basic pylon and prosthetic foot. The IPOP is intended to be used until the amputation wound has sufficiently healed and staples or sutures are removed. At that point, the patient is usually ready to transfer to a more substantial prosthesis.
The key to successful IPOP management is strict limitations on weight-bearing in early use. Patient ability to withstand early weight-bearing is individualized, but in general little or no weight should be applied except for prosthetic touchdown for the first day or two. Then, as patient tolerance and indications of satisfactory healing allow, weight-bearing can gradually be increased.
An IPOP alternative gaining some measure of popularity of late is the early post-operative prosthesis, or EPOP, which is typically applied five-to-seven days post-op. EPOPs are sometimes considered a better choice for patients with vascular disease, as the wound can be regularly examined before the EPOP is applied. Another advantage is that the prosthetist can fabricate an EPOP at the bedside rather than having to be present in the operating room during surgery.
Prefabricated Post-Operative Systems
For appropriate patients, prefabricated postoperative prosthetic systems, such as the Adjustable Postoperative, Protective and Preparatory System (APOPPS), offer a nice compromise between a soft and a rigid dressing, allowing for periodic wound evaluation and providing a degree of residual limb protection and contracture prevention and edema control.
Like the RRD and PSRD, prefabricated protective sockets can be removed for wound inspection, but unlike those options, systems like the APOPPS are intended to be used as the basis for an immediate prosthesis. APOPPS models are available for both transtibial and transfemoral amputees.
Today’s certified prosthetist is well prepared to assist surgeons in post-operative amputee management, beginning with initial dressing in the operating room if desired, and to work directly with nurses and therapists during early prosthetic activity. The tools, techniques, technical knowledge, and fabrication abilities are readily available to give patients the ample benefits of early prosthetic support. It only remains for those who chart the amputee’s rehabilitation course to put these resources to use.