Smeigrid Dressings in Early Ambulation of Below-Knee Amputees
Carl A. Paulsen, M.D.
Early ambulation in the treatment of the below-knee amputee was first described by Berlemont1 in 1961 and popularized in this country by Burgess et al . 2 after the work of Weiss in Poland in 1963 64 utilizing a rigid, thus non-distensible, postoperative dressing. This technique requires an "in house" staff of orthopedists and/or physiatrists, plus a prosthetist to apply a carefully molded plaster cast with patellar-tendon-bearing socket-like capability.
The Amputee Clinic at Sunnyview, as do many others across the United States, draws patients from many hospitals. Thus, the below-knee amputation is performed by a variety of surgeons, often with little or no skill in applying the rigid postoperative dressing, or the inclination to try this procedure. Thus, an alternate method of postoperative dressing which incorporates the benefits of the rigid dressing without the attendant risks and difficulties associated with the plaster technique is needed. The method described by Ghiulamila3 has been utilized at Sunnyview. This method uses a semirigid dressing with Unna paste. This paste is prepared by mixing one part zinc oxide, two parts gelatin, three parts water, and four parts glycerin, and heating in a double boiler until the mixture becomes smooth. The warm paste is brushed over succeeding layers of gauze applied to the limb. Bandages impregnated with a similar paste are commercially available (Dome Paste Bandage)*. Once applied, this bandage acts as a soft liner which maintains the shape of the stump.
The Unna paste bandage has many advantages not found in the plaster technique:
- The operating surgeon (often a general surgeon in our cases) can use a material familiar to him.
- The surgeon may make a brief inspection of the wound, either partially or totally in the postoperative period, without loss of the supportive effect of the dressing.
- The dressing is readily and rapidly changed in the patient's room, clinic or rehabilitation facility without the need to coordinate a multidisciplinary staff.
- The weight and bulk of the rigid dressing-socket is avoided.
- Referral of the amputee to another facility as an inpatient or outpatient produces virtually no loss of rehabilitation time if this technique is used.
- The technique may be instituted at virtually any phase of the patient's postoperative course.
- Fabrication of the actual prosthesis may await the availability of the prosthetist in the immediate or early postoperative phase, as well as in the delayed utilization of the technique.
- The method is ideally suited to the patient with ulceration, incomplete healing or areas of grafted skin, where friction at the prosthesis-skin surface would be undesirable.
- The technique has been utilized at Sunnyview for 18 months and has been applied to ten cases, two of them bilateral.
Application of Bandage
After the skin is closed in the operating room the suture line is covered with one layer of gauze or Telfa which is nonadherent. On top of this, a strip of clear adhesive plastic (Vidrape) is applied so as to isolate the wound completely.
The stump is wrapped with Unna paste bandage, applied directly over the skin, from the distal end up to the border of the middle and proximal thirds of the thigh.
In general, snug wrapping in the infrapopliteal region must be avoided so as not to create distal edema and a bulbous stump. Gentle traction is maintained on the bandage as it is applied. In those instances where a conically shaped stump is to be wrapped, the tight edge of the bandage is cut at right angles to its long axis through one-half to two-thirds of its width, so that all folds are avoided. A similar effect may be created by twisting the Unna paste bandage as in the use of roller bandages, thus permitting changes in direction without loss of the inextensible character of this material. In the delayed application of this technique it is often unnecessary to encase the knee joint and patella with the bandage unless edema is present in this region ( Fig. 1 , Fig. 2 , Fig. 3 , and Fig. 4 ). It is necessary to use 1, or 2- four-inch by ten-yard (10 cm. by 10 meter) bandages depending on the length and circumference of the stump.
The prewrapping application of felt pads as described by Burgess et al. and Ghiulamila was not employed in the cases reported here. When the technique was used initially, the cases involved were in the late postoperative period and felt pads did not appear necessary. Since that time the technique has been applied to immediate post-amputation cases and the felt pads have still not appeared to be necessary.
The synthetic balata (Polysar) socket is an important and integral feature in the application of this technique. Its use has been described by Wilson5 and the staff of the Veterans Administration Prosthetics Center4. A double layer of stockinet is pulled over the stump, followed by application of the tube of Polysar which has been softened by heating it in water at about 180 deg. for 4 to 6 minutes. While the tube is being pulled over the stump to a level above the femoral condyles, traction applied to both ends of the outer layer of stockinet minimizes friction against the sensitive postoperative stump. The tube is fitted snugly to the stump utilizing elastic pressure-sensitive tape and is then hand-molded to define the tibial crest, the medial flare, and the infrapopliteal anteroposterior dimension ( Fig. 5 ). With help, our prosthetists have been able to incorporate the adjustable jig and a portion of the pylon while the Polysar hardens as it cools. The pylon minimizes the droop of the distal end of the tube by providing a "handle" which can be used to maintain the alignment of the hardening tube. The socket is then removed from the stump and trimmed. It is fitted with the supracondylar strap, anterior thigh strap, SACH foot and shoe ( Fig. 5 ).
The Polysar below-knee socket can be fitted over the damp Unna paste dressing by applying a stump sock which may be cleansed readily ( Fig. 6 ). However, the bandage will generally dry in 12 to 18 hours and the temporary prosthesis is usually fitted at that time. As shrinkage occurs loss of tissue bulk is compensated for by additional stump socks until the volume of the stump seems to have stabilized, and then the Polysar socket is reshaped or occasionally replaced. When there has been no further discernible shrinkage of the stump, the Unna paste bandage is discontinued, but use of a stump shrinker at night is instituted. Ambulation is accomplished in the Polysar socket and a temporary prosthesis utilizing stump socks for padding and relief of friction. Occasionally, in addition to regular length stump socks, short socks carried only to the level of the tibial tubercle are used to facilitate compression of the distal portion of the stump and decrease the distal circumference of the occasional stump which may be bulbous at this stage. Utilizing these modifications of technique, there appears to us no urgency for fitting a permanent PTB-type prosthesis and thus it is possible to virtually eliminate the need for a second smaller permanent PTB socket several months after fabrication of the initial permanent limb.
We at the Sunnyview Amputee Clinic consider this method of fitting to be a distinct advance in the early treatment of the below-knee amputee in those facilities lacking the staff and capability of a major prosthetics center. In addition, the technique seems to have distinct advantages over the rigid postoperative dressing and fewer of the wound complications noted in the immediate postoperative fitting technique which involves the use of plaster.
Sunnyveiw Hospital and Rehabilitaion Center; Schenectady, New York
1. Berlemont, M., Notre Experience de l'Appareillage Precoce des Amputes des Mem-bres Inferieurs aux Etablissements Helio-Marins de Berck. Annales de Medicine Physique, Tome IV, No. 4, Oct.-Nov,-Dec. 1961.
2. Burgess, E. M., R. L. Romano, and J H. Zettl, Management of lower extremity amputations. Prosthetic and Sensory Aids Service, Veterans Administration, TR 10-6, August 1969.
3. Ghiulamila, R. I., Semirigid dressing for postoperative fitting of below-knee prosthesis. Arch. Phys. Med and Rehab., 53:4:186 190, April 1972.
4. Staff, Veterans Administration Prosthetics Center, Direct forming of below-knee patellar-tendon-bearing sockets with a thermoplastic material. Orth. and Pros.. 23:1:36-61, March 1969
5. Wilson, A. B., Jr., Evaluation of synthetic balata for fabricating sockets for below-knee amputation stumps Artif. Limbs, 14:2:58 62, Autumn 1970.