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Early Fitting of Prostheses Following Amputation
Early Fitting of Prostheses Following Amputation CLINTON L. COMPERE, M.D., F.A.C.S.*
The very early or immediate application of prosthetic components to lower extremity amputation stumps is a relatively recent concept that is proving to be a significant step forward in amputee management. The general principles were brought to this country through our Committee on Prosthetic Research and Development of the National Academy of Sciences, National Research Council. The stimulating source of information was Dr. Marian Weiss, Director of the Rehabilitation Clinic of the Medical Academy, Warsaw, Poland, who was specifically interested in amputee rehabilitation and in electromyographic studies of muscle function in amputation stumps. Beginning in early 1964, research programs were established in this country and there has been a continued exchange of personnel and ideas between the Weiss group in Poland and our various prosthetic amputee centers in the United States. A French surgeon, Berlemont,t preceded Weiss in use of the immediate fitting principles, but his work and publications were unknown to our group during the early phases of the program. A controlled research program was established under Veterans Administration auspices in Seattle with Dr. Ernest W. Burgess as the director, and also at the Naval Hospital in Oak Knoll under the direction of Captain Frank Golbranson. Smaller projects were initiated at Marquette University, the University of Miami, the University of California in San Francisco, at Northwestern University, at New York University, at Rancho Los Amigos, and the early pylon-fitting program at Duke University was expanded to include work with immediate fitting. Two national conferences on this routine were held in Chicago for review and coordination of the various routines and procedures. The outgrowth of these conferences has been the establishment of shortterm training courses in the three major prosthetic education programs which are under the supervision of the Departments of Orthopedic Surgery of New York University, University of California in Los Angeles, and Northwestern University. As of June, 1967, over 700 amputee patients had been treated with *Professor of Orthopedic Surgery, Northwestern University Medical School, Chicago, Illinois
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variations of the immediate postsurgical fitting routine with the largest series being in the Seattle-Portland area, at the Naval Hospital in Oak Knoll, and with Dr. Augusto Sarmiento in Miami. In our Northwestern program, the procedure has been used for 40 patients drawn from our private practices, the Veterans Administration Research Hospital, and Children's Memorial Hospital. In order to have conforinity in our discussions and educational efforts, certain definitions covering components and equipment are essential. The University Council on Prosthetic-Orthotic Education has agreed upon the following definitions. 1.
2.
3. 4.
5. 6. 7.
A mildly compressive total contact plaster wrap applied to the stump immediately following surgery for the purpose of controlling edema and pain. PYLON: An adjustable rigid supporting member, usually tubular, whose proximal end is attached to the below-knee socket, or to the knee unit of an above-knee prosthesis, and whose distal end is connected to a footankle assembly. IMMEDIATE POSTSURGICAL PROSTHESIS: A prosthesis consisting of a suitable reinforced rigid dressing, a pylon, and a foot-ankle assembly applied to a closed amputation immediately after surgery. PREPARATORY PROSTHESIS: A functional, but not necessarily cosmetic prosthesis, consisting of a plaster or plastic socket, pylon, and foot-ankle assembly fitted and aligned in accordance with accepted biomechanical principles. It is designed to be worn for a limited period of time to expedite training and stump maturation, and to permit better evaluation of the prosthetic needs and potentials of the patient. DEFINITIVE PROSTHESIS: A permanent replacement for a Inissing member which meets accepted check-out standards for comfort, fit, alignment, function, appearance, and durability. IMMEDIATE POSTSURGICAL FITTING: The use of an immediate postsurgical prosthesis with intent to initiate progressive weight-bearing and ambulation within the first several postoperative days. EARLY PROSTHETIC FITTING: The fitting of a preparatory prosthesis at about the time of suture removal, 10 to 14 days postoperatively, preferably after use of an immediate postsurgical rigid dressing. RIGID DRESSING:
Except in the case of an emergency traumatic amputation, the procedure begins preoperatively with the medical evaluation of the patient and the involved extremity. The preoperative evaluation should include the prosthetist, who will be responsible for providing the appropriate prosthetic components and for close follow-up supervision. The expected routine should be explained to the patient, as well as the possibility of certain complications. The presence of an active dermatitis or of an open infection may be considered a contraindication, and the full value of the procedure cannot be expected for any patient who does not have ambulation capabilities.
SURGERY The choice of level of amputation must be determined by the surgeon's experience, judgment, and skill. The basic principles of the procedure are adaptable for any amputation level, and the routine is especially successful with the Syme and below-knee amputations. Meticulous surgical technique is essential, as the majority of our amputations are accomplished for peripheral vascular insufficiency.
1
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For many patients, a pneumatic tourniquet is used in order to expedite and facilitate the procedure, but in the diabetic or arteriosclerotic peripheral vascular extremity, it is usually neither necessary nor advisable. The recommended method is to apply the tourniquet as a precautionary step, and not to inflate it unless necessary during the operation. For both the above-knee and below-knee amputations, relatively equal anterior and posterior flaps are preferred when there is no obvious regional ischemic problem. The flaps are usually fashioned in a fishmouth manner with the anterior and posterior flaps approximately 2 inches longer than the level of the elective bone section. With an ischemic situation, secondary to extreme peripheral vascular disease or embolism, we are in agreement that the posterior flap should be made long to permit subsequent placement of the suture line anteriorly. The most common site of skin necrosis is in the long anterior flap, and our experience proves that the posterior flap has a more adequate circulation for primary healing. The skin incision is made through the deep superficial fascia with minimal dissection of this fascia from the subcutaneous fat. With reflection of the skin and fascia, the muscles are sectioned and permitted to retract, and the bone is then sectioned with an appropriate saw. For the below-knee amputation, the anterior portion of the distal tibia is carefully beveled and the sharp edges are rounded off with a heavy rasp with minimal disturbance of the periosteum. The fibula is sectioned 1/4 to 112 inch shorter than the tibia, which is a variation from our previous teaching. We are convinced that leaving the fibula almost as long as the tibia provides a broader and more cylindrical stump, which is superior for prosthetic use. The major blood vessels are identified and individually ligated, using small plain catgut for the small and medium size vessels and nonabsorbable ligatures for the major arteries. When the tourniquet is not inflated, it is obvious that the major vessels must be identified and clamped prior to complete section of the extremity. In the above-knee amputation, the sharp rough edges of the bone are rasped and the lateral margin of the end of the femur is smoothed to minimize the formation of exostoses, which might cause irritation against the lateral wall of the prosthetic socket. To minimize the formation of symptomatic neuromas, the large nerves are clamped, placed on moderate traction, and sharply sectioned with a knife as high as possible. Ligation of the major nerves is neither necessary nor advisable. The sciatic artery and vein should be individually identified and ligated, as occasionally disturbing bleeding may occur from this vessel group. At this stage there are differences of approach in the various centers with regard to muscle stabilization in the stump. Dr. Weiss and the Seattle group recommend a procedure termed "myodesis" which involves placing drill holes close to the distal end of the bone through which nonabsorbable sutures are looped through the major muscle groups back through a drill hole and tied with the knots in the intramedullary canal. While the sutures are being placed, the individual muscle groups, such as the muscles of the anterior tibial compartment,
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the gastrocsoleus, and the posterior-lateral flexor groups are maintained on moderate tension. Excess muscle tissue is then carefully trimmed off flush with the end of the tibia. It is believed that the myodesis procedure gives a more uniform cylindrical stump with improved proprioception and feedback. It is true, however, that other centers are obtaining excellent results with the immediate postsurgical routine using conventional fascioplastic closure of the stumps, with suture of the posterior fascia to the anterior fascia and periosteum. Before closure, meticulous hemostasis is obtained after release of the tourniquet, if such is used. Postoperative drainage is recommended, preferably with the use of a perforated polyethylene tube with machine suction for approximately 48 hours. This tube is not sutured into the skin, but is drawn out proximally through the top of the subsequent rigid dressing. The tube can then be easily removed without disturbing the plaster cast. Closure is completed with approximation of the deep superficial fascia, subcutaneous tissue, and skin.
RIGID DRESSING One layer of surgical silk, Telfa, or Vaseline gauze is applied over the suture line. A small handful of lamb's wool, polyethylene foam, or fluffed up Lisco gauze sponges is placed over the end of the stump and a 5-ply wool or Spandex stump sock is then applied. It must be smooth and snug, at!d traction is maintained on the stump throughout the subsequent application of the rigid dressing. Specially prepared felt pads are glued to the stump sock with Dow Chemical medical adhesive. These pads are to remove excess pressure from the tibial crest, head of the fibula and patella. Sheet wadding is not used, and no other padding is routinely applied. The first layer of the plaster rigid dressing is applied with elastic plaster. Until recently, a German plaster (Ruhrstern) with a rubber strand base was used, but we now have available an excellent elastic plaster developed primarily for our purposes by Johnson & Johnson. Care is exercised to apply appropriate pressure over the lateral and medial aspects of the end of the stump and to not make a constricting band at any level. Additional standard plaster is then applied, immobilizing the knee for the below-knee rigid dressing to give appropriate strength. For the above-knee amputation, a well formed spica cast molded around the pelvis is quite effective, but is difficult to apply effectively. A special routine developed by the Seattle group is now recommended, which permits free hip motion while still maintaining snugness of the rigid dressing to the body. This method requires special components, practice and skill for successful use. Appropriate suspension with web straps is applied to the below-knee rigid dressing and the above-knee dressing is maintained in position with a special heavy combination abdominal-pelvic belt.
POSTSURGICAL PROSTHESIS This completes the first and second stages of the procedure, the surgery, and the application of the rigid dressing. With reasonable
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experience, the rigid dressing may be applied by the surgical team, but prosthetic. assistance is of value and is truly a necessity for the next step, which is the application of the prosthetic components. The prosthetic pylon attachment device may be applied immediately in surgery, a short time later in the recovery room, or it may be delayed indefinitely for reason. The immediate application has significant psychological benefit and the delayed application may be painful and awkward with the patient awake. The attached pylons are removed by use of the quick-disconnect device when the patient is in bed for sleeping. With the shank and foot attached, there are rotation forces from moving around in bed that tend to loosen the socket, cause pain, and detract from the value of smooth, uninterrupted tissue support.
AMBULATION In the usual uncomplicated case, standing is encouraged the day following surgery, and the prosthetist at this time completes the adjustments for alignment and length. Exercise both in bed and standing is encouraged and the degree of progressive ambulation with walker, parallel bars, crutches, etc., is controlled by the surgeon's judgment. The young person with amputation for bone tumor or trauma will often bear progressive weight up to free ambulation without special discomfort and without apparent interference with rapid primary healing. Many patients, however, are debilitated, may often have been bedridden for months with chronic indolent ischeinia, and for these patients weight-bearing and ambulation are grossly restricted. The rehabilitation of the most severe of this group may begin with the use of a standing or tilt board. The prognosis for a very small group may be severe enough to prohibit any effort at ambulation until after change of the rigid dressing and wound inspection.
EARLY FITTING With satisfactory clinical progress, the original rigid dressing is not disturbed for 12 to 15 days postoperatively. At this time the wound is usually healed and the stitches are removed. One must not leave the stump exposed for longer than 10 or 15 minutes as dangerous swelling may occur due to the release of tissue support. A new plaster socket of the patellar-tendon bearing type is applied to the below-knee stump with prosthetic extension and foot, and pelvic belt suspension. The aboveknee stump is fitted with a plaster quadrilateral socket or occasionally with a specially prepared plastic quadrilateral socket, which is incorporated in plaster. The preparatory prosthesis is completed with application of the above-knee pylon attachment, shank, and foot. A special pelvic belt is necessary for suspension. Weight-bearing and ambulation are routinely increased and many patients may walk with full weightbearing without external support after this change. This socket usually loosens and may be prepared for removal and reapplication, but it is imperative that the stump be kept in the socket throughout the 24-hour
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period to prevent serious edema that may occur in certain patients. Close attention from the prosthetist is obviously necessary for the successful application of the preparatory prosthesis and for modifications of the socket and alignment, as needed for changes in stump shape and increased ambulation. The majority of patients whose stumps have healed per primam may be measured for and fitted with a definitive socket and prosthesis in from 25 to 35 days postoperatively. The definitive prosthesis, however, may be delayed for several reasons: a large flabby above-knee stump that obviously is going to change rapidly in shape may be fitted with several plaster sockets before shrinking to the point of making a definitive socket feasible; ambulation prognosis may be too poor for certain patients to warrant the change to a definitive socket and prosthesis; and very common is the lack of financial authorization for payment, or the delay in obtaining agency financial authorization for purchase of the definitive prosthesis. ADVANTAGES Those of us with experience in this procedure are firmly convinced of its value, but no part of the routine should be attempted without appropriate background knowledge, adequate prosthetic component availability, and skillful prosthetic assistance. The advantages to the patient are psychological, physiological, and economic: 1. From the beginning, the patient knows that he will not be immobilized in bed or in a wheel chair, and that he will be upright and ambulating with external assistance without delay. 2. The unbroken physiological activity decreases the incidence of pulmonary cardiovascular complications, particularly in the older patient. 3. The rigid dressing prevents or minimizes swelling and edema and this unquestionably speeds up stump maturation. 4. Our universal experience is that pain is decidedly less in the amputee group with the rigid dressings and early ambulation, than in others with routine care. 5. Atrophy of muscle groups appears to be minimized, particularly with the use of the myodesis technique. Many of the patients express improved proprioception, feeling that their gait feedback simulates normal walking. 6. Total rehabilitation costs are usually reduced with shortened hospitalization, early full ambulation with a definitive prosthesis and a faster return to work in a normal environment. The major causes for amputation, such as severe peripheral vascular diseases and embolic gangrene, carry an inherent certainty of a percentage of failure due to wound necrosis or infection. Approximately 10 per cent of the below-knee amputations from this group will not heal and revisions to a higher level must then be accomplished. However, from my own experience and from a review of the other programs, it is crystal clear that we are obtaining a higher percentage of lasting and
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Figure 1 (Case 1). Male, age 46. A, Crushing injury of left lower extremity 26 years prior to consultation. Uninterrupted osteomyelitis with odoriferous suppuration and neoplastic change; contracture of knee. B, Above-knee amputation with primary closure accomplished; immediate fitting with plastic brim and Hemovac drainage. C, Immediate postsurgical prosthesis completed with abdominal pelvic belt for suspension and adjustable above-knee pylon with cosmetic covering and SACH foot. The application of this prosthesis requires about 45 minutes with appropriate skill and preparation. (For continuation of
Figure 1, see opposite.)
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Figure 1 (Continued). D, Patient ambulating with crutch protection third day after operation. The shoulder strap is a necessary addition for suspension when ambulating. E, Removal of rigid dressing fourteenth day. Wound well healed without edema or hematoma formation. Stitches removed and preparatory prosthesis applied. F, Socket and prosthesis removable for bathing. At 3 weeks, stump is healed, exceptionally mature and pain-free with essentially full weightbearing during previous 7 days.
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useful below-knee amputations than with our older approaches. It is our belief that the meticulous surgery and the rigid dressing are the major contributing factors toward these improved results. The patients in these series also obtained exceptionally skillful care and treatment for all medical problems. Our statistics reverse the old ratio of aboveknee amputations to below-knee amputations, which used to be 3 to 1 for above-knee and is now 3 to 1 for below-knee in most of our practices. The occurrence of complications requiring revision or reamputation must be expected but the over-all value of our efforts to obtain a functional below-knee amputation, particularly for the elderly patient, is clear. The patient with the below-knee amputation can frequently be completely rehabilitated for a return to his normal level of activity, while the aboveknee amputation for the elderly patient is severely disabling. Those of us who are active in the amputation and prosthetic research programs are unanimous in endorsing the use of a skillfully applied plaster rigid dressing immediately following the surgical amputation. The value of the physiological protection of the wound with this type of dressing during the first two weeks of healing appears to have been established by widespread use and observation. The technique for application of the rigid dressing may be quickly learned by senior surgeons or surgical assistants, and the procedure may be used in situations where prosthetic assistance is not readily available. The participation of a prosthetist with experience in the immediate fitting techniques is essential if the immediate postsurgical prosthesis is to be used. During the past two years, a small number of surgeons and prosthetists have been trained in the full procedure by visiting the prosthetic research units in Seattle, Oak Knoll, Miami, Northwestern, etc. Unfortunate failures with untrained use of the routine have been called to our attention, and surgeons who wish to use these techniques are strongly encouraged to do so, but only after appropriate indoctrination for both the surgeon and the prosthetist. The task of teaching these new routines has been accepted by the University Council on Prosthetic Orthotic Education, and each of the three university centers-New York University, Northwestern University, and the University of California at Los Angeles-will present several three-day short courses during the current year for physicians and prosthetists. Information in regard to these special courses may be obtained by writing one of the following: Director, Prosthetic-Orthotic Education Northwestern University Medical School 401 East Ohio Street Chicago, Illinois 60611
Director, Prosthetics and Orthotics Postgraduate Medical School New York University 317 East 34th Street New York, New York 10016
Director, Prosthetic Education Post Office Box 24901 Department K University of California Extension Los Angeles, California 90024
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Figure 2. Legend on opposite page.
L.
CoMPERE
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Figure 2 (Case 2). Male, 76 years of age, with diabetic peripheral vascular disease. A, Short below-knee amputation at time of closure after failure of transmetatarsal amputation. The Hemovac tube exits 2 or 3 inches from the line of the closed incision. B, The im-
mediate postsurgical prosthesis is applied with Hemovac tube exiting from the top of the cast; the pelvic belt suspension is being attached. C, Patient ambulating between parallel bars on second day postoperatively. Continued ambulation with crutches for support during subsequent 10 days. D, Appearance of stump 15 days after operation at time of removal of rigid dressing. Note the long posterior flap with anterior placement of closure. Complete healing has occurred. E, Patient standing at bedside with walker for ;uljustment of alignment of patellar-tendon-bearing preparatory prosthesis on sixteenth postoperative day. Patient discharged on eighteenth postoperative day to be followed as an outpatient for prosthetic fitting.
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REFERENCES 1. Weiss, Marian: The prosthesis on the operating table from the neurophysiological point of view. Report of Workshop Panel on Lower Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February, 1966. 2. Berlemont, M.: Notre Experience de l'Appareillage Precoce des Amputes des Membres Inferieurs aux Etablissements Hello-Marins de Berek. Annales de Medicine Physique, Tome IV, No. 4, Oct.-Nov.-Dec., 1961. 3. Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees. Prosthetic and Sensory Aids Service, Department of Medicine and Surgery, Veterans Administration, Washington, D.C., April, 1967. (This is a complete summary of the Seattle project prepared by Dr. E. Burgess and published by the Veterans Administration. It is available from the Government Printing Office, and is Bulletin TR 10-5.) 737 North Michigan Boulevard Chicago, Illinois 60611
The very early or immediate application of prosthetic components to lower extremity amputation stumps is a relatively recent concept that is proving to be a significant step forward in amputee management. The general principles were brought to this country through our Committee on Prosthetic Research and Development of the National Academy of Sciences, National Research Council. The stimulating source of information was Dr. Marian Weiss, Director of the Rehabilitation Clinic of the Medical Academy, Warsaw, Poland, who was specifically interested in amputee rehabilitation and in electromyographic studies of muscle function in amputation stumps. Beginning in early 1964, research programs were established in this country and there has been a continued exchange of personnel and ideas between the Weiss group in Poland and our various prosthetic amputee centers in the United States. A French surgeon, Berlemont,t preceded Weiss in use of the immediate fitting principles, but his work and publications were unknown to our group during the early phases of the program. A controlled research program was established under Veterans Administration auspices in Seattle with Dr. Ernest W. Burgess as the director, and also at the Naval Hospital in Oak Knoll under the direction of Captain Frank Golbranson. Smaller projects were initiated at Marquette University, the University of Miami, the University of California in San Francisco, at Northwestern University, at New York University, at Rancho Los Amigos, and the early pylon-fitting program at Duke University was expanded to include work with immediate fitting. Two national conferences on this routine were held in Chicago for review and coordination of the various routines and procedures. The outgrowth of these conferences has been the establishment of shortterm training courses in the three major prosthetic education programs which are under the supervision of the Departments of Orthopedic Surgery of New York University, University of California in Los Angeles, and Northwestern University. As of June, 1967, over 700 amputee patients had been treated with *Professor of Orthopedic Surgery, Northwestern University Medical School, Chicago, Illinois
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variations of the immediate postsurgical fitting routine with the largest series being in the Seattle-Portland area, at the Naval Hospital in Oak Knoll, and with Dr. Augusto Sarmiento in Miami. In our Northwestern program, the procedure has been used for 40 patients drawn from our private practices, the Veterans Administration Research Hospital, and Children's Memorial Hospital. In order to have conforinity in our discussions and educational efforts, certain definitions covering components and equipment are essential. The University Council on Prosthetic-Orthotic Education has agreed upon the following definitions. 1.
2.
3. 4.
5. 6. 7.
A mildly compressive total contact plaster wrap applied to the stump immediately following surgery for the purpose of controlling edema and pain. PYLON: An adjustable rigid supporting member, usually tubular, whose proximal end is attached to the below-knee socket, or to the knee unit of an above-knee prosthesis, and whose distal end is connected to a footankle assembly. IMMEDIATE POSTSURGICAL PROSTHESIS: A prosthesis consisting of a suitable reinforced rigid dressing, a pylon, and a foot-ankle assembly applied to a closed amputation immediately after surgery. PREPARATORY PROSTHESIS: A functional, but not necessarily cosmetic prosthesis, consisting of a plaster or plastic socket, pylon, and foot-ankle assembly fitted and aligned in accordance with accepted biomechanical principles. It is designed to be worn for a limited period of time to expedite training and stump maturation, and to permit better evaluation of the prosthetic needs and potentials of the patient. DEFINITIVE PROSTHESIS: A permanent replacement for a Inissing member which meets accepted check-out standards for comfort, fit, alignment, function, appearance, and durability. IMMEDIATE POSTSURGICAL FITTING: The use of an immediate postsurgical prosthesis with intent to initiate progressive weight-bearing and ambulation within the first several postoperative days. EARLY PROSTHETIC FITTING: The fitting of a preparatory prosthesis at about the time of suture removal, 10 to 14 days postoperatively, preferably after use of an immediate postsurgical rigid dressing. RIGID DRESSING:
Except in the case of an emergency traumatic amputation, the procedure begins preoperatively with the medical evaluation of the patient and the involved extremity. The preoperative evaluation should include the prosthetist, who will be responsible for providing the appropriate prosthetic components and for close follow-up supervision. The expected routine should be explained to the patient, as well as the possibility of certain complications. The presence of an active dermatitis or of an open infection may be considered a contraindication, and the full value of the procedure cannot be expected for any patient who does not have ambulation capabilities.
SURGERY The choice of level of amputation must be determined by the surgeon's experience, judgment, and skill. The basic principles of the procedure are adaptable for any amputation level, and the routine is especially successful with the Syme and below-knee amputations. Meticulous surgical technique is essential, as the majority of our amputations are accomplished for peripheral vascular insufficiency.
1
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For many patients, a pneumatic tourniquet is used in order to expedite and facilitate the procedure, but in the diabetic or arteriosclerotic peripheral vascular extremity, it is usually neither necessary nor advisable. The recommended method is to apply the tourniquet as a precautionary step, and not to inflate it unless necessary during the operation. For both the above-knee and below-knee amputations, relatively equal anterior and posterior flaps are preferred when there is no obvious regional ischemic problem. The flaps are usually fashioned in a fishmouth manner with the anterior and posterior flaps approximately 2 inches longer than the level of the elective bone section. With an ischemic situation, secondary to extreme peripheral vascular disease or embolism, we are in agreement that the posterior flap should be made long to permit subsequent placement of the suture line anteriorly. The most common site of skin necrosis is in the long anterior flap, and our experience proves that the posterior flap has a more adequate circulation for primary healing. The skin incision is made through the deep superficial fascia with minimal dissection of this fascia from the subcutaneous fat. With reflection of the skin and fascia, the muscles are sectioned and permitted to retract, and the bone is then sectioned with an appropriate saw. For the below-knee amputation, the anterior portion of the distal tibia is carefully beveled and the sharp edges are rounded off with a heavy rasp with minimal disturbance of the periosteum. The fibula is sectioned 1/4 to 112 inch shorter than the tibia, which is a variation from our previous teaching. We are convinced that leaving the fibula almost as long as the tibia provides a broader and more cylindrical stump, which is superior for prosthetic use. The major blood vessels are identified and individually ligated, using small plain catgut for the small and medium size vessels and nonabsorbable ligatures for the major arteries. When the tourniquet is not inflated, it is obvious that the major vessels must be identified and clamped prior to complete section of the extremity. In the above-knee amputation, the sharp rough edges of the bone are rasped and the lateral margin of the end of the femur is smoothed to minimize the formation of exostoses, which might cause irritation against the lateral wall of the prosthetic socket. To minimize the formation of symptomatic neuromas, the large nerves are clamped, placed on moderate traction, and sharply sectioned with a knife as high as possible. Ligation of the major nerves is neither necessary nor advisable. The sciatic artery and vein should be individually identified and ligated, as occasionally disturbing bleeding may occur from this vessel group. At this stage there are differences of approach in the various centers with regard to muscle stabilization in the stump. Dr. Weiss and the Seattle group recommend a procedure termed "myodesis" which involves placing drill holes close to the distal end of the bone through which nonabsorbable sutures are looped through the major muscle groups back through a drill hole and tied with the knots in the intramedullary canal. While the sutures are being placed, the individual muscle groups, such as the muscles of the anterior tibial compartment,
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the gastrocsoleus, and the posterior-lateral flexor groups are maintained on moderate tension. Excess muscle tissue is then carefully trimmed off flush with the end of the tibia. It is believed that the myodesis procedure gives a more uniform cylindrical stump with improved proprioception and feedback. It is true, however, that other centers are obtaining excellent results with the immediate postsurgical routine using conventional fascioplastic closure of the stumps, with suture of the posterior fascia to the anterior fascia and periosteum. Before closure, meticulous hemostasis is obtained after release of the tourniquet, if such is used. Postoperative drainage is recommended, preferably with the use of a perforated polyethylene tube with machine suction for approximately 48 hours. This tube is not sutured into the skin, but is drawn out proximally through the top of the subsequent rigid dressing. The tube can then be easily removed without disturbing the plaster cast. Closure is completed with approximation of the deep superficial fascia, subcutaneous tissue, and skin.
RIGID DRESSING One layer of surgical silk, Telfa, or Vaseline gauze is applied over the suture line. A small handful of lamb's wool, polyethylene foam, or fluffed up Lisco gauze sponges is placed over the end of the stump and a 5-ply wool or Spandex stump sock is then applied. It must be smooth and snug, at!d traction is maintained on the stump throughout the subsequent application of the rigid dressing. Specially prepared felt pads are glued to the stump sock with Dow Chemical medical adhesive. These pads are to remove excess pressure from the tibial crest, head of the fibula and patella. Sheet wadding is not used, and no other padding is routinely applied. The first layer of the plaster rigid dressing is applied with elastic plaster. Until recently, a German plaster (Ruhrstern) with a rubber strand base was used, but we now have available an excellent elastic plaster developed primarily for our purposes by Johnson & Johnson. Care is exercised to apply appropriate pressure over the lateral and medial aspects of the end of the stump and to not make a constricting band at any level. Additional standard plaster is then applied, immobilizing the knee for the below-knee rigid dressing to give appropriate strength. For the above-knee amputation, a well formed spica cast molded around the pelvis is quite effective, but is difficult to apply effectively. A special routine developed by the Seattle group is now recommended, which permits free hip motion while still maintaining snugness of the rigid dressing to the body. This method requires special components, practice and skill for successful use. Appropriate suspension with web straps is applied to the below-knee rigid dressing and the above-knee dressing is maintained in position with a special heavy combination abdominal-pelvic belt.
POSTSURGICAL PROSTHESIS This completes the first and second stages of the procedure, the surgery, and the application of the rigid dressing. With reasonable
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experience, the rigid dressing may be applied by the surgical team, but prosthetic. assistance is of value and is truly a necessity for the next step, which is the application of the prosthetic components. The prosthetic pylon attachment device may be applied immediately in surgery, a short time later in the recovery room, or it may be delayed indefinitely for reason. The immediate application has significant psychological benefit and the delayed application may be painful and awkward with the patient awake. The attached pylons are removed by use of the quick-disconnect device when the patient is in bed for sleeping. With the shank and foot attached, there are rotation forces from moving around in bed that tend to loosen the socket, cause pain, and detract from the value of smooth, uninterrupted tissue support.
AMBULATION In the usual uncomplicated case, standing is encouraged the day following surgery, and the prosthetist at this time completes the adjustments for alignment and length. Exercise both in bed and standing is encouraged and the degree of progressive ambulation with walker, parallel bars, crutches, etc., is controlled by the surgeon's judgment. The young person with amputation for bone tumor or trauma will often bear progressive weight up to free ambulation without special discomfort and without apparent interference with rapid primary healing. Many patients, however, are debilitated, may often have been bedridden for months with chronic indolent ischeinia, and for these patients weight-bearing and ambulation are grossly restricted. The rehabilitation of the most severe of this group may begin with the use of a standing or tilt board. The prognosis for a very small group may be severe enough to prohibit any effort at ambulation until after change of the rigid dressing and wound inspection.
EARLY FITTING With satisfactory clinical progress, the original rigid dressing is not disturbed for 12 to 15 days postoperatively. At this time the wound is usually healed and the stitches are removed. One must not leave the stump exposed for longer than 10 or 15 minutes as dangerous swelling may occur due to the release of tissue support. A new plaster socket of the patellar-tendon bearing type is applied to the below-knee stump with prosthetic extension and foot, and pelvic belt suspension. The aboveknee stump is fitted with a plaster quadrilateral socket or occasionally with a specially prepared plastic quadrilateral socket, which is incorporated in plaster. The preparatory prosthesis is completed with application of the above-knee pylon attachment, shank, and foot. A special pelvic belt is necessary for suspension. Weight-bearing and ambulation are routinely increased and many patients may walk with full weightbearing without external support after this change. This socket usually loosens and may be prepared for removal and reapplication, but it is imperative that the stump be kept in the socket throughout the 24-hour
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period to prevent serious edema that may occur in certain patients. Close attention from the prosthetist is obviously necessary for the successful application of the preparatory prosthesis and for modifications of the socket and alignment, as needed for changes in stump shape and increased ambulation. The majority of patients whose stumps have healed per primam may be measured for and fitted with a definitive socket and prosthesis in from 25 to 35 days postoperatively. The definitive prosthesis, however, may be delayed for several reasons: a large flabby above-knee stump that obviously is going to change rapidly in shape may be fitted with several plaster sockets before shrinking to the point of making a definitive socket feasible; ambulation prognosis may be too poor for certain patients to warrant the change to a definitive socket and prosthesis; and very common is the lack of financial authorization for payment, or the delay in obtaining agency financial authorization for purchase of the definitive prosthesis. ADVANTAGES Those of us with experience in this procedure are firmly convinced of its value, but no part of the routine should be attempted without appropriate background knowledge, adequate prosthetic component availability, and skillful prosthetic assistance. The advantages to the patient are psychological, physiological, and economic: 1. From the beginning, the patient knows that he will not be immobilized in bed or in a wheel chair, and that he will be upright and ambulating with external assistance without delay. 2. The unbroken physiological activity decreases the incidence of pulmonary cardiovascular complications, particularly in the older patient. 3. The rigid dressing prevents or minimizes swelling and edema and this unquestionably speeds up stump maturation. 4. Our universal experience is that pain is decidedly less in the amputee group with the rigid dressings and early ambulation, than in others with routine care. 5. Atrophy of muscle groups appears to be minimized, particularly with the use of the myodesis technique. Many of the patients express improved proprioception, feeling that their gait feedback simulates normal walking. 6. Total rehabilitation costs are usually reduced with shortened hospitalization, early full ambulation with a definitive prosthesis and a faster return to work in a normal environment. The major causes for amputation, such as severe peripheral vascular diseases and embolic gangrene, carry an inherent certainty of a percentage of failure due to wound necrosis or infection. Approximately 10 per cent of the below-knee amputations from this group will not heal and revisions to a higher level must then be accomplished. However, from my own experience and from a review of the other programs, it is crystal clear that we are obtaining a higher percentage of lasting and
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Figure 1 (Case 1). Male, age 46. A, Crushing injury of left lower extremity 26 years prior to consultation. Uninterrupted osteomyelitis with odoriferous suppuration and neoplastic change; contracture of knee. B, Above-knee amputation with primary closure accomplished; immediate fitting with plastic brim and Hemovac drainage. C, Immediate postsurgical prosthesis completed with abdominal pelvic belt for suspension and adjustable above-knee pylon with cosmetic covering and SACH foot. The application of this prosthesis requires about 45 minutes with appropriate skill and preparation. (For continuation of
Figure 1, see opposite.)
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Figure 1 (Continued). D, Patient ambulating with crutch protection third day after operation. The shoulder strap is a necessary addition for suspension when ambulating. E, Removal of rigid dressing fourteenth day. Wound well healed without edema or hematoma formation. Stitches removed and preparatory prosthesis applied. F, Socket and prosthesis removable for bathing. At 3 weeks, stump is healed, exceptionally mature and pain-free with essentially full weightbearing during previous 7 days.
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useful below-knee amputations than with our older approaches. It is our belief that the meticulous surgery and the rigid dressing are the major contributing factors toward these improved results. The patients in these series also obtained exceptionally skillful care and treatment for all medical problems. Our statistics reverse the old ratio of aboveknee amputations to below-knee amputations, which used to be 3 to 1 for above-knee and is now 3 to 1 for below-knee in most of our practices. The occurrence of complications requiring revision or reamputation must be expected but the over-all value of our efforts to obtain a functional below-knee amputation, particularly for the elderly patient, is clear. The patient with the below-knee amputation can frequently be completely rehabilitated for a return to his normal level of activity, while the aboveknee amputation for the elderly patient is severely disabling. Those of us who are active in the amputation and prosthetic research programs are unanimous in endorsing the use of a skillfully applied plaster rigid dressing immediately following the surgical amputation. The value of the physiological protection of the wound with this type of dressing during the first two weeks of healing appears to have been established by widespread use and observation. The technique for application of the rigid dressing may be quickly learned by senior surgeons or surgical assistants, and the procedure may be used in situations where prosthetic assistance is not readily available. The participation of a prosthetist with experience in the immediate fitting techniques is essential if the immediate postsurgical prosthesis is to be used. During the past two years, a small number of surgeons and prosthetists have been trained in the full procedure by visiting the prosthetic research units in Seattle, Oak Knoll, Miami, Northwestern, etc. Unfortunate failures with untrained use of the routine have been called to our attention, and surgeons who wish to use these techniques are strongly encouraged to do so, but only after appropriate indoctrination for both the surgeon and the prosthetist. The task of teaching these new routines has been accepted by the University Council on Prosthetic Orthotic Education, and each of the three university centers-New York University, Northwestern University, and the University of California at Los Angeles-will present several three-day short courses during the current year for physicians and prosthetists. Information in regard to these special courses may be obtained by writing one of the following: Director, Prosthetic-Orthotic Education Northwestern University Medical School 401 East Ohio Street Chicago, Illinois 60611
Director, Prosthetics and Orthotics Postgraduate Medical School New York University 317 East 34th Street New York, New York 10016
Director, Prosthetic Education Post Office Box 24901 Department K University of California Extension Los Angeles, California 90024
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Figure 2. Legend on opposite page.
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Figure 2 (Case 2). Male, 76 years of age, with diabetic peripheral vascular disease. A, Short below-knee amputation at time of closure after failure of transmetatarsal amputation. The Hemovac tube exits 2 or 3 inches from the line of the closed incision. B, The im-
mediate postsurgical prosthesis is applied with Hemovac tube exiting from the top of the cast; the pelvic belt suspension is being attached. C, Patient ambulating between parallel bars on second day postoperatively. Continued ambulation with crutches for support during subsequent 10 days. D, Appearance of stump 15 days after operation at time of removal of rigid dressing. Note the long posterior flap with anterior placement of closure. Complete healing has occurred. E, Patient standing at bedside with walker for ;uljustment of alignment of patellar-tendon-bearing preparatory prosthesis on sixteenth postoperative day. Patient discharged on eighteenth postoperative day to be followed as an outpatient for prosthetic fitting.
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REFERENCES 1. Weiss, Marian: The prosthesis on the operating table from the neurophysiological point of view. Report of Workshop Panel on Lower Extremity Prosthetics Fitting, Committee on Prosthetics Research and Development, National Academy of Sciences, February, 1966. 2. Berlemont, M.: Notre Experience de l'Appareillage Precoce des Amputes des Membres Inferieurs aux Etablissements Hello-Marins de Berek. Annales de Medicine Physique, Tome IV, No. 4, Oct.-Nov.-Dec., 1961. 3. Immediate Postsurgical Prosthetics in the Management of Lower Extremity Amputees. Prosthetic and Sensory Aids Service, Department of Medicine and Surgery, Veterans Administration, Washington, D.C., April, 1967. (This is a complete summary of the Seattle project prepared by Dr. E. Burgess and published by the Veterans Administration. It is available from the Government Printing Office, and is Bulletin TR 10-5.) 737 North Michigan Boulevard Chicago, Illinois 60611