Focus on IPOPs, EPOPs: Does Early Mobility Benefit Amputees?
"Although amputations have been performed for centuries as a lifesaving procedure, the current protocols for care of the person undergoing this life-altering surgical procedure, in some cases, may not reflect the complete and active lifestyle in which the amputee can now engage.
"Therefore, amputation must be viewed as a reconstructive procedure, and the postoperative protocol must be designed to enhance the functional potential of persons forced to undergo this physically and emotionally difficult surgery"--Overview of the Clinical Standards of Practice (CSOP) Conference on Postoperative convened in 2003 by the American Academy of Orthotists & Prosthetists
Although this article focuses mostly on the use of immediate postoperative prostheses (IPOPs and early postoperative prostheses (EPOPs), "whole person" postoperative care of the amputee is a highly complex subject involving a multitude of interrelated factors. The reader is thus encouraged to consider the report of the findings and conclusions of this CSOP Conference for a more nearly complete picture.
This intense two-day event, cochaired by Douglas G. Smith, MD, and Gary M. Berke, MS, CP, brought together a multidisciplinary group including orthopedic surgeons, vascular surgeons, physiatrists, prosthetists, physical therapists, and peer counselors. The results were published in the Journal of Prosthetics and Orthotics [JPO] in March, 2004. Another important study, referred to in the JPO article, is a valuable, extensive review of the current literature in the May/June 2003 issue of the Journal of Rehabilitation Research & Development (JRRD), published by the Department of Veterans Affairs (VA). Titled, Postoperative Dressing and Management Strategies for Transtibial Amputations: A Critical Review, the article can be accessed online at www.vard.org/jour/03/40/3/pdf/Smith.pdf
The purpose of CSOPs is to define the current
status of patient care, establish points of consensus in treatment,
and define research priorities.
The CSOP participants adopted five postoperative care strategies previously identified in the literature: 1) soft dressings, 2) nonremovable rigid dressings without an immediate prosthetic attachment, 3) nonremovable rigid dressings with an immediate postoperative prosthesis, 4) removable rigid plaster dressings (RRDs), and 5) prefabricated postoperative prosthetic systems.
As noted, these five strategies are only part of the care protocols. As noted in the published overview, the conference defined the various aspects of care that should be considered, including those relating to improving mobility, enhancing healing, limb volume management, and improving outcomes.
Also discussed were care goals associated specifically with amputation, such as pain management, fall prevention, and improved mobility, along with goals associated with overall patient care, such as musculoskeletal reconditioning and cardiopulmonary training, contralateral lower limb preservation, emotional care, and minimizing systemic complications.
Strategic goals of postoperative care include the vital ones of 1) preventing knee contractures, 2) reducing edema, 3) protecting against external trauma, and also can include 4) facilitating early weight bearing.
IPOPs and EPOPs are strategies which can be used to help accomplish these goals.
History of IPOP Development
Interestingly, the history of IPOPs goes all the way back to the
early part of the 20th century. Until World War I, postoperative
soft gauze bandages were most commonly used. WWI troops were fitted
with plaster casts affixed with wooden or metal tips. An early
pioneer in the use of IPOPs, noted orthopedist P.D. Wilson, MD, of
New York reported on the benefits of early weight bearing. Later,
the use of weight bearing casts lost favor between the world wars,
notes the JRRD article.
However, the technique was reintroduced in the late 1950s and early 1960s in France and Poland by Michel Berlemont, MD, and Marian Weiss, MD. Berlemont introduced a thigh-level rigid plaster cast with a prosthesis attached immediately in the operating room and reported results in 1961; Weiss reported on similar accomplishments in 1966. In 1964, Ernest Burgess, MD, and J.H. Zettl brought the technique to the United States and established the Prosthetics Research Study in Seattle, Washington.
In 1970, J.M. Little, MD, introduced a pneumatic postoperative prosthesis in Australia to allow for easy removal and residual limb inspection, according to the JRRD article, which adds that in 1977, Yeongchi Wu, MD, Northwestern University, Chicago, Illinois, developed a shorter version of a plaster cast system that did not encompass the thigh, called the "removable rigid dressing technique."
In discussing the history of IPOPs, John Bowker, MD, professor emeritus of Orthopaedics and Rehabilitation at the University of Miami Miller School of Medicine, Miami, Florida, points out the work on postoperative amputation techniques by vascular surgeon James Malone, MD, in the 1980s, and Douglas Smith, MD. Although not an inclusive list, other developments were made by Lew Schon, MD; Michael Pinzur, MD; John Rheinstein, CP; Wallis Farraday, CP; and Robert Brown, CPO, LPO, FAAOP.
IPOPs are put on in the operating or recovery room and include a rigid, nonremovable dressing with a pylon and foot attachment. A nonremovable rigid dressing is a lightweight thigh-level cast made of plaster, fiberglass, or a combination, with a proximal socket-style brim and which may include a soft or rigid spica component around the waist. A knee unit may or may not be included. An EPOP is similar, except that it is put on generally five to seven days after surgery, rather than immediately. Also, there are commercial IPOP systems available.
Rigid Dressing Benefits
A removable rigid dressing, also made of plaster,
fiberglass, or a combination, may be put on right after surgery.
Removable and nonremovable rigid dressings have the advantage of
controlling edema and shaping and protecting the limb, notes Karen
Andrews, MD, a physiatrist with the Mayo Clinic, Rochester,
Minnesota. Bowker adds that these types of dressings help to reduce
pain and protect the wound from injury and contamination.
The RRD has the added advantage of allowing the physician to monitor the limb for wound healing and any skin breakdown without having to cut it off and re-fabricate it, explains Andrews. Also, it's easier to add socks as limb volume rapidly decreases and to help new amputees master the art of sock management under supervision, she adds. Being able to remove the dressing also assists with hygiene. However, when the RRD is removed, it's important to not leave it off more than 20 minutes or so, since edema can set in rapidly and affect the fit, Andrews points out.
The trimline of the RRD for transtibial amputees is at the distal patella anteriorly and lower posteriorly to allow knee flexion, Andrews explains. The RRD thus allows the amputee to do range-of-motion (ROM) exercises. For the transfemoral amputee, the trimline is below the ischial tuberosity posteriorly and adequately distal anteriorly to allow hip flexion. A nonremovable rigid dressing extends above the knee and is closely molded to the femoral condyles. It thus keeps the knee in extension and controls edema. With the nonremovable dressing, there's no worry about knee flexion contractures, but the patient cannot actively work the knee. However, Andrews notes that this is a good option for a patient who is noncompliant with range-of-motion exercises due to cognitive impairment or other reasons.
Another factor to consider in whether to use an RRD or opt for a nonremovable rigid dressing is where the patient will be going after release from the hospital, Andrews observes. An RRD requires knowing donning and doffing protocol, but with the nonremovable dressing, the patient simply goes back to the surgeon in ten days for checking and replacement of the dressing. However, although the procedure with the RRD isn't difficult, sometimes the patient, nursing home aide, or family member puts it on incorrectly. "But if people are aware of the procedure, there"s no problem," says Andrews.
Preventing knee and elbow flexion contractures is a major reason for using RRDs or nonremovable rigid dressings. As Bowker points out, these flexion contractures can set in quickly and be very difficult to work out. Preventing limb injury as the surgical wound heals is also vital. New amputees often have the sensation that the missing limb is still present, and if awakened suddenly from sleep, for instance, to answer a ringing phone, can get out of bed and suddenly fall. Andrews recalls an incident when she was at the University of Michigan Medical Center when a patient suddenly fell and split open the incision. Since these types of injuries can take three to six months to heal, that experience led to University of Michigan patients being put in an RRD in the operating room. Andrews is a strong proponent of RRDs and has written a chapter for a vascular surgery textbook on the subject.
Advantages of IPOPs, EPOPs
Both Bowker and Andrews note that the advantages of IPOPs
include early ambulation and fewer complications due to prolonged
EPOPs rather than IPOPs often are used for various reasons. At Mayo, generally only younger patients who are amputees due to tumors or trauma are put in IPOPs, says Andrews. "Since most of our cases are due to vascular disease, the surgeon wants to be able to check the incision, so the patient is first put into a splint. Three days postoperatively, the patient starts partial weight bearing with a pylon cast, but the patient is always in a protective dressing."
Although surgeons generally can apply the dressings, an IPOP requires a prosthetist to fit and align the pylon and foot correctly, says Bowker. "An IPOP does require a skilled applicator. Surgeons can certainly put on the cast and obtain one of the best results of an IPOP--rigid immobilization--but when you have applied a shank and a foot, it's better to have a prosthetist in the operating room, not only to mold the cast so its comfortable but also to fit and align the foot properly. That's just second nature for them."
However, both Bowker and Andrews comment that it's often hard for many surgeons to have a prosthetist available in the operating room, due to their schedules and general availability, although Mayo's team approach does include a prosthetist on call. "That's probably why some surgeons arrange for an EPOP instead to be fit within five to seven days, since the prosthetist can put it on at bedside or in the clinic," observes Bowker.
Notes the CSOP conference, "The presence of an open wound or the presence of sutures does not necessarily preclude weight bearing. In many circumstances, institution of (or continuation of) activity can be helpful in controlling edema and facilitating healing. This has been demonstrated in the literature since the early 1920s."
An EPOP also can be used for a transfemoral amputee, says Andrews. Both Andrews and Bowker point out that early weight bearing and mobility are psychologically very important, since amputees realize very early that they can be functional again. For transfemoral amputees, the staff has them walking with a reciprocal gait pattern and partial weight bearing. The knee is locked, "since we don't want shearing over the limb," explains Andrews.
However, Bowker doesn't feel that IPOPs and EPOPs work well for transfemoral or transhumeral amputees, since he believes its important to have the knee or elbow for suspension. He adds, "In between are elbow and knee disarticulations, because they have some bony prominences from which you can suspend the prosthesis."
Vital for Upper-Limb Amputees
Both Bowker and Andrews stress that that IPOPs or EPOPs are especially important for upper-limb amputees. "A lower-limb amputee is going to want to walk anyway," says Bowker. "But if you wait too long to fit an upper-limb amputee with a prosthesis, he's going to learn how to do everything one-handed, and it will be much less likely he'll want to use a prosthesis." The amputee would thus lose some of the advantages of being bimanual. "There's a golden window of opportunity within the first 30 days or so to get an amputee accustomed to using a prosthesis with a terminal device," Bowker notes. And with a bilateral amputee, early prosthetic fitting is essential, since without the prostheses, "he's helpless," says Bowker.
When is an EPOP or an IPOP not a good idea? They are
not indicated if you are dealing with a situation where the
protocol regarding use and care of the wound and the prosthesis is
unlikely to be followed. This noncompliance can be related to the
quality of care the amputee will be receiving, a lack of cognitive
skills on the part of the amputee, and the lack of regular followup
care. For instance, indigent patients may not be able to return
when necessary. Also, another contraindication of use would be when
rehab team members are not knowledgeable about the application and
use of IPOPs and EPOPs.
Bowker also points out that successful IPOP and EPOP use as reported in studies has generally involved amputees in supervised, controlled conditions, such as soldiers undergoing rehab in military centers. "The VA and public hospitals could keep patients as long as they wanted in those days. Amputees could get an IPOP after surgery, get up, and walk on it every day under supervision.
"But nowadays hospital administrators and insurers want patients out five days after amputation," Bowker continues. "You can't closely manage those types of situations. That's why I usually use a cast version without weight bearing, since as soon as they can get around on crutches or a walker, they're out the door. When I first started caring for amputees, I could keep them in rehab for a couple of months."
Decrease in Use?
There is a general perception that IPOPs and EPOPs are currently being used less frequently than in the past, although Robert Brown, CPO, FAAOP, of Flo-Tech O&P Systems Inc., Trumansburg, New York, sees increasing interest in the technique. What contributes to a possible decrease in use? Bowker and Andrews point out that, overall, vascular surgeons rather than orthopedic surgeons are performing the majority of amputations. In general, vascular surgeons are not as familiar and comfortable with using plaster and working with rigid dressings and immediate or early prostheses as orthopedic surgeons, they observe. However, orthopedic surgeons perform the majority of amputation surgeries at Mayo, Andrews adds. Another reason mentioned previously is that prosthetists aren't always available when needed.
The Ideal IPOP
Andrews describes what she would like to see in the future
regarding IPOPs, "Since a prosthetist isn't always available to do
an IPOP, EPOP, or dressing, I'd like to see a system that would be
universally safe to use without technical expertise being
available. It would be easy to put on, customizable, and stretchy
enough to put on without shearing on the residual limb, but then
cling to fit the limb well.
"It would be universal for everyone. If you wanted a pylon cast, you could convert it. It would have supracondylar trimlines, knee locks, and a pylon attachment so that it could be used for weight bearing when desired. But since the pylon attachment is heavy and awkward for transfers or sleeping, you would be able to remove the attachment and the upper cuff, but still have the cast to protect the limb. Socks could be used with it to allow for limb shrinkage and progressive compression. It would be something between an EPOP and a rigid removable dressing."
Needed: More Studies
Although Andrews' ideal postoperative device is not yet
available, she is a firm believer in the benefits of RRDs and
immediate or early postoperative prosthetic fitting. "We need to
get the word out--and we need more evidence-based studies," she
The CSOP findings as reported in the JPO agree with Andrews' view that more studies are needed. The CSOP committee noted, "...the literature and evidence to date are primarily anecdotal and insufficient to support many of the claims made [about the various strategies]. Based on the literature review and the expert opinions presented, the conference participants agreed that it is currently not possible to provide evidence-based protocols or make conclusive evidence-based recommendations for the use of one strategy over another."
The CSOP overview reported in the JPO analyzes what the literature does support:
- Nonremovable rigid dressings result in significantly accelerated rehabilitation times compared with soft gauze dressings;
- Nonremovable rigid dressings result in significantly less edema compared with soft gauze dressings;
- Prefabricated postoperative prosthetic systems were found to have significantly fewer postoperative complications compared with soft gauze dressings; and
- Prefabricated postoperative prosthetic systems lead to few higher-level revisions compared with soft gauze dressings.
The report adds, "No studies directly compared prefabricated
postoperative prosthetic systems with rigid dressings, and no
reports compared all types of dressing within one study.
Standardization of the strategies for postoperative management of
lower-limb amputations and comparative randomized studies is
critical," the CSOP report continues. Although the conference noted
that a thorough examination of all five main strategies is needed,
it zeroed in on the three it regards as of the highest interest:
1) soft dressings, 2) traditional
thigh-level IPOPs made from casting material with a foot
attachment, and 3) prefabricated devices with a
foot attachment designed as a prosthetic system.
What does the future hold for postoperative management strategies, standardized protocols, scientific studies, and better patient outcomes? Although time will tell and much work remains to be done, the road now appears to be outlined and ready to follow.
- Burgess EM,Romero RL: The management of lower extremity amputees using immediate postsurgical prostheses. Clin Orthop 1968;57:137-146.
- Malone JM, Fleming LL, Roberson J et al: Immediate, early, and late postsurgical management of upper limb amputation. J Rehabil Res Dev 1984; 21:33-41.
- Smith DG, Ferguson JR: Transtibial amputations. Clin Orthop Rel Res 1999; 361: 108-115.
- Schon LC, Short K W, Soupiou O et al: Benefits of early prosthetic management of transtibial amputees. Foot Ankle Intl, 2002; 23:509-514.
- Wu Y, Keagy RD, Krick HG et al: An innovative removeable rigid dressing technique for below- the- knee amputation. J Bone Joint Surg 1979; 61: 724-729.
- Bowker JH: The art of prosthesis prescription, in Smith DG, Michael JW, Bowker JH (eds): Atlas of Amputations and Limb Deficiencies. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004, p742.
Editors Note: Results of the Academys Consensus Conference
on Postoperative Management of the Lower Extremity were published
in the March 2004 issue of the JPO. Academy members can access the
article at www.oandp.org/jpo/library/index/2004_03S.asp
The CSOP also provides the basis for the Academys new online learning course on this subject. For more information on the course or to register, go to the Academys website: www.oandp.org