Robert N. Brown, Sr., CPO, FAAOP History of Postoperative Prosthetics Surviving Lower Extremity Amputation Robert N. Brown, Sr., CPO, FAAOP

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

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)

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

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

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

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

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”

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

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

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

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

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

“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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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