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Use of removable rigid dressing for transtibial amputees rehabilitation: A Greenwich Hospital experience
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Use of removable rigid dressing for transtibial amputees rehabilitation: A Greenwich Hospital • experience
The outcome for transtibial amputees is improved by the use of a post amputation removable rigid dressing (RRD).The benefits of this technique include reduction of stump trauma and oedema, early weight bearing and desensitisation. The RRD system is easily applied by the amputee and assists eventual progression to a definitive prosthesis. [Hughes S, Ni Sand Wilson S: Use of removable rigid dressing for transtibial amputees rehabilitation: AGreenwich Hospital experience. Australian Journal of Physiotherapy 44: 135137]
ince the early pioneering work of Marion Weiss of Poland and Jean-Paul Willot of France into the effect of early prosthetic fitting after lower limb amputation, much work has been undertaken into the efficacy of immediate post-surgical fitting (IPSF) of a rigid dressing and temporary prosthesis (Burgess 1968 and 1969, Mooney et al 1971). These works demonstrate the importance of early stump management as a means to hastening prosthetic rehabilitation. Despite good clinical outcomes from the·use of the rigid dressing in amputee rehabilitation, the practice of Key words: Amputation; immediate application of a rigid Amputees; Bandages; dressing after amputation has not been Rehabilitation; universally applied in Australia, principally because of surgeons' concerns about wound infection, breakdown and difficulty of direct S Hughes GradDipPhty is a physiotherapist at visual inspection of the stump. Lady Davidson Hospital, Sydney. At the time of The use of elastic bandage in writing this Clinical Note she was a conjunction with an IPSF thigh high physiotherapist with the Amputee Rehabi Iitation cast or a soft dressing has also been Program at Greenwich Hospital in Sydney. part of a standard early stump S Ni BScMed(Hons), MBBS, FAFRM{RACP) is a preparation. This technique Staff Specialist in the Department of traditionally involves the use of an Rehabilitation Medicine at Greenwich Hospital. elastic lOcm width bandage. In the S Wilson MBBS, FRACGP, FAFRM{RACP) is a event of poor hand dexterity, a stump Senior Staff Specialist in the Department of shrinker sock is another alternative. Rehabilitation Medicine at Greenwich Hospital. The difficulty of achieving consistent Correspondence: Sheila Hughes, 20 Greendale bandaging skills by the applicants and Avenue, Frenchs Forest New South Wales 2086. problems related to skin breakdown,
pressure areas and poor patient tolerance have been well discussed and documented (WU and Krick 1987, Wu et al 1979). These difficulties are particularly prevalent among the elderly amputee population. Wu and Krick (1987) first advocated the use of a removable rigid dressing (RRD) system as a means to overcome such limitations. The RRD system is essentially a thin below-knee cast suspended by a stockinette to the supracondylar cuff with socks added underneath the cast to provide a continuous controlled compression (Figure 1). The usefulness of this technique in the early phase (day 7 to day 21) of stump management has been confirmed by nine years of clinical experience (WU and Krick 1987). The RRD system works principally by providing a non-expandable environment to prevent the development of oedema following amputation. The controlled compression of the residual limb avoids skin breakdown and facilitates stump shrinkage. The additional benefits of direct stump visualisation will no doubt gain popularity with surgeons over time. The advantages of early application of RRD include:
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figure 1. Eqllipment used for post-amputation removable rigid dressing includes: thin below-knee cast, supracondylar cuff, stockinette for suspension, stump sock for compression and pouch and strap attachmellts for exercise program.
..
rapid stump oedema shrinkage; " desensitisation of the stump; promotion of early wound healing; prevention of stump trauma; elimination of skin complications caused by poor bandaging technique; opportunity for frequent stump observation; " development of stump tolerance to weight bearing (Figure 2); .. anti contracture management; and .. self implemented quadriceps exercise (Figure 3). Greenwich Hospital Amputee Rehabilitation Program first introduced the RRD system in late 1992. A refinement to the system uses a pouch attached to the frame of the wheelchair to assist with a selfimplemented quadriceps exercise, anticontracture and anti oedema program (Figure 3). Within a 4-year period, the average length of stay of our unilateral below knee amputee has declined from an average of 80 days in 1991 (the year prior to the introduction ofRRD) to 36 days in 1995. This decline is due primarily to
.. .. ..
successful early mobilisation and marked reduction in stump complication rate. A similar experience has also been reported by Wu and Flanigan (1978). We utilised the RRD system in our inpatient amputee rehabilitation program with the exception of patients who could not
co-operate with the rehabilitation program because of cognitive impairment or active stump infection. The Greenwich Hospital experience in the case of uncomplicated unilateral transtibial amputation is that we have now achieved an average time to the fitting of a definitive prosthesis during the patient's inpatient stay to 46 days. This is an improvement from the average time of 101 days in 1993. Furthermore, throughout this period we have not observed any complications arising as a result of the use of the RRD system. More dramatically, the annual incidence of stump injury decreased from 22 per cent in 1990 (prior to the introduction of RRD) to nil within one year of introduction, with no subsequent stump injuries. In view of our experience we conclude that the use of the RRD system in early stump management is both effective and efficient. We hope that the use of the RRD system will be actively promoted in Australia, especially in the elderly vascular amputee population. We anticipate further controlled clinical trials will be conducted in the coming years to compare the traditional rigid dressing program with the RRD system.
figure 2. Patient wearing a removable rigid dressing is able to commence weight bearing through stump, aileviating the need for an interim prosthesis.
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References Burgess EM and Romano RL (1968): The management of lower extremity amputees using immediate postsurgical prosthesis. Clinical Orthopaedics 57: 137-146. Burgess EM, Romano RL and Zettl]H (1969): The management of lower extremity amputations. Technical Report TR 10-6. Washington DC: Prosthetic and Sensory Aids Service, Departments of Medicine and Surgery, Veterans Administration. Jones Rand Burniston GA (1970): A conservative approach to lower limb amputations. Medical Journal ofAustralia 2: 71l. Mooney V, Harvey]P, Mcbride E and Snelson R (1971): Comparison of postoperative stump management: Plastervs soft dressings.Journal ofBone and Joint Surgery 53 (App.): 241-49. Wu Yand Flanigan DP (1978): Rehabilitation of the lower extremity amputee with emphasis on a removable below knee rigid dressing. In Bergan] and Yao ST (Eds): Gangrene and Severe Ischemia of the Lower Extremities. New York: Grune and Stratton, pp. 435-453. Wu Yand KrickH (1987): Removable rigid dressing for below-knee amputees. Clinical Prosthetics and Orthotics 11 (1): 33-44.
Figure 3. Addition of a pOlich attached to tile framework of the wheelchair ernables patients to perform quadriceps exercises, and assists with tile prevention of contractures ami oedema.
NOT E
Use of removable rigid dressing for transtibial amputees rehabilitation: A Greenwich Hospital • experience
The outcome for transtibial amputees is improved by the use of a post amputation removable rigid dressing (RRD).The benefits of this technique include reduction of stump trauma and oedema, early weight bearing and desensitisation. The RRD system is easily applied by the amputee and assists eventual progression to a definitive prosthesis. [Hughes S, Ni Sand Wilson S: Use of removable rigid dressing for transtibial amputees rehabilitation: AGreenwich Hospital experience. Australian Journal of Physiotherapy 44: 135137]
ince the early pioneering work of Marion Weiss of Poland and Jean-Paul Willot of France into the effect of early prosthetic fitting after lower limb amputation, much work has been undertaken into the efficacy of immediate post-surgical fitting (IPSF) of a rigid dressing and temporary prosthesis (Burgess 1968 and 1969, Mooney et al 1971). These works demonstrate the importance of early stump management as a means to hastening prosthetic rehabilitation. Despite good clinical outcomes from the·use of the rigid dressing in amputee rehabilitation, the practice of Key words: Amputation; immediate application of a rigid Amputees; Bandages; dressing after amputation has not been Rehabilitation; universally applied in Australia, principally because of surgeons' concerns about wound infection, breakdown and difficulty of direct S Hughes GradDipPhty is a physiotherapist at visual inspection of the stump. Lady Davidson Hospital, Sydney. At the time of The use of elastic bandage in writing this Clinical Note she was a conjunction with an IPSF thigh high physiotherapist with the Amputee Rehabi Iitation cast or a soft dressing has also been Program at Greenwich Hospital in Sydney. part of a standard early stump S Ni BScMed(Hons), MBBS, FAFRM{RACP) is a preparation. This technique Staff Specialist in the Department of traditionally involves the use of an Rehabilitation Medicine at Greenwich Hospital. elastic lOcm width bandage. In the S Wilson MBBS, FRACGP, FAFRM{RACP) is a event of poor hand dexterity, a stump Senior Staff Specialist in the Department of shrinker sock is another alternative. Rehabilitation Medicine at Greenwich Hospital. The difficulty of achieving consistent Correspondence: Sheila Hughes, 20 Greendale bandaging skills by the applicants and Avenue, Frenchs Forest New South Wales 2086. problems related to skin breakdown,
pressure areas and poor patient tolerance have been well discussed and documented (WU and Krick 1987, Wu et al 1979). These difficulties are particularly prevalent among the elderly amputee population. Wu and Krick (1987) first advocated the use of a removable rigid dressing (RRD) system as a means to overcome such limitations. The RRD system is essentially a thin below-knee cast suspended by a stockinette to the supracondylar cuff with socks added underneath the cast to provide a continuous controlled compression (Figure 1). The usefulness of this technique in the early phase (day 7 to day 21) of stump management has been confirmed by nine years of clinical experience (WU and Krick 1987). The RRD system works principally by providing a non-expandable environment to prevent the development of oedema following amputation. The controlled compression of the residual limb avoids skin breakdown and facilitates stump shrinkage. The additional benefits of direct stump visualisation will no doubt gain popularity with surgeons over time. The advantages of early application of RRD include:
CliNICAl
NOT E
figure 1. Eqllipment used for post-amputation removable rigid dressing includes: thin below-knee cast, supracondylar cuff, stockinette for suspension, stump sock for compression and pouch and strap attachmellts for exercise program.
..
rapid stump oedema shrinkage; " desensitisation of the stump; promotion of early wound healing; prevention of stump trauma; elimination of skin complications caused by poor bandaging technique; opportunity for frequent stump observation; " development of stump tolerance to weight bearing (Figure 2); .. anti contracture management; and .. self implemented quadriceps exercise (Figure 3). Greenwich Hospital Amputee Rehabilitation Program first introduced the RRD system in late 1992. A refinement to the system uses a pouch attached to the frame of the wheelchair to assist with a selfimplemented quadriceps exercise, anticontracture and anti oedema program (Figure 3). Within a 4-year period, the average length of stay of our unilateral below knee amputee has declined from an average of 80 days in 1991 (the year prior to the introduction ofRRD) to 36 days in 1995. This decline is due primarily to
.. .. ..
successful early mobilisation and marked reduction in stump complication rate. A similar experience has also been reported by Wu and Flanigan (1978). We utilised the RRD system in our inpatient amputee rehabilitation program with the exception of patients who could not
co-operate with the rehabilitation program because of cognitive impairment or active stump infection. The Greenwich Hospital experience in the case of uncomplicated unilateral transtibial amputation is that we have now achieved an average time to the fitting of a definitive prosthesis during the patient's inpatient stay to 46 days. This is an improvement from the average time of 101 days in 1993. Furthermore, throughout this period we have not observed any complications arising as a result of the use of the RRD system. More dramatically, the annual incidence of stump injury decreased from 22 per cent in 1990 (prior to the introduction of RRD) to nil within one year of introduction, with no subsequent stump injuries. In view of our experience we conclude that the use of the RRD system in early stump management is both effective and efficient. We hope that the use of the RRD system will be actively promoted in Australia, especially in the elderly vascular amputee population. We anticipate further controlled clinical trials will be conducted in the coming years to compare the traditional rigid dressing program with the RRD system.
figure 2. Patient wearing a removable rigid dressing is able to commence weight bearing through stump, aileviating the need for an interim prosthesis.
CLINICAL
NOT E
References Burgess EM and Romano RL (1968): The management of lower extremity amputees using immediate postsurgical prosthesis. Clinical Orthopaedics 57: 137-146. Burgess EM, Romano RL and Zettl]H (1969): The management of lower extremity amputations. Technical Report TR 10-6. Washington DC: Prosthetic and Sensory Aids Service, Departments of Medicine and Surgery, Veterans Administration. Jones Rand Burniston GA (1970): A conservative approach to lower limb amputations. Medical Journal ofAustralia 2: 71l. Mooney V, Harvey]P, Mcbride E and Snelson R (1971): Comparison of postoperative stump management: Plastervs soft dressings.Journal ofBone and Joint Surgery 53 (App.): 241-49. Wu Yand Flanigan DP (1978): Rehabilitation of the lower extremity amputee with emphasis on a removable below knee rigid dressing. In Bergan] and Yao ST (Eds): Gangrene and Severe Ischemia of the Lower Extremities. New York: Grune and Stratton, pp. 435-453. Wu Yand KrickH (1987): Removable rigid dressing for below-knee amputees. Clinical Prosthetics and Orthotics 11 (1): 33-44.
Figure 3. Addition of a pOlich attached to tile framework of the wheelchair ernables patients to perform quadriceps exercises, and assists with tile prevention of contractures ami oedema.