History of Postoperative Prosthetics Surviving Lower Extremity Amputation

1. History ofPostoperative ProstheticsSurviving Lower Extremity Amputation Robert N. Brown, Sr., CPO, FAAOP

2. 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

3. 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)

4. 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

5. 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

6. Surviving Early Postoperative Care • Boiling oil (500 B.C.) • Control bleeding • Prevent infection • Blood Letting(Taber’s Cyclopedia) • Eliminate disease • Leaches • Maggot Tx. (Stopped in the 20th Century) • Used to remove necrotic tissue • Cauterization • Heat, chemical, electrical & laser

7. Advances in Medicine in the Modern Era • Ligatures (Ambroise Pare, 1529) • Tourniquet (Morel, 1674) • Chloriform & Ether (1843) • Doppler Effect (early 1800’s) • C. Doppler 1803 to 1853 • Antiseptics (Lord Lister, 1867) • X-ray (Roentgen, 1895) • More

8. 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”

9. 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

10. Advances In Amputation Surgery • Ertl Procedure • Periosteal juncture • X-ray • Schon’s Bridge • Ertl adaptation • Bone and screws

11. 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

12. Postoperative Outcomes Continue to Improve with: • Soft Dressings (SD) • Compression bandages • Shrinkers • Physical therapy • Occupational therapy • Psycho/Social therapy

13. Immediate PostOperative Prosthetics & Early PostOperative Prosthetics Arrive • Berlemont (late 1950’s) • Modified by Weiss • Brought to the USA (1963) • Burgess/others adopt the technology

14. “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)

15. 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

16. Advantages of IPOP / EPOP • Protect wound site • Reduce falls • Speed-up the training and adjustment period • Improve balance and safety during transfers

17. 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

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

19. Pre-fabricated Sockets & Systems • Postoperative Treatment of Lower Extremity Amputees (Brown, Danforth, Klotz, Schon & others)

20. If It Ain’t 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

21. 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

22. 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

23. 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

24. Disadvantages of Pre-fabricated Removable IPOP / EPOP • Could be removed • Not for every patient • Could be incorrectly donned • Weight bearingmust 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

25. Available Pre-fabricated Sockets & Systems • Aircast Air-Limb™ -- • APOPPS-TF™ & APOPPS™ by FLO-TECH® ------

26. More Pre-fabricated Postoperative Systems & Sockets • Danforth – D-PASS ------- • Fillauer POP & POP-PY ----------------- • TEC ------------------------

27. 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

28. 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

29. 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