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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

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history of postoperative prosthetics surviving lower extremity amputation
History ofPostoperative ProstheticsSurviving Lower Extremity Amputation

Robert N. Brown, Sr., CPO, FAAOP

4 periods of general medicine
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
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 prosthetics1
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
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
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
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
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
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 surgery1
Advances In Amputation Surgery
  • Ertl Procedure
    • Periosteal juncture
      • X-ray
  • Schon’s Bridge
    • Ertl adaptation
      • Bone and screws
postoperative outcomes continue to improve with
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 with1
Postoperative Outcomes Continue to Improve with:
  • Soft Dressings (SD)
    • Compression bandages
    • Shrinkers
  • Physical therapy
  • Occupational therapy
  • Psycho/Social therapy
immediate postoperative prosthetics early postoperative prosthetics arrive
Immediate PostOperative Prosthetics & Early PostOperative Prosthetics Arrive
  • Berlemont (late 1950’s)
  • Modified by Weiss
    • Brought to the USA (1963)
  • Burgess/others adopt the technology
slide14
“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
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
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 epop1
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
Visual Trepidation
  • Bi-valved rigid removable dressing (Med. Journal Australia, Jones & Buriston, 1970)
  • RRD (Wu 1979)
  • PSRD (Swanson 1993)
pre fabricated sockets systems
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
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
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
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
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
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
available pre fabricated sockets systems
Available Pre-fabricated Sockets & Systems
  • Aircast Air-Limb™ --
  • APOPPS-TF™ & APOPPS™ by FLO-TECH® ------
more pre fabricated postoperative systems sockets
More Pre-fabricated Postoperative Systems & Sockets
  • Danforth – D-PASS -------
  • Fillauer POP & POP-PY -----------------
  • TEC ------------------------
other available techniques pre fabricated systems
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
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
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