Immediate Post–Operative Prosthesis for Early Weight-Bearing and Rehabilitation

Joseph S. Pongratz, CPO, FAAOP
Pongratz Orthotics & Prosthetics, Inc
Phoenix – Mesa – Tucson

Abstract – The ability for a new amputee to function during the immediate post–operative phase of rehabilitation is dependent on numerous factors, which include: pre-amputation function, level of amputation, cause of amputation, and type of immediate post-operative treatment utilized. Following any level of limb removal, providing the new amputee with a removable immediate post-operative prosthesis(IPOP) has shown to have both psychological and physiological benefits. IPOP’s are commonly utilized as an external semi-rigid protective device to promote residual limb healing, reduce limb contractures, and minimize post-operative edema. Having the availability to remove these plastic devices for daily dressing changes and residual limb inspection has also shown to increase the effectiveness of this treatment by decreasing the unobservable pressure areas common in the plaster cast IPOP. The semi-rigid protective device has an adjustable bi-valve closure for control of post-operative edema. In addition, further benefits of having an external frame with pylon and foot, which attach to the protective device separately, decrease the weight and stresses on the post-operative limb while non-weight bearing. As the patient begins rehabilitation, exercises introducing partial weight bearing and strength and range of motion conditioning will promote balance and a stable base of support. The new amputee will gain confidence and endurance while the residual limb is protected from disruption common from post-operative falls.

The immediate post-operative phase of prosthetic care is a crucial period of time, which directly impacts an amputee’s rehabilitation. In the past, the new amputee was encouraged to remain supine with the residuum elevated to decrease the amount of fluid build-up, or edema, in the limb. The limb was often protected using plaster or fiberglass removable rigid dressings (RRD), which would help to control edema through compression as well as prevent suture disruption should the patient fall during transfers or otherwise disrupt the suture line. Applying weight on the new surgical site was discouraged, as the chance of suture disruption was evident. However, during recent year’s physicians, physical therapists, and prosthetists have changed the focus on post-operative amputee rehabilitation to include early weight bearing along with protection and healing as a primary goal. Physical rehabilitation with partial weight bearing on the protected residuum has shown to be a more effective treatment plan now. The new approaches using removable immediate post-operative prosthetics(IPOP) with external frames, have allowed patients to return to pre-amputation activity levels much sooner than when using removable rigid dressings alone. 2,4

In 1987, Dr. Yoengchi Wu and Harold Krick, CP published a paper which outlined a method for fitting an amputee with a removable rigid dressing immediately after surgery. The paper elaborated on the benefits of RRD application over non-protected healing. “Clinical experiences since 1977 have shown the benefits of the RRD to be the following:

  1. Rapid residual limb shrinkage
  2. Prevention of edema
  3. Possibility of frequent residual limb observations
  4. Soft tissue immobilization to facilitate wound healing
  5. Elimination of skin breakdown commonly seen in elastic bandaging
  6. Simplicity of donning and doffing
  7. Development of tolerance to weight bearing
  8. Prevention of residual limb trauma
  9. Reduction of wound pain” 6

Also, in a 1977 study, it was determined that the average stay at the V.A. Lakeside Medical Center was reduced by an average of 90 days following the development and use of the RRD. 6 During this time the goal of post-operative prosthetic involvement focused on healing prior to the start of physical rehabilitation. Many of the studies performed prior to the early 1980’s suggest that early ambulation was beneficial to promote physiological rehabilitation. The problems that were often encountered were patient non-compliance and no standard care of follow-up when weight-bearing IPOPs were fit. Apparently, physicians, physical therapists, and prosthetists were not properly educated on the importance of regular limb inspection and follow-up during immediate post-operative weight bearing. The importance of early weight bearing has been recognized for years, but the indication of early weight bearing has only recently come to fruition.

Many of the recent published reports on IPOP use have given consistent reasons as to why IPOP’s should be considered on most, if not all, transtibial and transfemoral amputations. In a non-scientific report, Judith Otto discussed psychological reasons why immediate post-operative treatment is necessary for a positive prosthetic outcome. When a patient wakes from a transtibial amputation with an IPOP and foot attachment in place, ”The patient does not experience a period of ‘limblessness’ with attendant neurological and psychological ramifications.”2 Although, the patient has endured a life altering procedure, he/she has awakened in the recovery room with two legs beneath the sheets. Feelings of being ‘disabled’ or less than whole are often replaced with a sense of hope and encouragement. Commonly family members and loved ones have a more difficult time coping with the thought of an amputation than the new amputee does. In many cases the new amputee supports the whole family structure during the immediate post-operative phase.

During a one-year period at Pongratz Orthotics and Prosthetics, Inc., our staff has had the opportunity to fit over 42 IPOP systems on transtibial and tranfemoral amputees ranging from 9 to 86 years of age. We have been very successful in establishing an evaluation, fitting and follow-up protocol for a modified polyethylene and polypropylene IPOP that was designed while working with a number of physicians in the Phoenix area. The patients that we have fit with IPOP systems have had several different causes of amputation including: elective surgery, trauma, cancer or related osteosarcoma, burn or electrical condition, and diabetes. No patient has been omitted from IPOP application due to cause of amputation. We have found that close follow-up and education will allow most, if not all, amputee patients to be fit with an IPOP and return to pre-amputation activities sooner. The protocol that we have established consists of pre-amputation education and measurement, fabrication of IPOP, post-operative IPOP fitting usually in the operating room, daily follow-up with dressing changes while an in-patient, and following discharge, bi-weekly follow-up with the patient until suture removal.

The physicians that we have had the opportunity to work with during the past year have allowed us to introduce a new IPOP system for their transtibial and transfemoral amputees. The protocol that has been established begins pre-operatively. The physician contacts the office as soon as a transtibial amputation has been scheduled. We either meet with the patient and family in the hospital or office setting to answer any questions or concerns the patient or family may have. Family members often have different concerns then the amputee. Family members tend to focus on cosmetic issues ”…will it look like a real leg…” while the patient focuses on function. Informative brochure and handouts regarding adapting to limb loss are given to the amputee and family. This type of reading material is always beneficial because it covers topics not always asked by the amputee or mentioned by the prosthetist. These handouts outline the IPOP, temporary, and definitive phases of prosthetic management and what to expect during each phase. The patient is shown actual samples of prosthetics in each phase so the expectations are know prior to prosthetic management. At this meeting, we take measurements of the limb to be amputated so that a custom clamshell IPOP can be fabricated. The measurements required are 1) circumference 4” proximal to patella, 2) circumference at patellar tendon, 3) circumference at mid-shaft of the tibia, 4) distance from patellar tendon to floor, and 5) foot size. Following this initial meeting with the patient and family, the referring physician is contacted to determine the best possible residuum length. Once all of the required information is obtained, the custom clamshell IPOP can be fabricated within 2 hours.

The day after the amputation the patient is seen for follow-up with the physical therapist and prosthetist present. At that time the patient is encouraged to begin standing exercises using the IPOP for balance and limited weight bearing for commode transfers. The physical therapist continues this type of exercise and weight bearing until day three, at which time the physician completes the first dressing change. During the dressing change the limb is inspected for redness, irritation, edema, and excessive drainage. If the limb appears to be in good shape, orders are written to begin 15% weight bearing exercises and limited gait training. If problems exist, the physician reschedules a dressing change for two days later. During the next ten to 14 days, follow-up with the patient every other day is imperative to ensure the limb healing well and is protected. If problems are encountered the physician is contacted immediately. If no problems exist, the patient is encouraged to continue weight bearing and rehabilitation as tolerated while using crutches or a walker. At post-operative day 14, the physician schedules a follow up appointment to evaluate residuum for suture removal. Of the 42 cases evaluated, only 3 patients have gone past the 14-day mark for suture removal. Immediately following suture removal, a stump shrinker is applied to the limb while the patient is still in the physician’s office. A recommend wearing schedule that the patient wear the prosthetic shrinker 12 hours on and 6 hours off during the next two days and increased to 23 hours on and one hour off for the next five days. At the seven-day mark following suture removal, the patient is scheduled in the office for a temporary prosthetic casting. Of the 42 IPOP cases using a custom clamshell IPOP, only 3 patients have taken longer than 16 days from amputation to be fit with a temporary prosthesis.

The immediate post-operative phase of prosthetic care is a time period, which plays an important part of any amputee’s rehabilitation. In the past, the new amputee was encouraged to remain supine with the residuum elevated while healing took place. Removable rigid dressings were designed to address suture line healing with no focus placed on weight bearing, physiological or psychological healing. During recent years, immediate post-operative prosthetics have seen a rise in popularity with a focus on limb protection, healing of the suture line, residual limb edema control, and proper limb positioning. Additionally, early physical rehabilitation with limited weight bearing has been emphasized. By providing a new amputee with a protected healing atmosphere to heal faster physically and weight bear sooner, hospital and rehabilitative costs are reduced. The custom clamshell immediate post-operative prosthesis can be fabricated with-in hours and that any new transtibial or transfemoral amputee is an IPOP candidate regardless of the cause of amputation. The success lies in thorough follow-up from all members of the rehabilitative team.

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