TR 1<>-<> 1 AUGUST 1969 the MANAGEMENT of LOWER-EXTREMITY AMPUTATIONS Surgery Immediate Postsurgical Prosthetic fitting Patient Care • fRNEST .M. !JURGESS, M.D., Principal Investigator ROBERT L ROMANO, M.D., Associate lnv.stlgator JOSEPH H. ZEJTL, C.P., Director Prosthetics Research Study Seattle, Washington This publfeatiClO wu !ffijp>~red fQ!' the Pmtittletlc ¥td Sensory Aids $t!MC6 VeteraN> Adminlstnttoo undet"tne teor>$ of Cootraet No. V526JP-438 f'ar tal~ by ft!e Svperlrotendent of DIKIItMOU, U.S. Ooven'lment Pf'hffing Offtce WoJtllngtQn, O.C, 2()402 ·Price $LS0 FOREWORD &nne two years ago I had the pleasure of writing a wish to undertake thC!JC procedura There must be foreword to the puhlkatimr, "Immediate Post>.urgi<:al a.'! effective relationship among tl•e several disciplines Prosthetics in tl1e Manage.rnent of Lower l:.xmmity nmcerned with amputee rehabilitation; the tontribu~ Amputees," under the authonhlp of Durgcstl, Traub, tions of trained prosthetisU are particularly desirable. and WilroJl. That handbook, publitbcd in 1967 artd Finally, and perhaps of most importance, the respon­ rold hy the Superintendent of Docwnents~ has bren ex" sibility of the surgt'~n cannot end with the skinful and .::cedingly well recr:ivcd. The demand for that publi­ meticulous ampubtiou of a limb, He rnm>t follow th<' cation i& indicative of the interest ilio;vn by clinicians progress oi his patient at least until optimum rehabili­ in thest". relatively new procr:dures, Undoubtedly, th~~ tation is achieved. tle'.'ll publication, reflecttng the additional c:.>pericnce It is heartening that many groups, both in the Vet· and insight~ gained by the Prosthetks Research Study erans Administration and in the medical community itt Seattle, funded through the VA Hospital in Seattle, generally, have been suceeSJ>futly using immediate and will have a still greater impact on dinica! prac~ice. early po-stsurgical prosthetic fitting techniques. The This new monograph is much more comprehensive Committee on Pwsthetics Research and Development, .·: than its predecessor. A "how lo do it" approach is National Research Council, has been very helpful in utilized for all the sequences involved. Illustrations are facilitating the exchange of research and clinical in­ abundantly used to facilitate the reader's unders-tand+ fonnation on this as well a~ many o!her prosthetics ing of the various procedures described. The decision problems. The specialized cout-sos at tlw three univer~ of the authors to repeat certain sequences in each of sities with prosthetics education programs have made the <-hapten; dealing with the various levels of ampu­ it possible for clinicians to at:quire systematic instruc~ tatiom eliminates the need for the reader to rvfer ton~ tion in these procedures, This :w:w publication should stantly to di:fi'erent parts of tho book. Each chapter ean serve as a reference source in the same manner as did thus serve as a ready refen::n<:e for a given le ..-d of the April 1967 manuaL amputation. We know that a _great amount of eflort on the part A \\'"ell~described and illustrated presentation on im­ of the Seattle Prosthetics Research Stvdy went into the mediate postsurgical prosthetic~ mar.agemcm is ob­ preparation of this book. Our sincere appreciation g-oe;; viom;ly not enough to aASure that thr amputee derives not only to Dr. Ernest M- Eurgt;"SS, Dr, Robert L Ro­ the maximum advantages whkh th<::K tcthn!qun; ran mano, Mr. Joseph H. Zettl, and UH~it eotlcagtt-e! of afford. As Dr. Burge~ statesl the procedures are not the Prosthetics Research Study1 but to the Dinxtor technically <.liffirah, but pr(x)sion is e=ntial. Though and his staff of the VA Hospital ln Seattle. rome-what difftTent techniques fmmerly used by the Seattle grot~p or other methods employed by other groups in this country or ahf<:).;jd have achieved gratify­ ing sw:ecss, the refineU procedures described in this ROBERT E. STEWART, D.D$. book have been found to be highly effeetixe if followed Director \\--lthoot deviation. Prosthetic and Scm-ory Aids Service Partieipation in one of the trnin.ing programs now Department of Medidne and Surgery offered at New York t:'nivC-tSity, UCLA, and !\orth­ Veterans AdminUltr:a.tiou wcstern L'niversity h recommended for clinicians who Washington, D.C. PREFACE Widespread and growing interest in amputation prosthetic management in amputee rehahil.itation jus. surgery and substam.ial imptm't"ment in the I~iate tify the high hopes of its proponents. Pmtsurgi<al Prosthetic Fitting technique prompt the The method is not tedmkally difficult, but it is p1c­ preparation of a major revised manual less than two cise. The stakes to the amputee are high, lt is neces­ years after its first appearance. Reports from thro11gh­ sary to undemand and correctly apply each stage of out the world now indude an expefl(;nce numbering care if the full potential for improved amputee reha­ ~ral th0U'i13nd cases. Although widely varying de'" hilitatioo is to be realized, grees of sucrcss are bf<.ing recotdcd, the- technique t:on­ We have attemptcd to outline specifically each as­ tinues to gain rapid acceptance, pect of this care, Careful attention to detail wiU be The additional knowle-dge gained from analyst,_ of rev.rarded by prompt and maximum restoration of accumulating experience together with the greater function. understanding gleaned from the very high number of successful cases and indeed from the relatively few failures has stimulated the preparation of this new book The many advantages. of immediate postsurgical ERNEST M. BtJRGESS1 M.D. v ACKNOWLEDGMENTS c The authors would like to express their grateful Scientific Illustrator, all from the VA Prosthetics appreciation to the following persons who have con­ Center in New York City, are gratefully acknowledged. tributed significantly to the preparation and final Gratitude is also expressed to Joseph E. Traub, Con­ production of this manual: Shirley M. Forsgren, Ad­ sultant, Prosthetics and Orthotics, Social and Rehabili­ ministrative Assistant; Robert D. Schrock, Jr., M.D., tation Service and to A. Bennett Wilson, Jr., Executive Fellow in Prosthetic Research; Connie E. Torget, Sta­ Director, Committee on Prosthetics Research and De­ tistical Coordinator; and Marlyn Jake Gardner, Re­ velopment, for their previous contributions in the search Prosthetist, all from the Prosthetics Research writing of "Immediate Postsurgical Prosthetics in the Study in Seattle. Also, our appreciation for editorial Management of Lower Extremity Amputees." Above work and printing preparation is extended to William all, the support and encouragement of Dr. Robert E. M. Bernstock, Assistant Chief, and Rhoda Beiser, Stewart, Director, Prosthetic and Sensory Aids Service, Writer-Editor of the Research and Development Divi­ have been a continuing source of inspiration. sion, Prosthetic and Sensory Aids Service, New York City. In addition, the contributions and efforts of Anthony Staros, Director; Dr. Edward Peizer, Chief, E. M. Burgess Bioengineering Research Service; William J. Romahn, R. L. Romano Jr., Visual Aids Specialist; and Phillip S. Carson, J. H. Zettl VI CONTENTS FOREWORD, Dr. Raben E. Stewart._ on­ PREFACE, Dr. Ernest M. Burgess. v !ili­ ACKNOWLEDGMENTS. vi ive :Je­ tlre CHAPTER 1 THE PRS MANAGEMENT OF AMPUTATIONS .. the I. History and Rationale_ I we A. Wound Healing .... 2 E. B. Ambu1ation ... 5 .cc, C. Su.gical Technique and Level of Amputation, . 5 D . .'Psychologicat ..... 5 lL General Principles .. 5 A. Level Determination ... s n. Surgery ..... 7 C. MUScle Stabilization, . 7 D. Special Considerations, .. 7 IlL Preoperative Preparation of the Patient .... 12 CHAPTER 2 THE BELOW-KNEE AMPUTATION ... 13 L Preoperative Instructions to the Prosthetist ... 13 IL Preoperative Preparations by the Prosthetist of Materials and Cbmponentl'L .... 14 III. The Below-Knee Amputation Surgery. ..... 16 A. Tlw Preparation. ............ 16 B. The Operative Plan ........ l7 C. The tndsion... ..... 17 D. The Amputation .. 17 E. The Posterior Mu51;le Flap ... , .. 18 F. Myodesis or Myoplasty ........ 18 G. The Skin Closure ..... 18 IV. The Below-Knctl Immediate Postsurgical Pro<;ihesis. 24 A Application of Felt (or Polyurethane) Pressure Relief Pads:. ...... 24 B. Application of the Rigid Dressing ....... 27 C. Application of the Prosthetic CniL. _ 33 D. Below-Knee Prog,thetk Cous.lderatlons. 38 vii --! Pug< CHAPTER 3 THE ABOVE-KNEE AND KNEE-DISARTICULATION AMPUTATIONS . ............... 4{) L Preoperative Instructions to the Prosthe.tist., .. , .. , .. 40 IL Preoperative Preparations by the Prosthetist of Materials and Components._ 4{) Ill. The Above-Knee Amputation Surgery,,,., . .......... 45 IV, The KneewDisartkulation Surgery. ..... 41 V. The Above-Knee and Knee-Disarticulation Immediate Post· surgical Prosthesis .............. , .. , .. , . ..... 48 A. Preparatory Requirements befure Application of the Rigid Dressing .......... , . ..... 48 B. Application oft..lte Rigid Dressing. ..... 52 C. Application of the Prosthetic Unit.. _ ..... 63 D. The Knee·D.isarticulation Immediate Postsurgical Prosthesis. ... , .... 70 E. Above·Knee and Knee-Disarticulation Prosthetic Con- slderations ... , .... 71 CHAPTER 4 THE SYME AMPUTATION 74 L Preoperative Instructions to the Prosthetist .... 74 ll, Preoperative Preparations by the Prosthetist of ~faterials and Components .................. 74 III. The Syme Amputation Surgery, .... 75 IV. The Syme Immediate Postsurgical ProsthesU.. ..... 76 A. Application of Felt (or Polyurethane) Pressure Relief