Up-Date on Immediate Post Surgical Fittings
Robert F. Hayes, CP.
I would like to express some thoughts regarding the use of the technique of immediate post-surgical fittings of prostheses for below-knee amputees.
Nearly all of us certainly agree that there are definite advantages to the patient in the use of prosthesis immediately after amputation, especially in the case of the BK amputee. However, the I.P.S.F. technique is not being used as standard practice in many areas. Perhaps one of the reasons is the lack of continuing education courses dealing with immediate postsurgical procedures.
When the concept of immediate postsurgical fitting was first introduced approximately fifteen years ago there was a heavy concentration to the point of saturation on the application of prostheses in the operating room. This was good, because it gave us all an opportunity to be educated in such a revolutionary technique of treatment. However, today, there are many people entering the field involving amputation and amputee care every year, surgeons and prosthetists and in most cases they have only a limited knowledge of the I.P.S.F. techniques.
Obviously, and for good reason, most surgeons are reluctant to use a technique with which they themselves are not familiar. It then becomes the role of the prosthetist to educate and encourage the use of I.P.S.F. and, ideally, apply the concept himself.
Another reason for lack of use of I.P.S.F. is the inconvenience created by scheduling between doctor, prosthetist, and operating room. Often hours of valuable time are wasted when things are not proceeding on schedule, which is the norm rather than the exception.
Another reason why I.P.S.F. techniques are abandoned is that when a surgeon and prosthetist first attempt this technique, they sometimes use a patient whose probability of healing is marginal under the best of circumstances. And sometimes ambulation is attempted too early, causing stump breakdown. The result is a surgeon convinced that this technique is not for his patients.
Still another factor that discourages use of the I.P.S.F. concept is the application of a poorly fitting weight-bearing cast by individuals not fully trained. There have been individuals who, after reading an article or hearing a thirty-minute lecture on I.P.S.F., attempted to apply a weightbearing cast. Some of the more skilled are able to do this, but most have problems. If a cast is intended to bear weight, it must fit well, have proper relief areas and distal padding to provide relief if the patient should atrophy and settle in the socket.
It is my opinion that no weight-bearing cast at all is better than a poor application of one that is supposed to bear weight. Please note, I said "weightbearing cast" and not a rigid dressing, which is and should be more readily applied immediately after the operation and does not require the same precision as does the weight-bearing cast. This will be taken up later.
Now that we have discussed some of the problems that may have discouraged the utilization of I.P.S.F.- and I'm sure there are many more- let's constructively consider a couple of approaches that seem to work well.
Since the inception of I.P.S.F., most of us have changed our thinking for some very solid reasons. One of the primary problems arose in the attempt to have the patient weightbearing and often ambulating within forty-eight hours postoperatively. We have learned that, in most cases, this concept is a disadvantage rather than an advantage and can be the cause of stump breakdown. If we agree that early ambulation is not intended, we may apply an immediate rigid dressing with the appropriate snugfitting sterile stump sock.
Schematic
When the rigid dressing is not intended for weightbearing, most surgeons will make the application since they need not be concerned about felt pads for relief over pressure areas. The initial rigid dressing can be left on for approximately two weeks. During this time we have:
Protected the wound by
Keeping external contaminates out
Preventing injury to the stump
Protecting the posterior flap from undue pressure
Maintained the size of the stump, preventing edema, which alleviates pain
Made the patient more comfortable and able to move about without fear of injury to the stump
Prevented knee flextion contracture
Greatly reduced complaints of phantom limb
After two weeks the initial rigid dressing is removed; or, in some cases, the surgeon will remove the sutures and wait for an additional week or two. At the end of the two-week postoperative period, the prosthetist is called in to apply an early post-surgical prosthesis usually with a plaster socket and a pylon with a SACH foot.
In the fabrication of our plaster sockets, we strive to keep the plaster high up over the condyles to the mid thigh area. We find this is beneficial in eliminating knee flexion contractures and, most importantly, eliminating piston action within the socket, a very hazardous condition, especially in the early stages of fitting.
I know attempts are made to trim plaster to a P.T.B, level for increased knee motion. The advantages of enclosing the knee offset the short time needed for patients to regain knee motion. I also use a waist belt and fork strap for added suspension. This temporary prosthesis is worn for approximately six weeks.
The very thin patient may not need a cast change before the end of six weeks, but more muscular and fatty tissue will require cast changes according to the amount of atrophy.
After the patient has been ambulating for approximately six weeks, the plaster socket is bi-valved and a negative mold is taken for the definitive prosthesis. The plaster socket is then put back on the patient and closed with plaster or tape. The plaster socket and pylon stay on the patient until delivery of the definitive prosthesis and removed as needed for fittings. When minor changes in stump size occur, stump socks may be added while using the plaster pylon prosthesis.
To reduce some expense to the patient, the hospital can inventory several pylon assemblies suitable for temporary use. We also supply various sizes of used SACH feet that can be used temporarily. The patient is then charged only for the professional services of the prosthetist, thus saving the considerable expense of components.
I hope that some of my comments may be of assistance to others who would like to employ more immediate postsurgical prosthetic care for patients, and hopefully stimulate others to respond with other approaches so that we may all benefit.
I would like to acknowledge Dr. Elmer Franseen, from whom I have used references many times in this paper. Dr. Franseen is an Orthopedic Surgeon at Baystate Medical Center, Springfield, Mass. I am sad to say that Dr. Franseen is retiring this month, and I will miss working with this truly professional man. In the past fifteen years of working with Dr. Franseen, I have witnessed him employing I.P.S.F. on all of his B.K. amputees and only on rare occasions was a revision necessary.
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