6
Evaluation of a Temporary Prosthetic Insert in the Rehabilitation of Elderly Ischaemic Below-Knee Amputees: A Pilot Study The physiotherapy management of elderly, is- chaem/cbelow knee amputees is often com .. promised by delayedandlorcomplicated wound healing. Such patients are often unable to am.. bulate ana prosthesis for prolonged periods. Problems concommitant with immobilization such as weakness, contractures J and de.creased .morale tend to arise. This . pilot ,study investi- gated the efficacy of incorporating a shaped Dunlopi/lo insert into a temporary prosthetic socket to allow the at risk group to ambulate as soon as the sutures were removed regardless of the state of wound healing. Two parameters were evaluated, namely wound healing and stump maturation. A total of eighteen subjects were observed ina control and an experimental group. Both wound healing (p<O.05) and stump maturation (p < 0.05) were significant/yen- hanced by the inclusion ofa Dunlopillo insert. FIONA MacLEAN HALLAM Fiona M.Hallam, B. Phtyw is a Senior Tutor in the Department of Physiotherapy, University of Queens.. land, 51. Lucia, Queensland GWENDOLENA. JULL Gwendolen A.JuH,M.Phty., Grad. Dip. Manip. Ther., F.A.C.P.,is a Senior Lecturer in the Department of . Physiotherapy. University of Queensland, St. Lucia, Queensland. In Western medical centres approx- imately 80 to 90 per cent . of lower extremity amputees have undergone surgery as a result of peripheral vas- cular disease (Warren 1968, Baum- gartner 1977 ,Molone et 01 1979, Fleu- rant and Alexander 1980). This typically elderly population presents with both age and disease related prob- lems. Early·ambulation post surgery is desirable particularly with elderly pa- tients due to possible complications of deep venous thrombosis, pressure areas, contractures and weaknessaris- ing from prolonged bed rest (Parker 1969). The central limiting factor to earlyambulation is poor or delayed wound healing due to peripheral vas- cular disease (Burgess 1974,Chilvers et of 1971, Horne and Abramowicz 1982). Asa result, a number of dif- ferent forms of post-amputation stump management have been developed to combat this problem. Enhancement of wound healing is the fundamental aim of any treatment regime. According to the approach adopted, immediate t early or delayed ambulation . is encouraged. There are several documented approaches. One ideal post amputation approach is con- sidered to be the intra-operative appli- cation of a rigid dressing with or with- out attachment of a pylon. The rigid plaster cast limits formation of oedema thereby enhancing wound healing. Ad- ditionallyphantom and stump pain ap- pear to be lessened (Vitali and Redhead 1967). The worth of .this rehabilitative approach has been proven in extensive clinical and laboratory trials (Burgess and Romano 1968, Berlemont etaf 1969, Burgess andZettl 1969, Condon and Jordan 1969 tBurgess et of 1971 t Baker et af 1977 tReyeset of 1977 t Roonet of 1977, Fleurant and Alex- ander 1980 t Mueller 1982). However there are.several limitations to its wide- spread use. The regime requires twenty- four hoursurveillenceby skilled staff to ensure its safe and effective use (Cohenet of 1974). In most centres, staffing and expertise limit its feasibil ity.Wound infection and ischaemic breakdown are difficult to manage in less than ideal conditions with the rigid dressing technique (Ghiulamila 1972). Therefore alternative forms of post- surgical stump management were de- veloped in an attempt to combat wound infection and dehiscence. A number of different semi rigid dressings were de- veloped and trialled (Little 1970 and 1971 t Ghiulamila 1972, Little et a11972, La Forest and Walsh Regan 1973, Lit- tie 1973, Rossi 1974, Sher 1974t Ster- escu 1974 t Dowie 1975, Fish 1976, Bonner and Green 1982Jw Thesecom prise of "Unna' paste dressings t pneu- matic splints and plastic shrink film technique. These semi-rigid dressings are thought to limit oedema.and pre- venthaematoma formation due to their inextensible nature. Research .into the effectiveness of these approaches is limited; the trials are small. A further technique with similar aims is Controlled Environment Treatment (Kegal 1976 t Burgess 1978, Redhead and Snowden ·1978). This isa unique dressing in that it provides the stump with a sterile environment withregu- lation of humidity, temperature and pressure. This is delivered through a one way air consul via a plastic bag. Although wound healing appears to be facilitated t the apparatus is cumber- some and noisy, and prospects of early amhulation are limited. The most conservative approach to the post-amputation stump involves the use of soft dressings. Immediately after removal of the limb, a bulky soft dress- ing .is applied (Russek 1961). This is said to afford little more than a degree of hygiene and protection to the stump. Oedema formation is not limited and the benefits to wound healing are du- bious (Burgess 1982). When the sutures The Australian Journal· of Physiotherapy. Vol. 34, No.3, 1988 133

Evaluation of a Temporary Prosthetic Insert in the Rehabilitation of Elderly Ischaemic Below-Knee Amputees: A Pilot Study

Embed Size (px)

Citation preview

Evaluation of a Temporary Prosthetic Insert in theRehabilitation of Elderly Ischaemic Below-KneeAmputees: A Pilot Study

The physiotherapy management of elderly, is­chaem/cbelow knee amputees is often com..promised by delayedandlorcomplicated woundhealing. Such patients are often unable to am..bulate ana prosthesis for prolonged periods.Problems concommitant with immobilizationsuch as weakness, contracturesJ and de.creased

.morale tend to arise. This .pilot ,study investi­gated the efficacy of incorporating a shapedDunlopi/lo insert into a temporary prostheticsocket to allow the at risk group to ambulateas soon as the sutures were removed regardlessof the state of wound healing. Two parameterswere evaluated, namely wound healing andstump maturation. A total of eighteen subjectswere observed ina control and an experimentalgroup. Both wound healing (p<O.05) and stumpmaturation (p < 0.05) were significant/yen­hanced by the inclusion ofa Dunlopillo insert.

FIONA MacLEAN HALLAM

Fiona M.Hallam, B. Phtyw is a Senior Tutor in theDepartment of Physiotherapy, University of Queens..land, 51. Lucia, Queensland

GWENDOLENA. JULL

Gwendolen A.JuH,M.Phty., Grad. Dip. Manip. Ther.,F.A.C.P.,is a Senior Lecturer in the Department of .Physiotherapy. University of Queensland, St. Lucia,Queensland.

In Western medical centres approx­imately 80 to 90 per cent .of lowerextremity amputees have undergonesurgery as a result of peripheral vas­cular disease (Warren 1968, Baum­gartner 1977,Molone et 01 1979, Fleu­rant and Alexander 1980). Thistypically elderly population presentswith both age and disease related prob­lems. Early· ambulation post surgery isdesirable particularly with elderly pa­tients due to possible complications ofdeep venous thrombosis, pressureareas, contractures and weaknessaris­ing from prolonged bed rest (Parker1969). The central limiting factor toearlyambulation is poor or delayedwound healing due to peripheral vas­cular disease (Burgess 1974,Chilverset of 1971, Horne and Abramowicz1982). Asa result, a number of dif­ferent forms of post-amputation stumpmanagement have been developed tocombat this problem.

Enhancement of wound healing isthe fundamental aim of any treatmentregime. According to the approachadopted, immediatet early or delayedambulation .is encouraged. There areseveral documented approaches. Oneideal post amputation approach is con­sidered to be the intra-operative appli­cation of a rigid dressing with or with-

out attachment of a pylon. The rigidplaster cast limits formation of oedemathereby enhancing wound healing. Ad­ditionallyphantom and stump pain ap­pear to be lessened (Vitali and Redhead1967). The worth of .this rehabilitativeapproach has been proven in extensiveclinical and laboratory trials (Burgessand Romano 1968, Berlemont etaf1969, Burgess andZettl 1969, Condonand Jordan 1969tBurgess et of 1971 tBaker et af 1977tReyeset of 1977t~Roonet of 1977, Fleurant and Alex­ander 1980t Mueller 1982). Howeverthere are. several limitations to its wide­spread use. The regime requires twenty­four hoursurveillenceby skilled staffto ensure its safe and effective use(Cohenet of 1974). In most centres,staffing and expertise limit its feasibil~

ity.Wound infection and ischaemicbreakdown are difficult to manage inless than ideal conditions with the rigiddressing technique (Ghiulamila 1972).Therefore alternative forms of post­surgical stump management were de­veloped in an attempt to combat woundinfection and dehiscence. A number ofdifferent semi~rigid dressings were de­veloped and trialled (Little 1970 and1971 t Ghiulamila 1972, Little et a11972,La Forest and Walsh Regan 1973, Lit­tie 1973, Rossi 1974, Sher 1974t Ster-

escu 1974t Dowie 1975, Fish 1976,Bonner and Green 1982Jw Thesecom~

prise of "Unna' paste dressingst pneu­matic splints and plastic shrink filmtechnique. These semi-rigid dressingsare thought to limit oedema.and pre­venthaematoma formation due to theirinextensible nature. Research .into theeffectiveness of these approaches islimited; the trials are small.

A further technique with similar aimsis Controlled Environment Treatment(Kegal 1976t Burgess 1978, Redheadand Snowden ·1978). This isa uniquedressing in that it provides the stumpwith a sterile environment withregu­lation of humidity, temperature andpressure. This is delivered through aone way air consul via a plastic bag.Although wound healing appears to befacilitated t the apparatus is cumber­some and noisy, and prospects of earlyamhulation are limited.

The most conservative approach tothe post-amputation stump involves theuse of soft dressings. Immediately afterremoval of the limb, a bulky soft dress­ing .is applied (Russek 1961). This issaid to afford little more than a degreeof hygiene and protection to the stump.Oedema formation is not limited andthe benefits to wound healing are du­bious (Burgess 1982). When the sutures

The Australian Journal· of Physiotherapy. Vol. 34, No.3, 1988 133

Evaluation of a Temporary Prosthetic Insert

Amputee Status

were managed conventionally only afterwound healing was complete.

Table 1:Subject characteristics

SubjectsThe eighteen subjects included in this

study were drawn from patients whohad undergone a below-knee amputa­tion at the Repatriation General Hos­pital, Greenslopes, Brisbane. Patientsof both genders were included if theywere over the age of sixtY,sufferedperipheral vascular disease of diabeticor non diabetic origin,and had under­gone long posteriormyoplastic flapsurgical technique of amputation. Bothunilateral and bilateral amputees wereincluded in the study.

Many studies have been undertakento assess the efficacy of different formsof post amputation stump managementand inmost instances very few inclu­sion/exclusion criteria were observed(Vitali and Redhead 1967, .Burgess andRomano 1968, Burgess and Zettl 1969,Reyes et a/1977, Roon et a/.1977,Wuel a11979, Fleurant and Alexander1980). As a large percentage of lowerextremityamputeessuffer frompe­ripheral vascular disease and becausethese patients are most likely to en­counter wound healing delays it is mostappropriate to observe adysvascular

. population when evaluating post-am­putation stump management (Bucknelland Ellis 1984, Westaby 1985).

There were nine subjects in the ex­perimental group who were managedwith the Dunlopillo insert. The sourceof the control subjects was amputee

36

Peripheral VascularDisease

Diabetic Non-Diabetic6 3

2

Bilateral2

patients who had previously receivedthe· standard pre- and post-operativetreatment only. They entered the con­trol group by matching experimentalgroup patients on the criteria of age,amputee status and the nature of theirperipheral vascular disease (Table 1).

ApparatusThe temporary prosthesis consisted

ofa plaster socket, Otto Bock com­ponentsand attachments, a S.A.C.H.foot and patella .cuff suspension. Theprostheses were manufactured by theone physiotherapist responsible foreachsubjeet group. Comprehensivetraining in prosthetic manufacture, fitand alignment ensured good qualitycontroL The apparatus used was thesame for both groups of subjects. Theonly differentiating feature was theDunlopillo insert. This Dunlopillo in­sert was manufactured according to in­dividualstump dimensions. It wasmade from compressible foam rubb~r

and was seven centimetres in depth.The segment of Dunlopillo was shapedinto a hemisphere on a belt sander andthen partially hollowed out to surroundand accommodate stump tissue (Figure1). The insert was applied to the stumpwith approximately 50070 compressionduring socket manufacture. When thecast was removed the Dunlopillo re­gained its normal size and density (Fig­ure 2). Therefore total stump contactwas assured during ambulation. Acompression-release action occurredrespectively through stance and swingphases. This was aimed to simulate the

7

Unilateral7

Age

Control 72.67 ± 6.1(N = 9)

Experi- 71.67 ± 8.5mental(N = 9)

are removed, elastic compression band­aging or shrinker sock application isused in an attempt to shape the stumpand to limit oedema (May 1965,Vargheseet at 1980). In contrast to therigid dressing regime, this conventionalapproach is .considered to divorce thepatient from sensory and propioceptiveinput (Freidman 1971 ).Furthermorerehabilitation is comparatively pro­longed due to delayed patient ambu­lation.

Asa result of dissatisfaction withboth the rigid cast and conventionalsoft dressing regimes, a compromisewas suggested. This intermediate ap­proach employs the soft dressing inconjunction with early temporary pros­theticintervention (Staros 1959, Bugeletal 1959,Russek 1961, Record 1963,Tosberg 1965, Anderson etal 1966,Parker 1969, Crossland 1974, Sullivanand Tucker 1974, Giaccone and Cohen1975, Jamieson and Hill 1976, Jones1977,McDougall and Emmerson 1977,Katracand Baggott 1980 and Callen1981). Friedman (1971) claims that ifthe patient is mobilised on a temporaryprosthesis on the day the sutures areremoved, the entire rehabilitation pro­gram should take only two weeks longerthan it does using intra-operative ap.,.plication of the rigid dressing.

Wouud healing has again been thelimitation to early prosthetic interven­tion with the intermediate approach.For this reason it was proposed thatthe inclusionofa shaped Dunlopilloinsert into the socket of the interimprosthesis would afford both protec­tion and support to the stump by pro­viding gentle total contact within theinterim socket. The purpose of thispilot study was to determine whetherearly ambulation on a temporary pros­thesis using a Dunlopillo insert influ­enced wound healing and/or stumpmaturation·inthe at risk group,namely

.an elderly population of patients withbelow knee amputation resulting fromperipheral vascular disease. Resultsfrom this experimental group werecompared with a control group who

134 The Australian Journal of Physiotherapy. Vol. 34, No.3, 1988

Evaluation of a Temporary Prosthetic Insert

Figure 3: The lpull Through' method of prosthesis application

therapy management. Immediatelyafter removal of the limb during sur­gery a bulky soft dressing was appliedto the stump. Standard early post op­erative treatment was administered toall patients including chest manage­ment, positioning and exercise pro­grammes. The intra-operatively ap-

MethodBoth groups of patients received rou­

tine pre- and post-operative physio-

Figure 2: Superior view of a temporary socket with theincorporated insert

when otherwise it would not have beenpossible for them to don the prosthesislet alone embark on a gait programmeat such an early stage.

normal muscle pump activity of walk­ing. Although a number of authoritiessuggest the use of a distal insert in theinterim socket, none discuss how theinsert was applied nor do they reportany objective findings (Staros 1965,Crossland 1974, Mc Dougall and Em­merson 1977).

In some instances it was necessaryto modify the temporary prostheses topermit early intervention with walkingtraining. This was because the ampu­tation stumps were not shaped withcompression dressings until the sutureswere removed. Therefore the problemarose that the stump was typically bul­bous and oedematous distally. Thisprecluded donning of the prosthesis;the analogy being that it was like re­fitting a champagne cork back into thebottle.

The prosthesis was modified by cut­ting a hole in the distal end of thesocket. A length of string was attachedto the closed end of a woollen sockand then the sock was applied to thestump. A pull through method of pros­thetic applicaton, similar to one sug­gested by La Forest and Walsh Regan(1973), was employed. Thus the distalbulk of soft tissue was drawn throughthe relatively narrow socket inlet (Fig­ure 3). This enabled a number of thesubjects to be included in this study

The Australian Journal of Physiotherapy. Vol. 34, No.3, 1988 135

Evaluation of a Temporary Prosthetic Insert

Table 2:Number of days from amputation to wound healing and stump maturation

Wound Healing (Days) Stump Maturation (Days)Control Experimental Control Experimental

1 237 28 371 962 34 36 109 973 44 63 157 1014 161 38 217 545 11 48 178 536 38 19 80 567 88 34 122 898 57 30 111 889 42 70 100 112

85.78 ± 69.1 40.66 ± 16w69 160.5 ± 89.8 82.89 ± 22.53

plied soft dressing remained in placeuntil the sutures were removedw Thisoccurred betwen fourteen and twenty­one days post-amputationw Thereafternursing staff swabbed and dressed thewound twice a day to ensUre hygieneand sterility. All subjects were intro­duced to gentle elastic compressionbandaging when sutures were removedto initiate the processes of stump shap-ing and shrinkagewIndividually de...signed exercise programmes were per...formed twice a day by all patientsw

Control subjects were not prescribeda temporary prosthesis until woundhealing was completew In contrast theexperimental subjects were cast fortemporary prosthesis on the day of su­ture removal regardless of whether ornot wound healing was completew Theprinciples of gait training were appliedsimilarly for bothgro-ups~Onephysl(l ...therapist was responsible for ·tehabili­tation of control subjects. Thoroughdocumentation of the gait training pro~

cedure allowed the same gait principlesto be applied in the experimental group.

The data collected was the numberof days from amputation to woundhealingw Wound healing was defined ascompletet pink, epithelial bridging ofthe suture linew Hospital records docu...mented wound healing progression ofcontrol subjects.

Additionally the number of daysfrom amputation to prescription of thedefinitive prosthesis was documentedfor the eighteen patients. This infor­mation was used to evaluate processesof stump maturation, namely pla­teaued stump shrinkage, shaping andcompletion of wound healing. This wasso because permanent limb prescrip...tion is directed by stump maturity. Allpatients were prescribed their definitivelimb by the one consulting physicianwho based her decisions on a standardset of criteria which included weeklydocumentation of stump measure­ments. The physician was unable to beprejudiced in her judgement as she wasunaware of which patients were in­cluded in the study.

ResultsThe data were compiled for both the

control and experImental groups withrespect to the number of days elapsingbetween amputation and wound heal­ing and amputation and prescriptionof a definitive prosthesis (Table 2). Theresults revealed that for the experi­mental group, wound healing occurredin 40.66 ± 16.69 days and a definitiveprosthesis Was prescribed in 85.78 ±69w 1 days. The results for the controlgroup were 82.89 ± 22.53 days and160.5 ± 89w8 days respectively.

The Mann...Whitney U non-parame­tric test was used to demonstratewhether the observed differences be­tween the groups were significant Thisform of statistical analysis was chosenbecause of the small sample size andbecause of the obvious variance of thetwo groups. AdditioIiallYt it is oIle ofthe most powerful of the non-para­metric tests;

the analyses dernonstrate that bothwound healing(p < 0.05) and stumpmaturation (p<O.05) were significantlyenhanced by the experimental proce"dure~

DisCUssionRehabilitation of the lower extremity

,amputee is often thwarted ·by poorwound .healing and lor delayed proc-

esses of stump maturation (Chilvers etat 1971 t Burgess 1974t Boontje 1980tHorne and Abramowicz 1982). Woundhealing is of paramount importance inamputation surgery, particularly whendealing with a dysvascular population.Failure of wound healing may resultin either re-amputation at a higher levelor delayed rehabilitation with the con­cummitant problems of prolonged im­mobilizationw Additionally, the enor­mous cost of hospitalization in theselong stay patients must be considered(Sullivan and Tucker 1974).

The results of this study indicate thatearly prosthetic intervention using theDunlopillo insert significantly reducedthe time taken for the stump to healin a compromised population (controlgroup mean = 85.78 days; experimen­tal group mean = 40.67 days)w

By incorporating the shaped Dun...lopillo insert into the interimsockett agentle positive support is given to thestump during walking. The resultantcompression""release phenomena whichoccurs respectively through stance andswing phases is proposed to act as analternative to normal musclepulllpac­tivity.Venous return would be en""hanced and as aresult circulatory stasisand oederna forrnationavoided.

The processes of stump maturationwere also significantly enhanced by

136 The Australian Journal of Physiotherapy. Vol. 34, No.3, 1988

Evaluation of a Temporary Prosthetic Insert

early prosthetic intervention using aDunlopillo insert (p <0.05). The inclu­sion of the Dunlopillo insert allowedthe experimental subjects to walk on atemporary limb within 14 to 24 daysof surgery whether or not the woundwas healed. In contrast, the controlpatients did not ambulate on a pros­thesis until wound healing was com­plete ..As a result their gait training wasdelayed, the period of delay rangingfrom 34 days to 237 days (Mean delay= 86 days).

There are several possible reasonsfor the difference in stump maturationtimes between the two groups. For ex­ample the control patients mobilizedon crutches or walking frames until thetemporary prosthesis was prescribed.Thus the stump was held in a depen­dant state for prolonged periods of timeand the resultant venous congestionwith persistance of oedema may ·havecontributed to inferior stump matura­tion in these patients. In contrast, ex­perimental patients were subjected tofirm total stump contact from an earlystage. It is postulated that, as a·result,both the rates of stump shaping theshrinking were escalated. Firm totalcontact was ensured by applying theinsert with compression; by utilizingthe pull through method of socket ap­plication and by accommodating tostump shrinkage by using increasingnumbers of stump socks under theprosthesis. Additionally, the proposedcompression-release effect provided bythe insert during ambulation would as­sist in reduction of oedema.

This pilot study was undertaken toinvestigate an alternative approach tomanagement of the difficult problemof amputation in a dysvascular popu-­lation. It is recognized that there aremany inherent variables in such apopulation which may affect outcome.This fact together with the size of thesubject groups in this study places con­straints on the significance of resultswHowever positive trends have been re­vealed which encourage further re­search into the use of the simple Dun­lopillo insert.

ConclusionThe elderly ischaemic below-knee

amputee is fraught with age and diseaserelated problems which profoundlylimit his rehabilitation potentiaLCli­nicians are presented with the dilemmaof poor wound healing and a concom­mitantdelay in ambulation. It is pro­posed that these problems result in in­creased patient morbidity and lengthy,expensive hospital stays. Preliminaryresults suggest that early temporaryprosthetic intervention using a Dun­lopillo insert may provide an inexpen­sive, safe and effective alternative so­lution to this problem. The simplicityof this regime is surprising when theenormity of the problem is considered.

ReferencesAnderson AD, Levine SA and Colmer M (1966),

The temporary walking device for the mobili­zation of the elderly amputee, Geriatrics, 21,186~188.

Baker WH, Barnes RW and Shurr DG (1977),The healing of below knee amputations, TheAmerican Journal ofSurgery, 133(16), 716-718.

Baumgartner R(l977), Leg amputation due todefective arterial circulation, Prosthetics andOrthotics International 1, 5-7.

BerlemontM, Weber Rand WiUot JP (1969), Tenyears of experience with the immediateappli­cation of prosthetic devices to amputees of thelower extremities on the operating table, Pros­thetics International, 3: 8-18.

Bonner FJand Green RF (1982), Pneumatic.airlegprosthesis; report of 200 cases, Archives ofPhysical Medicine and Rehabilitation,·63(8),383­385.

BoontjeAH (l980), Major amputations of thelower extremity for vascular disease, Prostheticsand Orthotics International, 4, 87~88.

Bucknell TE and Ellis H (1984), Wound healingfor surgeons, Bailliere Tindall, England, 55-58.

Bugel HJ, Zilmer W and Grigsby J (1959), Ad..vantages of intermediate prosthesis in the reha­bilitation of the lower extremity amputee: Apreliminary report, Archives of Physical Med­icine and Rehabilitation, 39,28-35.

Burgess EM and Romano RL (1968), The man­agementof lower extremity amputees using im",mediate post--:surgical prosthesis, Clinical Or­thopaedicsand Related Research, 57, 137-146.

Burgess EM and Zettl JH (1969), Amputationbelow the knee, Artificial Limb, 13(1), 1-12.

Burgess EM, Romano RL, Zettl JH and SchrockRO (Jnr) (1971), Amputation of the leg forperipheral vascular insufficiency, The Journalof Bone and Joint Surgery 53A(5), 874-890.

Burgess EM (1974), Wound healing, Bulletin ofProsthetics Research, Fall, 109, 113-114.

Burgess EM (1978), Wound healing after Ampu­tation: Effect of controlled environment treat..ment, The Journal of Bone and Joint Surgery60A(2), 245-246.

Burgess EM (1982), Rehabilitation ManagementofAmputees, edited by BannerjeeSN, Williamsand Wilkins, Baltimore, London, 190",193.

Callen S (1981), Hexcellite temporary prothesesfor lower limb amputees, Physiotherapy, 67(5),138-139.

Chilvers AS, Briggs J,. Browse NC and VinmonthJB (1971), Below and throughknee amputationsin ischaemic disease, British Journal ofSurgery,58(11), 824-826.

CohenSI, Goldman LD, Salzman EWandGlotzerDJ (1974), The deleterious effect of immediatepost operative prostheses in below-knee ampu­tation for ischaemic disease, Surgery, 76(6),992­1001.

Condon ER and Jordan PH (Jnr) (1969), 1m..mediate post operative prostheses in vascularamputations, Annals of Surgery, 170(3), 435~

447.Crossland S (1974), Rehabilitations of the below",

knee amputee using the pre-formed socket ,Physiotherapy, 60(2), 50-51.

Dowie AD (1975), Amputation stump manage­ment: A preliminary report of the use of shrinkplastic film asa surgical dressing in amputationsurgery, The Medical Journal of Australia, 2,127-129.

Fish SL (l976),Semirigid dressing for stumpshrinking,Physical Therapy, 56, 137.

FleurantWand Alexander J (1980), Below~kneeamputation and rehabilitation of amputees, Sur­gery,Gynaecology and Obstetrics, 151,(7), 41­44.

Friedman LW (1971), The indications for the mod",ern m~nagement of conventional amputation,Talk before the American College ofAngiology,Vascular Surgery,S, 36-41.

Ghiulamila RI·(l972), Semi-rigid dressing for post­operative fitting ofbelow-knee prostheses; Pros­thetics, Orthotics and Devices, 4, 186-190.

GiacconeMA and Cohen M (1975), Modificationsof the. temporary below knee prosthesis, Phys~

ical Therapy 55(5), 508,,510.Horne G and Abramowicz J(1982), The man­

agement of healing problems in the dysvascularamputee, Prosthetics and Orthotics In terna­tional,6, 38",40.

Jamieson CW and HillD (1976), Amputation forvascular disease, British Journal ofSurgery, 63,683~690.

Jones RF (1977), Amputee rehabilitation: Basicprinciples in prosthetic assessment and fitting,The Medical Journal of Australia, 2, 290-293.

Katrac PH and Baggott JB (1980), Rehabilitationofeldedy lower extremity -amputees, The Med­ical Journal of Australia, 6, 651-653.

Kegel NT (1976), Controlled environment treat­ment (C.E.T.) for patients with below-knee am­putations; Physical Therapy, 56(12), 1366-1371.

LaForest NT and Walsh Regan L (1973), Thephysical therapy program after an immediatesemi~rigid dressing and temporary below-kneeprosthesis, Physical Therapy 53(5), 497-501.

Little JM (1970), The use of air splints as im"'mediate prostheses after below-knee amputationfor vascular insufficiency, The Medical Journalof Australia, 11, 870-827.

Little JM (1971), A pneumatic weight bearingprosthesis for below-knee amputees, The Lan­cet, 2, 271-273.

Little JM, Gosling L and Weeks A (1972), Ex­perience With a pneumatic lower Iimb>prosthesis,The Medical Journal ofAustralia,6,1300-1302~

The AustraHan Journal of Physiotherapy. Vol. 34, No.3; 1988 137

Evaluation of a Temporary Prosthetic Insert

Little JM (1973), Amputation ofthe leg - A dulltopic revisited, The Medical Journal of A us­tralia,9,442-445.

McDougall A.andEmmersonA (1977), The pre­formed socket and modular assembly for pri'­mary amputees, The Journal ofBone and JointSurgery, 59B(l), 77-79.

Malone JM,MooreWS, Goldstone J and Malone8J (1979), Therapeutic and economic impact ofa modern amputation program, Anna/sof Sur­gery, 189(6), 798.;802.

May MJ (1965), Stump bandaging of lower ex­tremityamputee, Orthopaedic and ProstheticAppliance Journal, 6, 145-153.

Mueller MJ(l982), Comparison of removable rigiddressings and elastic bandages in pre-prostheticmanagement of patients with below-knee am­putations, Physical Therapy, 62(10), 1438-1441.

Parker OD (1969), Evaluating the temporary py­lon and permanent prosthesis ina rehabilitationamputee clinic, Artificial Limbs, 13(2),43-45.

Record EE (1963), Surgical amputation in thegeriatric patient, The Journal ofBoneandJointSurgery 43B(8), 1742-1749.

Redhead RG and Snowdon C (1978), Anew ap­proach to the management of wounds of theextremities. ·Controlled environment treatment

and its derivatives, Prosthetics and OrthoticsInternational, 2, 148-156.

Reyes L, Leahey EBandLeaheyEB (Jnr) (1977),Elderly patients with lower extremity amputa­tions: 3 year study in a rehabilitation setting,Archives of Physical Medicine and Rehabilita­tion, 58(3), 116-122.

Roon AJ,Moore WS and Goldstone T (1977),Below-knee amputation: .,.- A modern ap­proach, The American Journal of Surgery134(7), 153-158.

Rossi LFA (1974), Rehabilitation following below­knee amputation, Proceedings of the Royal So­cietyof Medicine, 67(11), 37-38.

Russek AS (l961), Management oflower extremityamputees, Archives of Physical Medicine andRehabilitation, 10, 687.;703.

Sher MD (1974), The air splint. An alternative tothe immediate post-operative prosthesis, Ar­chives of Surgery, 108, 746-747.

Staros A (1965), Prosthetic considerations for thegeriatric amputee, Prosthetics International, 2(4­5), 15-29.

Sterescu LE (1974), Semi rigid (Unna) dressing ofamputations, Archives ofPhysical Medicine anRehabilitation,55(19), 434-443.

Sullivan RA and Tucker J (1974), Amputee man­agement using a fitted temporary prosthesis,Archives of Physical Medicine and Rehabilita.,.tion, 55(9), 409-412.

TosbergWA (1965), Temporary prostheses, Or.,.thopaedic and Prosthetic Appliance Journal, 6,142.,144.

Varghese G,Hindle P, ZilberS, Perry J andRedford J (1980), Pressure applied by elasticprosthetic bandages: Acompartive study,American Congress ofRehabilitation Medicine,10,30.,.36.

Vitali M and Redhead RG (l967), The modernconcept of the general management of amputeerehabilitation indudingimmediatetive fitting, Annals of the Royal College ojSurgeons· of England, 251-260.

WarrenR (1968), Early rehabilitation of the el­derly lower extremity amputee, Surgical Clinicsof North America, 48(4), 807-'817.

Westaby, S. (1985), Wound Care, William Hei­nemann Medical Books Ltd., London, 17-21.

WU Y, Keagy Rd, Krick HJ, 8tratigos JSandBettsHB (1979), An innovative removable rigiddressing technique for below the knee ampu­tation, The Journal oj Bone and Joint Surgery,61A(5), 724-729.

138 The Australian Journal of Physiotherapy. Vol. 341 No.3, 1988