Immediate FIT Prosthesis

Copyright © IFAC Control Aspects of Prosthetics and Orthotics Ohio. USA. 1982

IMMEDIATE FIT PROSTHESIS

J.

Hayes, B. Bostick, M. Williams and W. E. Evans Saint Anthony's Hospital, Columbus, Ohio, USA

Abstract. The idea of fitting patients with a prosthetic device immediately post-surgically, originated with Berlemont of France in 1958. Weiss of Poland modified Berlemont's work and created worldwide interest in this technique. The technique was first tried in the United States in 1963 at the University of California Medical School in San Francisco and at the U.S. Naval Hospital in Oakland, California. The most important part of the technique is the use of a rigid plaster of paris dressing. The dressing, when properly applied, reduces edema of the stump, and in limbs with impaired circulation the dressing promotes healing of the wound. Keywords.

Immediate Post Operative Prosthesis (IPOP); amputation.

I NTRODUCTI ON The idea of fitting amputation patients with a prosthetic device immediately post surgically, originated with Berlemont lO of France in 1958. Weiss l of Poland, modified Berlemont's work and created worldwide interest in this technique. The technique was first tried in the United States by Burqess 2 ,4 in 1963 at the University of talifornia Medical School in San Francisco and at the U.S. Naval Hospital in Oakland, California. The most important part of the technique is the use of a rigid plaster of paris dressing. The dressing, when properly applied reduces edema of the stump, and in limbs with impaired circulation the dressing promotes healing of the wound. The benefits attributed to the use of the immediate fit prosthesis incl ude: 2,11

Decrease in hospital stay.

6.)

Improved psychological outlook.

7.)

Improved stump stability.

8.) Earlier fitting of a definitive prosthesis . 9.)

Reduction in phantom limb pain. RIGID DRESSINGS

A major advantage in the use of an IPOP is the application of a rigid plaster dressing. Two prime functions of the rigid dressing are: 3 1.) Decrease in stump edema with a consequent reduction in pain and accelerated wound healing. 2 . ) Provision of a foundation on which the patient could bear weight or ambulate immediately (or sooner than with a conventional soft dressing). By this means the fitting of a definitive prosthesis could be expediated.

1.) Acceleration of wound healing and maturation of the stump.

There are advantages and disadvantages associated with the use of the rigid dressing. Some of the advantages include:

2.) Reduction of post surgical edema. 3.) pain.

5.)

Decrease in post surgical

1.) Decreased post surgical edema. The dimensions of the plaster cast are the limiting factor in any increase in the tissue volume.

4.) Earlier ambulation and prevention of gait abnormalities. 145

J. Hayes e t al.

146

2.) In addition stump movements, and pressure changes associated with standing and walking will promote reduction in stump volume (decrease edema).

1.) Senility, dementia or any condition that would prevent the patient from following instructions. Following instructions is important since early weight bearing must be limited.

3.) The pressure changes may also improve blood circulation in the tissues, thus speeding wound healing. There is also evidence to support the view that graded application of mechanical stress allows the mature healed wound to better tolerat5 the stresses of normal function. ' ,6

2.) Infection or potential infection at the amputation site. 3.) Lack of rehabilitation potential on the patients part. Although the use of a rigid dressing may be of value. 4.)

Open amputation

4.) Psychological benefits are obtained by early ambulation. In addition to the beneficial aspects of the rigid dressing there are several disadvantages to its application. 1.) Correct application requires a skilled prosthetist which may not always be available. Incorrect application can result in significant deleterious effects. 2.) Incorrect application or subsequent changes in stump dimensions may result in areas of localized high pressure. 3.) No easy access for stump inspection is provided. Changes in tissue conditions usually require changing the entire cast. Changing the cast delays rehabilitation since the cast requires 24 hours to dry. 4.) Plaster casts provide limited protection against bacterial infection and little or no control of temperature or humidity in the stump environment. The view of Cummings 8 is that the prime aim in applying a rigid dressing immediately post operatively is to enhance healing of the amputation stump. Early weight bearing, ambulation and prosthetics rehabilitation s hould be considered as fringe benefits rather than the prime goal. SELECTION OF IPOP PATIENTS12,13,14 Any patient that has the potential to heal their stump primarily, and in whom early ambulation would be a benefit ma y be fitted with an IPOP. IPOP's can be fitted at the below the knee, above the knee or hip disarticulation level. Contraindications for IPOP use include:

SURGICAL TECHNIQUE AND IPOP APPLICATION The surgical technique for IPOP application is the same as for the regular below the knee amputation. The extremity is prepped and draped in the usual fashion. An incision is made 8 cm. below the tibial tuberosity and carried down the medial and lateral sides halfway and then a posterior flap is made in the standard fashion. The tibia is cleaned off for about 1 cm. , with the periosteal elevator and using the Gigli saw, it is transected with a slight angle to minimize the presence of a bony · spur projecting on the skin. The fibula is transected about 1 cm. higher than the tibia with bone shears. The posterior fascial planes are sutured to the transected anterior fascia. Nerves are transected while under gentle traction and allowed to retract. Wounds are closed using superficial skin staples and are then covered with sterile 4 x 4 pads and gauze wraps. Elastic compression wraps are applied to stumps not receiving an IPOP. The cast component of the IPOP is applied with the patient still under the effects of general anesthesia. A premeasured sterile Orlon-Lycra sock is applied from the stump end to mid thigh. Proximal traction sufficient to flex the knee 5-15 is applied to the sock and maintained throughout the fabrication of the IPOP. Felt relief pads are applied over the bony prominences of the tibia, fibula and patella. A distal weight bearing cap of reticulated polyurethane (20 pores in-2) is placed over the stump end.

147

Immediate Fit Prosthesis

Four inch wide elasticized plaster wraps reinforced with non-elastic plaster wraps to mid thigh are applied for initial stump compression. A 1.5 inch wide cotton web suspension strap is incorporated into the plaster wrap and extended at least six inches above the waist. The cast is then compressed around the proximal femoral condyles to aid in antigravity suspension. Either a modified Bock or Veterans Administration Prosthetic Center (VAPC) coupling device with four suspension straps is incorporated into the casts distal end. The pylon/foot assembly is attached and adjustments for approximate leg length and alignment are made. One of two types of pressure monitoring systems are used to limit weight bearing during rehabilitation. Both devices produce an audible signal when weight bearing limits are exceeded. The Multi-Axis Audio Indicating Ankle (MAAIA) assembly incorporates anterior and posterior contact switches in the ankle region. " The Bee per" Tt1 we i g h t bear i ngin d i c a tor boot fits over the prosthetic foot. The boot employes contact switches similar to the MAAIA assembly. Sensitivity limits of both systems exceed minimum requirements set by the rehabilitation scheme. REHABILITATION The rehabilitation program for the IPOP patient follows the same basic principle as the traditional below the knee amputee program except in the areas of stump exercise and stump care instructions. Traditional care of the BK amputee involves stump exercise instruction begining the first or second postoperative day. These include: 1.) Range of motion exercises for knee and hip extension, abduction, rotation and flexion to 90. 2.) Strengthening exercises for hip abductors, abdul~ors, extensors and knee extensors. Upper extremity exercises are initiated the first post operative day if manual muscle test grades are found to be below the good strength level. 13

Gait training begins the second post operative day or when the patients condition permits it. Initial gait training is in the parallel bars progressing to a walker when the patient can ambulate 30 feet two time on the parallel bars. Crutch instruction begins when the patient can ambulate 150 feet using a walker. Stump wrapping instruction begins three to four days post operatively (as stump sensitivity permits). Patients are generally discharged 10-14 days post operatively (when independent in self care). IPOP REHABILITATION Gait training is initiated the first day post-op. Initially the patients stand between the parallel bars while prosthetic alignment is evaluated and corrected. The criteria for advancement from one assistive device to the next (parallel bars to walker to crutches) varies only in weight bearing limits. The IPOP patient has to meet the same criteria as the regular BK amputee while limiting weight bearing to within specified limits. Initial weight bearing is limited to ten pounds for the first three days. The limit is then increased to 20 pounds for the next 11 days. If stump healing is good, a maximum of 30 pounds of weight bearing is allowed after two weeks. COMPARISON OF THE CONVENTIONAL AMPUTEE TO THE IPOP PATIENT A total of twenty-four immediate postoperative prosthesis have been applied at st. Anthony's Hospital, Columbus, Ohio, since December, 1980. Patients with IPOP's and patients with conventional BK amputations (i .e., soft dressing) were randomly polled and asked the following questions: 1.) Do you have a permanent prosthesis? 2.) How long have you had your permanent prosthesis? 3.) Did you have a temporary prosthesis before receiving the permanent prosthesis?

14S

J. Hayes et a l.

4.) Did you ever fall when not wearing a prosthesis? How often? 5.) Did you injure your stump when you fell? 6.) Did your walking increase after receiving your permanent prosthesis?

permanent prosthesis. Of the 24 patients receiving an IPOP, 19 completed the program. Five casts had to be removed because of poor fitting, causing pressure sores on the stump. One of the five required a revision to an above the knee level, but this was not related to the IPGP.

7.) l~hat appl iances are you using to ambulate? BIBLIOGRAPHY 8.) Did you receive gait training after receiving your permanent prosthesis? These questions were answered by ten patients receiving an IPOP and 15 patients with a conventional BK amputation. Equal proportions of each group have a permanent prosthesis. The difference is in the time they received them. Those in the IPOP group received a permanent prosthesis at an average of six months (range 3 months to 9 months). The conventional amputees received their permanent prosthesis at an average of nine months (range 4 months to 22 months). Only 40 % of the IPOP group required a temporary prosthesis as compared to 66 % of the conventional BK group, which shows a significant difference. This is an indication that the IPOP patients stump is maturing gaster than the conventional amputees stump. Conventional BK amputees were not more likely to fall than IPOP patients. No IPOP patient had a fall related stump injury. where as 50 % of the conventional BK amputees had fall related stump injuries. The fact that earlier walkinq is one of the benefits of the IPOP, - is illustrated by noting that there was no increase in walking in the IPOP group after they received their permanent prosthesis. In the conventional BK group, 8 3% have increased their walkin g. Six of the conventional amputation patients have wheelchairs in their homes that they use at one time or another. None of the IPOP patients have a wheelchair. CONCLUSION In summary it appears that patient s with immediate post operative prosthetic devices heal and mature their stumps faster than conventional amputations. The average time for ?n IPOP patient to receive their

1. Weiss M.: The Prosthesis on the Operating Table from the Neurophysiological Point of View, report of the Workship Panel on Lower Extremity Prosthetic Fitting, Committee on Prosthetics Research and Development. National Academy of Science Meeting, February 6-9, 1966. 2. Burgess EM, Traub JE, Wilson AB, Jr.: Immediate Post-surqical Prosthetics in the ~anageme~t of Lower Extremity Amputees, technical report TR 10-5. Washinqton D.C., Veterans Administration, i967. 3. Kay, H.E: Wound Dressings: Soft Rigid or Semirigid? Orthotics and Prosthetics, 29, No. 2 pp. 59-68, June, 1975. 4. Dunphy, JE: The Fibroblast - A Ubiquitores Alley for the Surgeon. New England J. Med. 268: 1367-1377, 1963. 5. Grillo, HC, Watts GT and Gross J: Study in Wound Healing. I.Contraction and Wound Content. Ann Surg 148: 145-160, 1958. 6. Mooney V and Ferguson AB Jr: The Influence of Immobilization and Motion on the Formation of Febrocartilage in the Repair Granuloma after Joint Resection in the Rabbit. J Bone and Joint Surg 48 -A: 1145-55, Sept. 1966. 7. Hardt, A: Effects of External Limb Compression on Bone Blood Flow in Rabbits. J Bone and Joint Surg 56-A: 1488-92, October, 1974 - 8-. - Cummings V: Immediate Rigid Dressings for Amputees - Advantage and Misconceptions. New York State J Med 74: 980- 8 3, June 1974. 9. Burgess Ell, Romano RL and Zittle, JH: The tlanagement of Lower Extremity Amputations. TR 10-6, Washington, D.C., Veterans Administration 1969 10. Berlemont M, Weber Rand Willot, P: Ten Years of Experience with Immediate Application of Prosthetic Devices to Amputees of the Lower Extremities on the Operating Table. Pres. International 3: 8, 1969 11. ilooney V, Harve y JP Jr, McBride E, Smelson R: Comparison of PostOperative Stump Management: Plaster vs Soft Dressings. J Bone and Joint Surg 53-A: No. 2, pp . 241-49, t1arch T9IT