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Planning and Preparation: Key for Improving Outcomes After Amputation


Key for Improving Outcomes After AmputationAs the weather has begun to warm, many of us have started to plan and prepare for our gardens. The experts among us know that the early work of site planning and soil preparation will save them time and energy down the road and is the key to a successful garden. The principles of planning and preparation hold true in every endeavor in life. However, one area where individuals can fail to actively plan and prepare is with post surgery rehabilitation. Patients facing a below knee amputation need an experienced prosthetist to help them set the pace for their rehabilitation and achieve the many small goals leading up to the successful fitting of a prosthetic limb.

Planned post-amputation goals are:
1.    Reduce edema
2.    Prevent knee contracture
3.    Protect from external trauma
4.    Improve wound healing
5.    Reduce pain
6.    Prepare for early prosthetic fitting
7.    Rapidly achieve desired functional level

The planning and preparation stage begins weeks before the amputation whenever the situation allows. Here, we can get a better picture of a patient’s functional level before the amputation and develop a plan to get them back to the activities that they enjoy as quickly as possible.  Often the surgeon will consult with the prosthetist to determine optimal limb length for the most comfortable and functional prosthetic device. Most importantly, getting the prosthetist involved before amputation allows him to plan to be present as soon as the patient leaves surgery to begin preparing the limb for an optimal fit and quick healing.

The greatest challenges that I have faced with new prosthetic fittings have occurred because one or more of our first four goals were not met. When no post-amputation plan is in place, around 70% of patients are treated with soft dressings only.1 In many of these cases, the soft dressings have not effectively reduced edema, resulting in increased pain, greater time spent in bed, a difficult to fit limb shape, and the development of knee contractures.

A study by Ladenheim et al found that patients treated postoperatively with soft dressings only were cast for their first prosthetic socket an average 84.4 days after amputation.2  Setbacks from falls that damage the residual limb are all too common, and many patients become discouraged at how long it takes to heal enough to be fit with a prosthesis.

At Bristol Orthotics and Prosthetics we have incorporated an approach to post-amputation care that allows us to work with the rehab team to dramatically speed patient recovery and prosthetic fittings. On a recent case, after consulting with the surgeon, we were able to apply a rigid removable dressing to a patient’s residual limb in the operating room recovery area. This rigid dressing was molded to the patient’s limb through the use of a handheld vacuum pump. The rigid dressing was able to be opened and closed in order for the medical team to inspect the wound and change the soft dressing beneath. By encompassing the limb and extending to the thigh, the rigid dressing reduced edema, helped shape the limb, and eliminated the possibility of a knee contracture.  As the patient’s limb shape changed through the use of elastic bandaging, stump shrinkers, and gel liners, the rigid dressing was continually reshaped to provide firm protection to the limb. In this case, the patient experienced a fall that could have caused catastrophic damage to the limb, but thanks to the rigid dressing, the limb was protected. Rather than casting the patient at 84 days as cited above, we were able to cast at 21 days and are on track to fit the prosthesis at 31 days! These are the results of planning, coordination with the entire medical team, and empowering of the patient to determine the pace of his rehabilitation.

For more information or to schedule an appointment, contact Bristol Orthotics & Prosthetics at 1-800-524-4447 or www.bristoloandp.com.

1. Smith, Douglas G. MD; McFarland, Lynne V. PhD, MS; Sangeorzan, Bruce J. MD; Reiber, Gayle E. PhD, MPH; Czerniecki, Joseph M. MD. Postoperative Dressing and Management Strategies for Transtibial Amputations: A Critical Review. JPO:
July 2004. 16:3  pp S15-S25

2. Ladenheim, Eric MD, FACS; Oberti-Smith, Kerri CP, PT; Tablada, Gavin CP. Results of Managing Transtibial Amputations With a Prefabricated Polyethylene Rigid Removable Dressing. JPO: Jan 2007. 19:1 pp 2-4



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