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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.
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