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- Immediate
- Post
- Operative
- Prosthesis
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- Presentation by
- Tony van der Waarde, CP(C)
- Certified Prosthetist since 1975
- Award Prosthetics, Inc.
- Burnaby
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- Benefits of the IPOP Procedure ~
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- Accelerated recovery ~
- Early use of a prosthesis often results in shorter hospital stays and a
faster transition to a temporary prosthesis as patients begin to develop
a tolerance to weight bearing.
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- Controlled swelling ~
- Applying gentle pressure to
the patient’s residual limb, an IPOP will minimize swelling.
- This helps the healing process, shaping the limb, making the final
custom-made prosthesis easier to fit and in a more timely manner.
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- Reduced pain ~
- In controlling the swelling, pain is often reduced.
- This decreases the use of drugs, reducing costs and may even eliminate
drug dependency. Research
also indicates that early prosthetic use may reduce (or eliminate) the
occurrence and severity of phantom limb pain and sensations.
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- Protection and Safety ~
- Especially in patients who are in a weakened condition, elderly or have
other medical considerations, the IPOP practice shows a dramatic
reduction in the number of falls and can help prevent additional injury
to the wound.
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- Prevent knee flexion contractures and loss of muscle strength ~
- By allowing amputees to stand in very short order and to gradually begin
using their legs, an IPOP can significantly improve rehabilitation
- again, reducing hospital stays & costs.
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- Psychological benefits ~
- Patients learn immediately what it feels like to wear a prosthesis and
thereby can focus more on their rehabilitation than on their missing
limb.
- This is usually very positive as long as it does not delay the process
of accepting the loss of their limb.
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- Having an IPOP can help them return to their homes, or workplaces,
sooner especially if wheelchair accessibility is a problem.
- The new amputee generally has
- a more positive
outlook on their future.
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- The IPOP, although not widely in use, offers the highest rate of healing
of any of the post operative modality treatments. The primary reason for its modest
use has many ‘rationales’.
- These include the fact that the process itself is slightly more time
consuming in the O.R. (approx. 20 min), requires more monitoring of the
wound itself, payment issues for the prosthetist for the procedure,
including the frequent subsequent visits and lack of familiarity of the
treatment itself.
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- All of these, and any other objections, will be greatly offset by the
benefits to the patient.
- The primary positive aspects include:
- greatly reduced swelling of the residual limb (thereby reducing the
pain levels ~
- fewer medications),
- greatly reducing the chance of infections,
- appreciably reduces the amount of time in the hospital,
- significantly helps to prevent knee flexion contracture and most
importantly,
- psychologically, because the patient/client is up and mobile the day
after surgery, they feel a sense of normalcy right away!
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- There is no way around the fact that a major amputation is devastating
to the patient and their family - no matter what age or
circumstance. If a
pre-existing condition warrants the surgery, the decision rests largely
on the patient.
- In a traumatic situation there may not be the luxury of time or
cognitive ability to contemplate a course of action which they may have
chosen, given the option.
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- The concept of the IPOP is at well over 100 years old.
- The first recorded history of the IPOP is from 1893 when the German
surgeon,
- von Bier¹,
reported fitting patients with temporary prostheses within days of
amputation and allowed them to stand, begin walking with gait training
in one to two days.
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- In 1963, Dr. Marion Weiss, Warsaw, Poland, reported his first findings
of trans-tibial post-op casting.
- In 1971, Dr. E.M. Burgess reported satisfactory results in 193 lower
extremity amputations performed for peripheral arterial
insufficiency. In the
succeeding seven years he and his group performed more than 1500
amputations with the (then referred to) IPPF approach. (2)
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- A variation of this method called a “rigid dressing” is
similar to the plaster IPOP - but without the foot and pylon. (6)
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- With the decline in use of the immediate post-surgical fitting of
prostheses, most amputees do not walk for several weeks post-surgically.
(4)
- Given all the positive aspects of the IPOP, I cannot understand why it
isn’t used almost exclusively.
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- The impressive changes are in the immediate postoperative phase.
- The healing seems to be
quite excellent, and the patients are encouraged by the results. (9)
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- The San Francisco V. A. Hospital, through Dr. Wesley Moore, has had
experience with the early prosthetic fitting of 30 consecutive patients
with vascular diseases.
- Twenty-seven out of 30 of these have walked successfully on their
prosthesis at the end of a 6-week period of time.
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- This is certainly an improvement over our previous experience
- in this same hospital
with a similar number of below knee amputations. (10)
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- During the majority of post amputations, the healing period can vary
from three to 12 weeks.
- Patients are often forced to move about using crutches or to use a
wheelchair.
- They are most often bound to the hospital or a rehab facility.
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- Compared to the IPOP, this extended ‘waiting period’ to move
forward to wearing a prosthesis, increases the risk that they may
experience many negative elements.
- There will no doubt be increased limb weakness, body de-conditioning,
joint stiffness and in many cases, injury to the residual limb from
falling while trying to move about on one leg or forgetting that the
limb is now gone.
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- An IPOP, which is a rigid, locked knee above a "weightless"
prosthesis, gives the patient more stability than prior to the surgery,
when they undoubtedly had a painful or weak leg.
- It is usual practice to mobilize patients within 24 hours
post-surgically.
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- This would be a minimum - to have the patient stand and transfer to the
toilet or wheelchair using a limb.
- The importance of nominal ambulation in therapy from the second day
onwards cannot be emphasized enough.
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- There are a few reasons why the IPOP technique is not more widely used.
- Firstly, many of the surgeons performing the amputation are not trained
in these principles nor have knowledge of their benefits in the
rehabilitation aspect.
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- Many surgeons do not have a working relationship with a prosthetist that
will be performing this procedure in the O.R. immediately after they are
finished the amputation.
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- The prosthetist needs to be available for this critical time period to
apply the rigid dressing & the associated components.
- Any perceived scheduling difficulties can be easily overcome.
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- Often times, surgeons feel they have “lost” when an
amputation
- is either necessary
or requested.
- This last ditch effort to “save” a patient should not always
be
- viewed as defeat - a
negative.
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- In most cases, the patient is far better off than before the surgery.
- In many instances the lives of the patients are greatly improved.
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- In a good many situations, patients have been carrying around limbs
which are painful, weak and malformed.
- In other cases, years of
surgeries including long hospital stays, have proven not to work either
not at all or not for very long.
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- After amputation (and most especially with the IPOP procedure), many
patients have an opportunity at ‘normalcy’ - sometimes
for the first time in their lives!
- This can all be very positive as long as it does not delay the process
of accepting the loss of their limb.
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- One additional factor is to determine if there is any pain is present
and what the source of the pain is.
- If phantom pain is the issue, the protocol for treatment is considerably
different than surgical wound pain.
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- In addition to the wishes of
the patient (which should be strongly considered) their general health,
factors of mobility/strength/mental state, age, life styles and weight
should all be part of the final decision.
- Not all elements have equal value.
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- It is paramount for the surgeons involved to retain as much length in
the residual limb as possible.
- This provides for the optimum outcome for the patient giving he/she the
maximum leverage for using a prosthesis in the best possible way.
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- One or more of these elements can seriously outweigh another seemingly
important factor.
- For example, a concern regarding age can be easily offset by strong will
and determination.
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- Consultation
- Post op steps
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- When? Immediately after the
last suture or staple is applied.
- Surgeon cleans wound and inserts Penrose or Hemovac drain (plus
catheter-optional)
- Apply 4-packages of fluffed gauze
- Pull on sterile Orlon/Lycra sock.
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- Prosthetist and assistant works for about 10-15 minutes while patient
remains anesthetized.
- Pull on reticulated foam pad (with relief for bony prominences).
- Two layers of 6” wide elasticized p.o.p. bandages with a figure 8
wrapping technique.
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- Pylon anchor/adapter and foot is aligned.
- Regular p.o.p. bandages wrapped to fasten hardware plus suspension strap
below the patella.
- The wrap extends above the femoral condyles: for suspension and
non-removal by the patient.
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- Waist belt plus vertical suspension strap installed.
- Cut out patella pad to check for any pressure areas.
- Patient awakes - transfers to the recovery room.
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- Discuss plan of action with nursing staff and physiotherapist.
- Allow minimal (10%) weight bearing using walker or crutches.
- Check length and alignment.
- Walk for 10-15 minutes with supervision.
- Allow for increased weight bearing (up to 30%) prior to discharge after
1-10 days.
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- After 3-4 days - remove drain/catheter.
- Pull out through the top of the cast - if sutured in place, the cast
will need to be removed.
- Typically the hygroscopic action of the plaster is sufficient to absorb
any fluids. Often drain are
not used.
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- Day 14-21 - Cast removal, at doctors office or prosthetic lab.
- Removal of sutures and/or staples.
- Apply fibreglass cast immediately, allow knee flexion and socket removal
by patient after 3 days.
- Temporary socket fitting 4-8 weeks afterwards.
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- Not every patient is an ideal candidate for an IPOP.
- It should be a decision reached by the patient, the physician(s) and any
others in the rehab team to determine if the benefits outweigh the
risks.
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- Side effects can be avoided
or minimized with attentive care by a well-trained rehab team.
- Damage to the wound can occur from excessive weight bearing too soon
after amputation.
- To use an IPOP correctly, the patient must be able to limit the amount
of weight he or she applies to it.
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- Pre-existing disease issues can complicate matters
- Diabetes and other circulatory problems should be taken into
consideration along with general health, age and strength factors.
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- Although rare, in some cases a patient may develop an infection or
non-healing surgical wounds.
- In this situation, the use of the IPOP is discontinued while the problem
is being addressed.
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- This can be reinstituted at
the soonest appropriate time after the ‘problem’ has been
eliminated or determined.
- Sometimes a slight elevation in temperature has worried hospital staff
to the point that the IPOP is removed - only to find out that the wound
was perfectly fine.
- The IPOP/rigid dressing then has to be re-done.
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- Other issues would include cognitive dysfunction and delirium, poor
nutrition and the presence of a stroke.
- They would be strongly taken in to consideration in the determination to
use or not use an IPOP.
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- We would like to agree that the absence of a popliteal pulse is not a
contraindication to below-knee amputation.
- In our experience two thirds of the patients undergoing below-knee
amputation did not have a popliteal pulse.
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- The success rate in this group was 80 per cent.
- In these patients with a popliteal pulse the success rate approximates
100 per cent. (11)
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- A knee disarticulation amputation has many positive benefits to the
patient.
- A longer lever enables the amputee to maneuver the prosthesis more
easily.
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- My left ankle and foot was severely crushed at 22 months. I went through
50+ surgeries until I was 14 years old.
- In 2002 my foot was regularly seizing up and I was experiencing pain
regularly. It was then that I started looking at my options-one being an
amputation.
- I researched all that that would entail and I watched a video and read
testimonies of the IPOP procedure. The emotional aspect of the IPOP was
huge. My children had just lost their father to cancer and now were
faced with another trauma in their young lives, being that this was an
elective surgery and I was “choosing to cut off my leg”. In
my mind, it would be far gentler for them to see a leg and foot rather
than a “stump” after the surgery. That certainly was the case and
if I was to do it again I would definitely go the IPOP route.
- The other wonderful benefit for me was the fact that it gave me balance
straight away; it was certainly less traumatic emotionally as the
“grief” of loss of limb wasn’t so overwhelming. I felt
that although I wasn’t weight bearing in the leg it felt so good
still having “two” legs. I have never fallen on my limb and
especially early post surgery, when other amputees were falling due to
forgetting they had lost a limb, I never “forgot”.
- Marguerite Harrison, Trans-tibial amputee 2004, Surrey
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- 1. Dederich R. Amputationen
der unteren Extremitat. Operationstechnik und prothetische
Sofortversorgung. Stuttgart, Thieme, 1970.
- 2. Burgess EM. Immediate
postsurgical prosthetic fitting: A system of amputee management. Am J
Phys Ther. 1971;51:139-143.
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- 3. Moore WS. Below-knee
amputation. In: Moore WS, Malone JM, eds. Lower Extremity Amputation.
Philadelphia: WB Saunders Company; 1989:118-131.
- 4. Therapeutic and Economic
Impact of a Modern Amputation Program
- James M. Malone,
Wesley S. Moore, Jerry Goldstone, and Sandee J. Malone
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- 5. Heeyoune Jung, MD, ABPMR
- Department of Rehabilitation Medicine, Singapore General Hospital
- 6. John Rheinstein, CP - in
Motion article Volume 10, Issue 2, March/April 2000
- 7. Thomas L. Walsh, BS, CPO
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- 8. Robert E. Condon, M.D.,
Paul H. Jordan, Jr., M.D.:
Immediate Postoperative Prostheses in Vascular Amputations, From
the Department of Surgery, University of Illinois College of Medicine,
Chicago, Illinois; the Cora and Webb Mading Department of Surgery,
- Baylor University of
Medicine, Houston, Texas; the Surgical Services of the University of
Illinois Hospitals, Chicago, and the Veterans Administration and Ben
Taub General Hospitals, Houston, Texas
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- 9. Dr. Seymour Schwartz,
Rochester, 1969
- 10. Dr. Frank W. Blaisdell, San Francisco
- 11. Dr. Frank W. Blaisdell,
San Francisco
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