New Procedures Dramatically Shorten Rehabilitation Time After Amputation

Reprinted from the Newsletter, Division of Engineering, National Research Council, National Academy of Sciences, No. 59, March 1, 1967.

Surgeon-prosthetist teams from nine Veterans Administration hospitals distributed throughout the United States participated in an orientation course in immediate postsurgical prosthetics fitting techniques at the Prosthetics Research Study in Seattle early this January. This was a preliminary step in the introduction of the procedures, under controlled conditions, into general use in VA hospitals.

A conference on the new procedures was held at Northwestern University in the latter part of January. Participation in the conference included representatives from two other major centers of prosthetics-orthotics education-the University of California, Los Angeles, and New York University. The purpose of the conference was to review variations of the new procedures and to develop teaching material for the introduction of the technique into the prosthetics-orthotics education program.

Prior to the development of immediate postsurgical fitting procedures, the acceptable practice in the management of a lower-extremity amputee began with a closed conventional amputation. A reinforced gauze dressing was applied, and the patient was confined to bed until the wound healed. Elaborate precautions were required to insure that flexion contractures did not occur. After removal of the sutures, much time was devoted to keeping the stump properly wrapped with an elastic bandage to reduce the inevitable edema, and to "stabilize" the stump so that a permanent prosthesis could be fitted. With such conventional procedures, fitting of a permanent prosthesis could rarely be started prior to six weeks postoperative, with most cases requiring a good deal longer.

The concept of fitting patients with prostheses immediately after surgery and initiating ambulation training the following day seems to have been originated by Dr. Michel Berlemont in France during the late 1950's. Berlemont's procedure was modified by Dr. Marian Weiss of Poland, who brought it to the attention of Americans through a lecture which he delivered at the Sixth International Prosthetics Course in Copenhagen in 1963.

A visit by Dr. Weiss to the United States later during 1963 stimulated interest at the University of California Medical School, San Francisco, and at the U.S. Naval Hospital, Oakland. Promising results obtained at these institutions prompted the VA Prosthetic and Sensory Aids Service to support an experimental program proposed by the Prosthetics Research Study in Seattle. Other groups, notably Duke University, the University of Oregon, the University of Miami, Marquette University, and a group in New York City centered around the Hospital for Joint Diseases, became interested and embarked upon modest experimental programs.

To effect a basis for interchange of information between these groups, the Committee on Prosthetics Research and Development of the NRC Division of Engineering sponsored a series of meetings and created an ad hoc committee to follow developments and assist wherever possible.

Because there existed no written material or visual aids, each group approached the problem somewhat differently.

During November 1964 the Prosthetics Research Study team was able to visit Dr. Weiss in Poland to observe his then current technique, and returned to develop procedures which, it was hoped, combined the best features of the procedures developed more or less independently on both sides of the Atlantic.

The results obtained at Seattle and at other centers seem to bear out the claims made for immediate postsurgical fitting by the originators, namely: control of postsurgical edema, marked reduction in pain, improved wound healing, and a material reduction in "off-the-job" time. Moreover, it appears that in the case of patients with peripheral vascular disease many more knee joints can be saved than was formerly the case when more conventional methods were used.

Thus the apparent values of the immediate postsurgical fitting procedures as demonstrated on both sides of the Atlantic have stimulated general interest in surgical and prosthetic circles. A major new trend in the management of the lower-extremity amputee appears to be in the making.