1. Robert N. Brown, Sr., CPO, FAAOP
History of Postoperative Prosthetics Surviving Lower Extremity Amputation
Robert N. Brown, Sr., CPO, FAAOP

2. 4 Periods of General Medicine
Antiquity Period
2000 B.C. to 500 A.D.
Middle Ages
500 A.D. to 1400 A.D.
Renaissance Period
1400 A.D. to 1846
The Period of Modern Surgery
1846 to 20th Century
New Era?
Ertl Procedure and Adaptations

3. Amputations & Prosthetics
Surgical amputation
Stone Age - 3,000 B.C.
Pre-dates prosthetics
First recorded prosthesis 484 B.C.
500 years after the first recorded orthosis
Oldest prosthesis 300 B.C.
Destroyed in the bombing of London, W. W. II)

4. Amputations & Prosthetics
Silence until the 15th century
“Middle Ages” period of war
Amputations go largely unreported or forbidden
Castration
War continues to be the impetus for most prosthetic advances

5. Early Surgical Efforts
The operation was a success but 75% of all amputees died
Surgeons lacked knowledge
Asepsis
Sterile conditions
Ligation
Ligature to stop bleeding of severed blood vessels

6. Surviving Early Postoperative Care
Boiling oil (500 B.C.)
Control bleeding
Prevent infection
Blood Letting (Taber’s Cyclopedia)
Eliminate disease
Leaches
Maggot Tx. (Stopped in the 20th Century)
Used to remove necrotic tissue
Cauterization
Heat, chemical, electrical & laser

7. Advances in Medicine in the Modern Era
Ligatures (Ambroise Pare, 1529)
Tourniquet (Morel, 1674)
Chloriform & Ether (1843)
Doppler Effect (early 1800’s)
C. Doppler 1803 to 1853
Antiseptics (Lord Lister, 1867)
X-ray (Roentgen, 1895)
More

8. Post Amputation Concerns – As Technology Improves
Pain
Death
Infection
Contractures
Pressure sores
Psychological trauma
Adequate blood supply
Edema/shrinkage/swelling
Changes in transected bones
Neuroma formation/sensory loss
Desire to return to a “Normal Life”

9. Advances in Amputation Surgery
Guillotine
Contoured flaps
Suturing techniques
“Good Surgical Technique Creates A Functional Residual Limb.” (Thomas & Hadden, 1945)
Extended posterior flap (late 1960s)
Doppler

10. Advances In Amputation Surgery
Ertl Procedure
Periosteal juncture
X-ray
Schon’s Bridge
Ertl adaptation
Bone and screws

11. Postoperative Outcomes Continue to Improve with:
Bed rest
Light compression & early & continuous skin Traction (Barnard 1942)
Wound drainage
Hema-vac systems
Surgical & suturing methods
Staples

12. Postoperative Outcomes Continue to Improve with:
Soft Dressings (SD)
Compression bandages
Shrinkers
Physical therapy
Occupational therapy
Psycho/Social therapy

13. Berlemont (late 1950’s) Modified by Weiss Brought to the USA (1963)
Immediate PostOperative Prosthetics & Early PostOperative Prosthetics Arrive
Berlemont (late 1950’s)
Modified by Weiss
Brought to the USA (1963)
Burgess/others adopt the technology

14. “It Is Mandatory That The Surgeon Understand Prosthetic Principles & Available Components.” (Ernest M. Burgess, M.D., 1967)
PSAS (Prosthetics & Sensory Aides Service [V.A]) & PRS (Prosthetics Research Study)
IPOP (Burgess, Romano, Traub, Zettle/Van Zandt/Gardner, May 1964 to November 1966)
Independent studies of the positive and negative results of IPOP (Titus, Wilson & many others)

15. Why Immediate or Early Prosthetic Management?
Improves outcomes
Helps with challenging cases
Enhances the value of rehab care
Maximizes potential for future prosthetic use
“Functional Management” empowers patient, family & rehab team

16. Advantages of IPOP / EPOP
Protect wound site
Reduce falls
Speed-up the training and adjustment period
Improve balance and safety during transfers

17. Advantages of IPOP / EPOP
Patient gets more initial attention
Reduce other health complications
Reduce length of hospital stay
Psychological benefits
Re-establish bilateral function & body image
Psycho-social acceptance of prosthesis to become a functioning prosthetic user

18. Visual Trepidation
Bi-valved rigid removable dressing (Med. Journal Australia, Jones & Buriston, 1970)
RRD (Wu 1979)
PSRD (Swanson 1993)

19. Pre-fabricated Sockets & Systems
Postoperative Treatment of Lower Extremity Amputees (Brown, Danforth, Klotz, Schon & others)

20. If It Ain’t Broke, Why Fix It? - Plaster IPOP Lacks:
Opportunity for surgeon to examine limb to preserve wound integrity and quality
Opportunity for Therapists to examine residuum before & after weight bearing
Ability to shrink and swell with the patient
Ability to reproduce a quality outcome from one practitioner or one IPOP to another

21. Why Use a Pre-fabricated Removable IPOP Vs. Shrinker or Ace Wrap (SD)?
Minimize skin breakdown
More effective edema control
Ability to keep knee in extension
Consistency of donning and doffing
Ability to add graded weight bearing
More rapid maturation of residual limb
Protection of residual limb from trauma
Immobilizing soft tissue promotes healing

22. Why Use a Pre-fabricated Removable IPOP Over Plaster or Fiberglass?
“To remove all opportunity to watch the wound is not reasonable.” (Kerstein, Zimmer, & Dugdale, article IPOP - Poor Results )
Most systems are less bulky
Adjustability eliminates costly & time consuming cast changes
Longer useful life

23. Pre-fabricated Removable IPOP Vs. Plaster or Fiberglass
Adjust compression
Adjust wearing time
Shorter learning curve
Definitive components used
Can be reused by the same patient
Eliminates cast changes & realignment
Surgeon, prosthetist & patient save time
Can get wet or soiled and can be cleaned

24. Disadvantages of Pre-fabricated Removable IPOP / EPOP
Could be removed
Not for every patient
Could be incorrectly donned
Weight bearing must be controlled
Bulky relative to a custom made preparatory
Complications may be blamed on the socket or system
More initial material cost than plaster IPOP

25. Available Pre-fabricated Sockets & Systems
Aircast Air-Limb™ --
APOPPS-TF™ & APOPPS™ by FLO-TECH® 

26. More Pre-fabricated Postoperative Systems & Sockets
Danforth – D-PASS 
Fillauer POP & POP-PY 
TEC 

27. Other Available Techniques & Pre-fabricated Systems
Plaster IPOP
Removable Rigid Dressing
RRD
PSRD
Una paste soft dressings
The Michigan Limb
Hosmer PP-AM
USMC Prep TT/TF
DeWindt limb
Ossur 
Others & custom

28. The Future – Amputations on the Rise
Cost of Rehab (Malone, Pipinich, Leal, Hayden & Simpson, Maricopa Medical Center Study)
Non IPOP - $47,589
IPOP - $28,432 - adjusted ($42,535)
56,000 amputations per yr. - Diabetes (1997, American Diabetes Association)
90% of limb amputations in the western world are consequences of PVD/Diabetes
Rest of world - not far behind
Land mines
Especially children

29. Conclusion Not enough qualified prosthetists to meet demand
Prosthetists time better spent on surgeon/rehab team/patient relationships & on mentoring young prosthetists
Pre-fabricated systems reproduce quality from one prosthetist, one IPOP, to the next