Lower-Extremity Amputation With Immediate Postoperative Prosthetic Placement

David Folsom, MD, Terry King, MD, Jeffrey R. Rubin, MD, Cleveland, Ohio

To study the efficacy of an immediate postoperative prosthesis (IPOP) program, a retrospective review of 167 major lower-extremity amputations was performed. Patient enrollment in the IPOP pro- gram was based on the individual's potential for re- habilitation and participation in an aggressive post- operative physical therapy regimen, as determined by the surgeon, prosthetist, physical therapist, and social worker. Indications for amputation were in- tractable infection and/or severe unreconstructable arterial insufficiency. Sixty-five patients underwent 69 amputations with IPOP (59 below knee; 10 above knee). Successful program completion was defined as independent ambulation and occurred in 86% of those patients enrolled. The average inter- val from amputation to ambulation was 15.2 days for the below-knee amputees and 9.3 days for the above-knee amputees. Failure to complete the pro- gram occurred in 14% of patients and was due to noncompliance, stump infection, stump trauma, and death. The results of this review support the use of IPOP after major lower-extremity amputation.

From the Department of Surgery, Section of Vascular Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Requests for reprints should be addressed to Jeffrey R. Rubin, MD, 2074 Abington Road, Cleveland, Ohio 44106.

Manuscript submitted October 4, 1991, and accepted in revised form January 7, 1992.

D espite continued advances in preventive foot care and arterial reconstruction, major lower-extremity am-

putation is still frequently required for irreversible ische- mia and catastrophic soft-tissue and osseous infection. Conventional stump care after lower-extremity amputa- tion consists of the use of soft compressive dressings that are designed to contour the stump while healing occurs. After a delay of 4 to 6 weeks, the patient is fitted with a permanent prosthesis, and rehabilitation is initiated [1]. The time delay between amputation and return to ambu- lation may be devastating, both physically and emotional- ly, for patients who have already been confined due to chronic lower-extremity problems.

In the late 1950s, Berlemont proposed the idea of immediate prosthetic placement subsequent to amputa- tion, and his procedure was subsequently modified by Weiss et al [2]. With the increased incidence of lower- extremity amputation in the military, the Veterans' Ad- ministration Prosthetic and Sensory Aid Service initiated an experimental program, the Prosthetic Research Study, headed by Burgess et al [3] in Seattle, Washing- ton. This study suggested that immediate postoperative lower-extremity prosthetic placement and early initiation of rehabilitation resulted in faster healing and earlier ambulation. Facilitation of healing was believed to be due to increased comfort with local tissue immobilization. There also appeared to be better control of postoperative edema with subsequent enhancement of wound healing and stump maturation due to controlled pressure and total contact. All of these benefits are afforded by a rigid postoperative dressing. In addition, the psychologic bene- fit derived from early ambulation and a rapid return to a functional lifestyle is immeasurable [3]. Since this early work, subsequent immediate postoperative prosthesis (IPOP) studies have demonstrated improved healing rates, more rapid return to independent ambulation, and decreased operative morbidity and mortality rates when compared with conventional therapy [1,4-8]. One series, however, has cited increased wound healing complication rates following IPOP therapy for below-knee amputation [9].

In order to determine whether the major lower-ex- tremity amputation population has improved postopera- tive recovery and rehabilitation, as well as a rapid return to a functional lifestyle, with the use of IPOP, an IPOP amputation program was initiated. The results of this program are retrospectively evaluated here.

PATIENTS AND METHODS From 1985 to 1988, 139 patients underwent 167 ma-

jor lower-extremity amputations at the Cleveland Veter- ans Administration Medical Center. Ninety-nine below- knee and 69 above-knee amputations were performed.

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AMPUTATION WITH PROSTHETIC PLACEMENT

Sixty-five patients who underwent 69 lower-extremity amputations (42%) were selected for participation in an IPOP placement program. Selection for the program was based on the patient's ability to participate in an aggres- sive postoperative physical therapy regimen. This was determined by the surgeon in conjunction with the pros- thetist, physical therapist, and the social worker. All pa- tients who were accepted into the program were seen by the physical therapist and prosthetist prior to amputation. During this preoperative visit, the patients were taught about the program and familiarized with both a tempo- rary and a permanent prosthesis. The remaining 98 am- putations were treated conventionally with stump wrap- ping and delayed prosthetic placement.

Of the 65 patients, 39 (59%) were diabetic, 45 (69%) smoked, 27 (42%) were receiving treatment for hyperten- sion, and 9 (14%) were undergoing dialysis for end-stage renal disease. There were 56 men and 9 women, with 32 black and 33 white patients. Age ranged from 22 to 90 years, with a mean of 64.6 years. Prior femorodistal arte- rial bypass had been performed in 35 of 69 (51%) limbs, and 4 (6%) had undergone prior proximal arterial recon- structions. Of those having undergone lower-extremity revascularization, 11 (31%) had 2 or more attempts at revascularization.

Indications for amputation were intractable infection in 45 limbs (65%) and unreconstructible arterial insuffi- ciency in 24 (35%). Twenty-nine limbs (42%) had non- healing ulcerations, and 27 (39%) had gangrene.

Forty-three (73%) of the 59 below-knee amputations were performed primarily, and 16 (27%) had previous digital, transmetatarsal, and/or guillotine amputations. Of the 10 above-knee amputations, 4 were primary, 4 followed below-knee amputations that failed during the same hospitalization, and 2 followed previous below-knee amputations by more than 2 years.

The selection of amputation level was determined clinically and was based primarily on low thigh pressure, low thigh-to-brachial pressure indices, and transcuta- neous oxygen pressures. An absolute low thigh pressure of 70 mm Hg or greater or an index greater than or equal to 0.50 was considered adequate for healing a below-knee amputation. In addition, transcutaneous oxygen pres- sures greater than or equal to 40 mm Hg at the proposed amputation site were also thought to be consistent with excellent chances for healing of the below-knee amputa- tion. Skin temperature, capillary refill, level of infection, and skin bleeding at surgery were also considered.

Operative technique consisted of a gastrocnemius- based myocutaneous flap for the below-knee amputation and an anterior-to-posterior fishmouth closure for the above-knee amputation. All lower-extremity prosthetic graft material was removed at the time of amputation as previously described [10]. Application of the IPOP oc- curred immediately after surgery, either in the operating room or in the recovery room. An experienced prosthetist applied all of the prostheses. The below-knee prosthesis, as described by Burgess et al [3], includes the following: (1) sterile Orlon Lycra stump sock and overfluff gauze of lamb's wool; (2) felt or polyurethane relief pads; (3) eight

elastic plaster bandages; (4) conventional plaster wrap; (5) suspension strap; and (6) pylon hardware and foot.

Touchdown weightbearing was begun on the first postoperative day. Through the use of such ambulatory aids as crutches, parallel bars, walkers, and canes, pro- gressive weightbearing was initiated. Full weightbearing was expected within 2 weeks of amputation. Immediate postoperative prosthesis changes were planned for the 7th and 14th postoperative days, and patients received a tem- porary prosthesis on the 21st postoperative day.

RESULTS Participants in the current IPOP program experi-

enced uncomplicated stump healing in 59 of 69 limbs (86%). For the 53 below-knee amputations, the time from amputation to independent ambulation ranged from 5 to 53 days (mean: 15.2). The six above-knee amputations had times to ambulation ranging from 4 to 22 days (mean: 9.3).

Ten of 65 patients (15%) treated with IPOP therapy were unable to complete the program, 6 (9%) due to withdrawal from the program and 4 (6%) due to postop- erative death. Two withdrawals were due to patient non- compliance and unwillingness to participate in the rigor- ous rehabilitation program. Both patients eventually became ambulatory with conventional therapy. One limb required a below-knee to above-knee revision due to or- thopedic problems involving the knee joint. Two limbs developed local infection that required prosthesis removal and antibiotic treatment. One subsequently healed with- out further complications, whereas the second developed a catastrophic deep infection and generalized septicemia, and the patient subsequently died as a result of this com- plication. One patient fell, resulting in a traumatic dis- ruption of the stump. He was subsequently treated in a conventional fashion after secondary wound closure.

Of the four deaths in this series, three occurred after below-knee amputations. Three of the deaths occurred in patients with end-stage renal disease that required hemo- dialysis. Three were secondary to cardiac events, which occurred while the patients were progressing, on sched- ule, with their rehabilitation, and the fourth death was due to sepsis from an infected stump.

COMMENTS The implementation of IPOP placement to facilitate

major lower-extremity amputation healing has not gained universal acceptance, especially in dysvascular and/or infected limbs.

In support of IPOP treatment, Warren and Moseley [5], in 1968, reviewed 20 cases of below-knee amputa- tions with concomitant IPOP therapy. Eighteen (90%) healed primarily without complications, and 2 required higher-level amputations due to wound healing problems. There were no deaths in this series, and the patients received their permanent prostheses at an average of 27 days postoperatively. At the time of the report by Warren and Moseley, healing rates for amputation with conven- tional stump management and rehabilitation ranged from 53% to 75% [8,11-13].

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FOLSOM ET AL

Subsequently, several authors endorsed the use of IPOP, citing primary healing rates ranging from 85% to 93%, with suec~sful rehabilitation in 78% to 100% [6,8]. Weinstein et al [1] demonstrated a primary amputation healing rate of 89% in a review of 17 high-risk dysvascu- lar and infected limbs treated with an IPOP protocol.

On the other hand, Kane and Pollack [14] found no advantage in using the IPOP regimen with regard to improved wound healing, decreased stump necrosis, or the necessity for reamputation. In a study by Cohen et al [9], 6 patients underwent below-knee amputations with IPOP placement and experienced a complication rate requiring reamputation that was 10 times higher than that found when conventional stump handling and reha- bilitation was employed. In the latter study, the authors concluded that IPOP therapy was actually deleterious.

In a previous study from our institution, 9 of 36 (25%) patients treated with below-knee amputation and soft dressings, after previous lower-extremity revasculariza- tion, required revision to above-knee amputations [I 5]. From the same period, 12 of 39 (31%) patients undergo- ing below-knee amputation for infected or ischemic limbs, without previous revascularization, treated with soft dressings, required revision to above-knee amputa- tions.

In this study of 65 patients undergoing 69 major low- er-extremity amputations with IPOP placement, 85% completed this program and achieved early independent ambulation.

End-stage renal disease requiring hemodialysis was the only medical or surgical risk factor that was found to correlate with increased mortality after amputation with IPOP rehabilitation (x 2 = 9.34; p <0.005). Of the six limbs that required IPOP removal, two had prior arterial bypass procedures, both with in situ saphenous vein tech- nique, and neither had more than one procedure. Hospi- tal discharge occurred after a mean of 7 days postopera- tively, and patients completed their care in specialized care settings. Of those who successfully completed the IPOP program, the mean time to achieve independent ambulation was 15.2 days for below-knee amputees and 9.3 days for above-knee amputees.

The number of major lower-extremity amputations will continue to escalate since people are living longer, limb salvage arterial reconstructions are performed more often, and people are outliving their bypasses. Kane and Pollack [14] demonstrated that only 48% to 77% of be- low-knee amputees regain ambulatory status. An in- crease in the emphasis on the functional recovery of am- putees is mandatory to improve the lifestyle of this segment of the population while controlling the cost of rehabilitation. This review supports the use of an IPOP regimen following major lower-extremity amputation in an appropriately selected cohort of patients. The results

of our study show that IPOP facilitated operative recov- ery, rehabilitation, and the return to an independent am- bulatory status.

The rehabilitation of the amputee now begins in the operating room; the value of the patellar tendon prosthe- sis has been only slowly recognized by many surgeons. The work extends the concept successfully to above-knee amputations as well.

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