History of Postoperative Prosthetics Surviving Lower Extremity Amputation

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History ofPostoperative Prosthetics Surviving
Lower Extremity Amputation
Robert N. Brown, Sr., CPO, FAAOP
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4 Periods of General Medicine

• Antiquity Period
• 2000 B.C. to 500 A.D.
• Middle Ages
• 500 A.D. to 1400 A.D.
• Renaissance Period
• 1400 A.D. to 1846
• The Period of Modern Surgery
• 1846 to 20th Century
• New Era?
• Ertl Procedure and Adaptations

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Amputations Prosthetics

• Surgical amputation
• Stone Age - 3,000 B.C.
• Pre-dates prosthetics
• First recorded prosthesis 484 B.C.
• 500 years after the first recorded orthosis
• Oldest prosthesis 300 B.C.
• Destroyed in the bombing of London, W. W. II)

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Amputations Prosthetics

• Silence until the 15th century
• Middle Ages period of war
• Amputations go largely unreported or
  forbidden
• Castration
• War continues to be the impetus for most
  prosthetic advances

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Early Surgical Efforts

• The operation was a success but 75 of all
  amputees died
• Surgeons lacked knowledge
• Asepsis
• Sterile conditions
• Ligation
• Ligature to stop bleeding of severed blood vessels

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Surviving Early Postoperative Care

• Boiling oil (500 B.C.)
• Control bleeding
• Prevent infection
• Blood Letting (Tabers Cyclopedia)
• Eliminate disease
• Leaches
• Maggot Tx. (Stopped in the 20th Century)
• Used to remove necrotic tissue
• Cauterization
• Heat, chemical, electrical laser

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Advances in Medicine in the Modern Era

• Ligatures (Ambroise Pare, 1529)
• Tourniquet (Morel, 1674)
• Chloriform Ether (1843)
• Doppler Effect (early 1800s)
• C. Doppler 1803 to 1853
• Antiseptics (Lord Lister, 1867)
• X-ray (Roentgen, 1895)
• More

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Post Amputation Concerns As
Technology Improves

• Pain
• Death
• Infection
• Contractures
• Pressure sores
• Psychological trauma
• Adequate blood supply
• Edema/shrinkage/swelling
• Changes in transected bones
• Neuroma formation/sensory loss
• Desire to return to a Normal Life

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Advances in Amputation Surgery

• Guillotine
• Contoured flaps
• Suturing techniques
• Good Surgical Technique Creates A Functional
  Residual Limb. (Thomas Hadden, 1945)
• Extended posterior flap (late 1960s)
• Doppler

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Advances In Amputation Surgery

• Ertl Procedure
• Periosteal juncture
• X-ray
• Schons Bridge
• Ertl adaptation
• Bone and screws

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Postoperative Outcomes Continue to Improve with

• Bed rest
• Light compression early continuous skin
  Traction (Barnard 1942)
• Wound drainage
• Hema-vac systems
• Surgical suturing methods
• Staples

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Postoperative Outcomes Continue to Improve with

• Soft Dressings (SD)
• Compression bandages
• Shrinkers
• Physical therapy
• Occupational therapy
• Psycho/Social therapy

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Immediate PostOperative Prosthetics Early
PostOperative Prosthetics Arrive

• Berlemont (late 1950s)
• Modified by Weiss
• Brought to the USA (1963)
• Burgess/others adopt the technology

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It Is Mandatory That The Surgeon Understand
Prosthetic Principles Available Components.
(Ernest M. Burgess, M.D., 1967)

• PSAS (Prosthetics Sensory Aides Service V.A)
  PRS (Prosthetics Research Study)
• IPOP (Burgess, Romano, Traub, Zettle/Van
  Zandt/Gardner, May 1964 to November 1966)
• Independent studies of the positive and negative
  results of IPOP (Titus, Wilson many others)

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Why Immediate or Early Prosthetic Management?

• Improves outcomes
• Helps with challenging cases
• Enhances the value of rehab care
• Maximizes potential for future prosthetic use
• Functional Management empowers patient, family
  rehab team

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Advantages of IPOP / EPOP

• Protect wound site
• Reduce falls
• Speed-up the training and adjustment period
• Improve balance and safety during transfers

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Advantages of IPOP / EPOP

• Patient gets more initial attention
• Reduce other health complications
• Reduce length of hospital stay
• Psychological benefits
• Re-establish bilateral function body image
• Psycho-social acceptance of prosthesis to become
  a functioning prosthetic user

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Visual Trepidation

• Bi-valved rigid removable dressing (Med. Journal
  Australia, Jones Buriston, 1970)
• RRD (Wu 1979)
• PSRD (Swanson 1993)

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Pre-fabricated Sockets Systems

• Postoperative Treatment of Lower Extremity
  Amputees (Brown, Danforth, Klotz, Schon others)

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If It Aint Broke, Why Fix It? - Plaster IPOP
Lacks

• Opportunity for surgeon to examine limb to
  preserve wound integrity and quality
• Opportunity for Therapists to examine residuum
  before after weight bearing
• Ability to shrink and swell with the patient
• Ability to reproduce a quality outcome from one
  practitioner or one IPOP to another

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Why Use a Pre-fabricated Removable IPOP Vs.
Shrinker or Ace Wrap (SD)?

• Minimize skin breakdown
• More effective edema control
• Ability to keep knee in extension
• Consistency of donning and doffing
• Ability to add graded weight bearing
• More rapid maturation of residual limb
• Protection of residual limb from trauma
• Immobilizing soft tissue promotes healing

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Why Use a Pre-fabricated Removable IPOP Over
Plaster or Fiberglass?

• To remove all opportunity to watch the wound is
  not reasonable. (Kerstein, Zimmer,
  Dugdale, article IPOP - Poor Results
  - 1972)
• Most systems are less bulky
• Adjustability eliminates costly
  time consuming cast changes
• Longer useful life

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Pre-fabricated Removable IPOP Vs. Plaster or
Fiberglass

• Adjust compression
• Adjust wearing time
• Shorter learning curve
• Definitive components used
• Can be reused by the same patient
• Eliminates cast changes realignment
• Surgeon, prosthetist patient save time
• Can get wet or soiled and can be cleaned

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Disadvantages of Pre-fabricated Removable IPOP /
EPOP

• Could be removed
• Not for every patient
• Could be incorrectly donned
• Weight bearing must be controlled
• Bulky relative to a custom made
  preparatory
• Complications may be blamed on
  the socket or system
• More initial material cost than plaster IPOP

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Available
Pre-fabricated Sockets Systems

• Aircast Air-Limb --?
• APOPPS-TF APOPPS by FLO-TECH ------?

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More Pre-fabricated Postoperative Systems
Sockets

• Danforth D-PASS -------?
• Fillauer POP POP-PY -----------------?
• TEC ------------------------?

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Other Available Techniques Pre-fabricated
Systems

• Plaster IPOP
• Removable Rigid Dressing
• RRD
• PSRD
• Una paste soft dressings
• The Michigan Limb
• Hosmer PP-AM
• USMC Prep TT/TF
• DeWindt limb
• Ossur ----------?
• Others custom

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The Future Amputations on the Rise

• Cost of Rehab (Malone, Pipinich, Leal, Hayden
  Simpson, Maricopa Medical Center Study)
• Non IPOP - 47,589
• IPOP - 28,432 - adjusted (42,535)
• 56,000 amputations per yr. - Diabetes
  (1997, American
  Diabetes Association)
• 90 of limb amputations in the western
  world are consequences of PVD/Diabetes
• Rest of world - not far behind
• Land mines
• Especially children

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Conclusion

• Not enough qualified prosthetists to meet demand
• Prosthetists time better spent on
  surgeon/rehab team/patient relationships
  on mentoring young prosthetists
• Pre-fabricated systems reproduce quality from
  one prosthetist, one IPOP, to the next