Prosthesis at Surgery Aids Recovery

Reprinted from the Journal of the American Medical Association, Volume 195, No. 6, February 7, 1966.

Operating room fitting of lower limb amputees with temporary prostheses creates notable advantages for their rehabilitation, surgeons around the nation are finding.

Current experience with the procedure, first suggested by a Polish investigator, Marian A. Weiss, M.D., in 1963, was discussed by several clinicians at the recent American Academy of Orthopedic Surgeons sessions in Chicago.

Advantages of immediate fitting, "which violates a lot of principles I've practiced for years," were listed by Ernest M. Burgess, M.D., Seattle:

  • Accelerated wound healing and maturation;

  • Earlier ambulation, often by the second postoperative day;

  • Earlier regaining of proper gait and return to employment;

  • Earlier fitting with a permanent prosthesis.

Dr. Burgess, orthopedic consultant to the Seattle Veteran's Administration Hospital and Area Office, reported on his pilot study of the procedure with 55 patients. His current experience exceeds 70 cases.

The group studied, under VA sponsorship, ranged in age from 5 to 81 years. They included 15 above-the-knee, 35 below, five at the ankle (Syme's) and three knee disarticulations. Three procedures were bilateral, bringing the total amputations to 58.

Patients with vascular disturbances of diabetic or other origin, infections, traumatized limbs, congenital circulatory abnormalities and sarcoma have undergone the operations.

Fig. 1

Probably the most significant advantage gained by immediate fitting is accelerated wound healing. "Because an amputation is end surgery, we can apply closed pressure without disturbing circulation," Dr. Burgess told JAMA Medical News.

The tight-fitting bandage also reduces tissue edema and immobilizes tissue while maintaining its physiological integrity.

This opinion is shared by surgeons conducting the procedure elsewhere. "It is my impression that swelling which normally accompanies amputation destroys collateral circulation," said Augusto Sarmiento, M. D., assistant professor of orthopedic surgery at the University of Miami (Fla.).

"Immediate fitting also significantly reduces postoperative pain by tissue immobilization," he commented. "We now are able to get a greater percentage of successes in below-the-knee procedures, where healing is most difficult, especially among the elderly." The Florida surgeon has done more than 50 amputations with the method.

An even more dramatic result of the in-surgery fitting is ambulation of the patient, often by the second day. This is not mandatory, Dr. Burgess agreed, but may have definite physical and psychological advantages.

In his procedure, the muscles at the termination of the stump are kept under tension. This may assist the patient in maintaining a feeling of limb control, the Seattle surgeon theorizes.

"Phantom" symptoms are considerably reduced, most investigators believe. "With small children, they may not even realize an amputation has taken place," Dr. Burgess said. "You have to be careful they don't run off down the hospital corridor." In early cases, the Seattle team said "that some children did not realize they were walking on a prosthesis until it was changed."

Average hospital stay for the amputees studied by Dr. Burgess was 8 to 12 days. Permanent prostheses were fitted an average of 26 days postoperatively.

All surgeons currently doing the procedure stress that it is far from standardized. "It's critical that everything be done right," Dr. Burgess stressed. "If not, complications of a tragic sort can develop." Chafing and minor wound breakdowns were seen among his own first 16 cases, but have been eliminated with experience, he added.

"This is a technique which requires an experienced, team approach not normally available in small communities," commented William R. Murray, M. D,, of the University of California at San Francisco. His group, which did some of the earliest procedures, now uses the cast purely as a wound-healing device with the patient assisting with passive pressure, not early ambulation.

"At this point this must still be regarded as an experimental procedure," Dr. Sarmiento said. His colleagues agreed. The highly experienced surgeon-prosthetist team which conducts such operations on an almost daily basis still may encounter failures, they noted.

The procedure seems specifically contraindicated where, for some reason, the amputation site cannot be closed or there is a question of primary wound healing and if a subsequent, higher amputation may be needed.

Typical of nationwide efforts to discover more about the procedure and its possible complications is a three-year, $127,000 study just begun at the New York University Medical Center. Allen S. Russek, M. D., of the center's Institute of Physical Medicine and Rehabilitation, heads a team examining new surgical techniques, prostheses designs, and other variables.

Other groups reported actively engaged in immediate postoperative fitting include: The U. S. Navy Prosthetic Center, Oakland, California; Duke and Marquette universities.

Fig. 2