The "How" And The "Whys" Of Immediate Fitting

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

Why doesn't wound and stump breakdown occur in amputees fitted in the operating room?

The answer is an as yet unclear combination of individual surgical experience and skill, understanding of biomechanics and prosthetic design and, at times, personal, confidence.

Even though a relatively limited number of groups have attempted the procedure, each has its own deviations, based on increasing experience, intuition and individual circumstances. The technique described by Dr. Burgess, used in his VA study, is essentially that employed, however. ( See Prosthesis at Surgery Aids Recovery).

After amputation level is defined by clinical observation, arteriography, skin temperature and plethysmography determinations, a standard closed flap amputation is done.

An important deviation is that myoplasty is performed and the major muscle groups are sutured through drill holes at the end of the tibia.

A drain, inserted to bone level, is left in as the skin flaps are sutured symmetrically over the stump. A single-layer, sterile silk dressing is placed directly over the suture line, cut out for the drain. Up to 3/4-inch of fluffed gauze is added and a sterile stump sock is pulled over the dressings while constant pressure is maintained.

A pair of beveled felt strips are placed alongside the tibial crest to alleviate cast pressure and a felt relief pad is fitted around the patella. Elasti-cized plaster of paris is used to fabricate a socket in a design predetermined by the prosthetist.

The socket is carried to mid-thigh in below-knee procedures and includes the pelvis for above-knee and knee disarticulation support. Syme amputations carry support to the tibial plateau with patellar bearing conformation.

A layer of conventional plaster, the temporary detachable pylon unit, and auxiliary suspensory belt are fitted later, the latter in below-the-knee procedures.

The drain is removed 48 hours after surgery and even before then the patient may attempt weight bearing, if the surgeon deems it safe. Subsequent ambulation is carefully supervised.

An initial cast change is not done until 10 to 14 days postoperatively, when sutures are removed. At removal of the second cast, three to four weeks after surgery, the mold for the permanent prosthesis is made.