1. Use of TEC system for amputees and other innovations in early management of the amputee Dr F Kohler 19th August 2005

2. Advantages of early fitting of prosthesis
1. Quicker stump maturation
2. Preservation of muscle tone
3. Prevention of contractures
4. Facilitates gait retraining
5. Eliminates bad walking habits

3. Goals of Post-operative Management of residual limbs
1) Primary wound healing
2) Prevention of oedema
3) Facilitation of stump shrinkage
4) Prevention of stump trauma
5) Patient education
6) Prevention of contractures

4. Timing for prosthetic treatment
(A) temporary prosthesis ordered when
(1) wound appears healed
(2) sutures have been removed
(3) stump is no longer oedematous
(B) definite prosthesis
(1) stump is no longer oedematous and measurements are stable over a period of time.

5. Current best practice
1. General conditions permitting the patient stands on day 1 or 2 post-operative for 1 to 5 minutes.
2. This is delayed in debilitated disorientated or obese patients and bed exercises are substituted.
3. Weightbearing is encouraged from day 1 or 2 but limited to less than 20kg (further restriction may be necessary).
4. Full weightbearing from when the wound is healed.
5. Ambulatory training commences when the patient can stand for > 5 minutes. (weightbearing restricted to 10kg).

6. GENERAL OUTLINE (preoperatively)
Pre-operative Consultation
Explanation of programme
Psychosocial issues
Upper limb/contra lateral limb exercise programme
Mobilisation with aids

7. Perioperative Bed exercise programme Psychosocial aspects
Plan early home visit
Education of process

8. Postoperative (1) Day 2-3 - sit out of bed
Day stand and commence mobility training.
Day commence transfer practice.
About 1 week - home visit.

9. Postoperative (2) Week 2 Progress to mobilising with aids
Simultaneously may learn wheelchair independence, especially if TF amputee.
Self care retraining

10. Postoperative (3) Week (3)
Home visit with patient if required
Stump bandaging if surgeon is happy
Discharge home if possible
Transfer to rehabilitation unit if required.
- no home support
- unsuitable home environment

11. Postoperative (4) After Week 3
Stump bandaging
Temporary plaster prostheses as required
Prosthetic training, usually as outpatient
Definitive prosthesis about 3-4 months post amputation

12. New Innovations TEC stump protection fitted week 2 ICEX socket
Osseointegration
Polymer impregnated socks and removable rigid dressing

13. Definition
TEC stands for Total Environmental Control referring to the total skin contact, and the pressure relieving properties of the system. 3

14. Components of the TEC system
The system consists of TEC liner
TEC stump socket
TEC retainer 4

15. TEC Liner (1) made of urethane
has flow properties to decrease pressure areas
liner ‘flows’ from areas of high pressure to areas of lower pressures to even out pressure on the stump
pre-shaped
available in four different sizes
comes with or without cover 5

16. TEC Liner (2) 7

17. TEC Liner (3) 8

18. TEC Socket prefabricated, 4 sizes
adjustable to accommodate stump changes
firm to protect from impact of falls or trauma 6

19. TEC Retainer
Socket fits directly into retainer to which a pylon and foot can be attached in order to allow early mobilisation. 10

20. TEC Protector 9

21. Advantages 1) Stump protection 2) Earlier and better stump shaping
3) Enhances stump healing by assisting with management of oedema
4) Earlier mobilisation
5) Ease of review 11

22. Disadvantage of TEC System
May not fit well on all stumps as premoulded, not individualised
May not fit well secondary to the stump changes.
Cost, about $1000 per prosthesis and liner.

23. Implications (1)
Since it has been used, 2 patients who have had a significant fall onto their stump have not sustained any wound breakdown, unlike the 3 patients before use of TEC system, who required stump revision for 1 patient, conversion to above knee amputation for 2 patients. 12

24. Implications (2)
Patients can now get up about day 7, compared to day prior to use of this
earlier mobilisation results in earlier discharge
possibly a shorter time to definitive prosthesis 13

25. Economics Cost: Approximately $1000 per system
can be sterilised and reused - 2,3 or more times.
Savings: Unspecified, but likely to be many
times the outlay. Currently studying to quantify savings
Significant improvement in patient wellbeing. 14

27. Look at my new Flex-Foot
Barnaby is a 12-year-old horse from the UK.
Happily, pioneering surgery and assistance from Dorset Orthopaedic meant Barnaby didn't have to be put down following an infection in his foot.

28. ICEX
ICEX 100 is an integral part of the Icelandic Direct Casting (IDC) system, the unique direct casting system to make customized carbon fiber sockets directly onto the residual limb.
The direct casting system allows prosthetists to produce well fitting sockets time and time again.

29. ICEX 2
ICEX 100
Superior comfort and fit IDC provides a Total Surface Bearing ICEX socket through even pressure distribution
Strong and durable The ICEX 100 carbon fiber braid fits users of all activity levels upt to 100 kg. in weight
Lightweight Carbon fibers are the strongest and most lightweight casting material available

30. .                                                  

32. Polymer impregnated sock
Thin thermoplastic/silicone type sock
Lightweight removable rigid dressing
Decreases shear forces
Good stump compression
Results suggest that stump stability for fitting of prosthesis is decreased from 17 to 12 days

33. Patients with TEC protector (1)
JK: 55 year old lady
- bilateral PVD, malunion following trauma
- lives in caravan
- etoh abuser with cerebellar signs
- ® TT amputation 8/12/99
- Transfer to rehab. 22/12/99
- stump protector fitted 5/1/2000
- Independently mobile with prostheses and crutches
- quad stick including steps on discharge 24/1/2000
- ongoing outpatient PT & support
- now needs three distal pads in prosthesis

34. Patients with TEC protector (2)
DR: 86 year old lady living alone at home (self care unit). PVD; IHD; # (L) wrist whilst on gate leave 12/11
(l) TT amputation 27/7, slow to heal, bed rest 3/52.
Home to daughter’s house, independent with mobility on pick up frame
Awaiting wound healing on 10/9/99
Admit to Braeside Rehab 21/10/99 and TEC liver.
TEC prostheses fitted 25/10 - mobilising up to 150m outside with 2 crutches by 12/11
Had fall whilst transferring into car 14/11
Discharged home 24/11

35. Patients with TEC protector (2)
DR: 86 year old lady living alone in self care unit; PVD; IHD; # (L) wrist whilst on gate leave 12/11
(l) TT amputation 27/7, slow to heal, bed rest 3/52.
Home to daughter’s house, independent with mobility on pick up frame while awaiting wound healing on 10/9/99
Admit to Braeside Rehab 21/10/99 and TEC liver.
TEC prostheses fitted 25/10 - mobilising up to 150m outside with 2 crutches by 12/11
Had fall whilst transferring into car 14/11
Discharged home 24/11
definitve fitted mid December
still fitting well on last review 7/2/2000

36. TEC Patients (3) Mrs. MD - IDDM Bilateral TT amputations (L) 11/11/99
Poor wound healing - skin graft on left; slow healing on right; MRSA infection
peripheral neuropathy
CCF, IHD
Transferred to Rehab 5/1/2000
- primary goal: Wheelchair independence achieved by 25/1.
- Whilst awaiting home modifications (R) wound healed and a plaster prostheses was fitted on 27/1
- 28/1 standing practice and swivel transfers.

37. MD (2) 11/2 left TEC prostheses fitted
14/2 mobilised with prostheses x 2, FASF and assist x 2
15/2 - discharged

38. MD (3) 11/2 (l) TEC prostheses
14/2 mobilised with prostheses x 2, FASF and assist x 2
15/2 - discharged

39. TEC Patients (4) Mr AL, PVD, heavy smoker, lives on first floor
(R) TT amputation 27/9
Fall 19/10 and placed on bed rest
28/10 mobilised with stump protector only
4/11 discharge home on cruches
Readmitted 21/11 with abscess
(R) TF amputation 17/12
Admit rehab 10/1
D/c Home 21/1on crutches

40. TEC Patients (5) Mr RC vasculopath, diabetic,obese
(R) TF amputation 17/8
Fall end of August resulting in wound dehiscence and resuturing
Stump protector only fitted early September
Transferred to Rehab St Elsewhere wthout stump protector on 22/9
fall on 29/9 requiring resuturing (R) TT amputation 30/9

41. RC (2) Transfer to Rehab 7/10 commence prosthetic training 15/10
stump ooze increasing 22/10
recommence prosthetic training 28/10
independent with rollator frame 22/11
home mods required; discharge 3/12
definitive prosthesis fitted in January 2000

42. TEC Patients (6) Mr RK: PVD, AAA, smoker (R) TT amputation 21/10
Stump protector only fitted 2/11
Discharged home 2/11 hopping with PUF
17/11 mobilised with temporary TEC prosthesis
25/11 progressed to Canadian crutches
13/1 Definitive prosthesis fitted
4/2 minor adjustment to definitve prosthesis

43. Traditional (local) timing for prosthetic treatment
(A) temporary prosthesis ordered when
(1) wound appears healed
(2) sutures have been removed
(3) stump is no longer grossly oedematous
(B) definite prosthesis
(1) stump is no longer oedematous and measurements are stable over a period of two to four weeks

44. Local Study
Retrospective analysis of first 30 patients with TEC prosthesis and a sample of amputee patients for two years prior to using the TEC system.

45. Study Aim Compare retrospective samples of patients by: Age
Time taken to first get out of bed
Time taken to first mobilise
Time taken to first temporary prosthesis
Time taken to mobilising independently
Time taken to discharge and or transfer to a rehabilitation unit
Time taken to definitive prosthesis
Number of falls and consequences of falls

46. Method Retrospective chart analysis Patient identification by -
1) referral book
2) consult sheets
3) case conference lists

47. Inclusion criteria Transtibial amputation previously walking
cognitively able to participate with rehabilitation programme

48. Exclusive criteria Grossly incomplete data severe dementia Other:
morbidities excluding participation in rehabilitation programme
stump revision

49. Results (1) TEC used in 30 patients
6 patients no data available - transferred to other hospital soon after TEC issue
24 patients for analysis

50. Results (2) Comparison Group 40 - 8 deleted because of lacking data
32 remaining for analysis

51. Results (3)

52. Results (4)

53. Results (5)

54. Falls outcomes with TEC
TEC liner not worn 10 days lost due to bruising
Patient fell while not wearing TEC resulting in wound breakdown, required re-suturing and three weeks to heal
2 falls in one patient, one resulting in no complications, one resulting in a fractures arm
Patient developed fractured ribs
No stump damage

55. Falls outcomes without TEC
wound breakdown requiring one weeks bed rest and three weeks to heal
wound breakdown and subsequent infection requiring conversion to AKA
no complications
3 patients developed bruising to stump from fall delaying prosthetic fitting by 10 days or more

56. Analysis (1) Data not normally distributed
Mann-Whitney test used for statistical analysis
Not significant were:
time to first get out of bed
time to first mobilising
time to discharge
time to transfer to rehabilitation unit

57. Analysis (2) Highly significant differences for:
first mobilising with prosthesis
independent with prosthesis
Approaching significance:
Temporary Prosthesis first issued (0.057)

58. Conclusion
Tec stump protectors result in improved patient outcomes as measured by earlier independence in prosthetic mobility
There was a decreased incidence of serious stump trauma in patients who used the TEC protector.
There is no evidence from this study that there were significant other effects on patient management

59. Economic Consequences of Falls
Difficult to determine accurately but the stump revision required after the fall in the patient not wearing a TEC protector sways the costs markedly against not using a TEC liner or other protective device.
So far only 2 events with stump damage in the TEC protectors
At a hospitalisation cost of around $700 or more per day the cost/benefit ratio of TEC protectors seems favourable.

60. Discussion
Need for further studies/greater numbers to fully evaluate outcomes.
Need to review patient and staff satisfaction/acceptability
Changes in surgeons expectations.
No TEC=no mobilisation
Cost of protectors and who pays?
Reuse of protectors and effect on cost.
Other possible effects on results.

61. Prosthetist involvement in making of temporary prosthesis
This group consisted of amputees who were transferred to the Braeside inpatient rehabilitation unit from May 2003 onwards. The prosthetist reviewed the patients and made their temporary prosthesis while they were inpatients at Braeside. The data was collected prospectively.

62. Results (1)
A total of 11 transtibial amputees were treated in the prosthetist group. One patient discharged themselves against medical advice and was excluded from the analysis as many of the end points were not met. This patient had progressed quite well prior to discharge. This left ten patients who were analysed as part of the study.

63. Results (2)

64. Results (3)

65. Results (4)

66. HISTORY

67. 1961 Berlemont:
immediate prosthetic limb replacement on the operating table
applied plaster of paris following debridement of the infected and septic stump
weight bearing allowed early in the post-operative period
1963 Weiss - modified and improved the technique using it for closed lower extremity amputations and surgical stump revisions

68. Burgess & Romano
indicated that immediate post surgical prosthetic fitting had a significant positive effect on the plan of management
confirmed as useful treatment by Moore (1968), Condon & Jordan (1969)
Lim et al suggested the success was due to the rigid dressing, rather than early mobilisation
Sormiento (1970) recommended that full weightbearing be prohibited for at least 2 weeks after amputation.

69. Kiah et al (1970) demonstrated
faster wound healing
decreased complication rate
reduced hospital length of stay
This was as a consequence of using rigid dressings without prosthetic
Gerhardt & Assoc. (1970) advocated the use of an immediate post-operative fitting to achieve better soft tissue healing in addition to help control post surgical oedema, reduce pain and prevent the complications of inactivity.

70. Mooney & co-workers (1971) demonstrated that application of a functional, mechanical stress by means of progressive controlled weightbearing is beneficial in the soft tissue healing of the stump wound.
- also demonstrated that early ambulation (< 1 month) post-operative) provided some physical or mental advantages to the patients, which allowed them to become functional prosthetic users to a greater degree

71. Cohen et al (1974)
This immediate post-operative prosthesis technique had a tenfold increased incidence of wound complication
Nicholas et al (1976) showed that the rigid dressing resulted in 100% healing of stumps by primary intention, compared to 78% primary healing in their conventional dressings (published figures 60-80%)

72. Mid 1970s it was generally felt that immediate post-operative prosthesis should be reserved for patients undergoing amputations for trauma or tumour, and the occasional good risk artheroschlerotic amputee.
Generally weightbearing is allowed from about 2 weeks post operation

73. Baker et al in 1977 showed that plaster dressing significantly shortened hospitalisation and enabled earlier rehabilitation. The patients with soft dressings, almost uniformly had stump oedema despite wrapping with an elastic bandage, the persistence of which postponed the beginning of gait training.

74. They allowed protective/partial weightbearing on parallel bars/crutches as early as the first post-operative day, but did not hesitate to discontinue weightbearing if the patient was unable to control weightbearing.
They demonstrated that maintenance of knee range of motion, stair climbing, walking up and down ramps, and standing up and sitting down were facilitated by this process, especially in the geriatric patient.

75. Wu & Assoc. (1979 &1980) first described a removable rigid dressing technique
The below-the-knee removable rigid dressing is a below-the-knee plaster cast held by a suspension stockinette to a supracondylar plastic cuff. Being removable, it permits frequent observation and progressive shrinkage of the stump (by adding socks), and eliminates the need of elastic stump bandaging.

76. In addition, it still maintains the advantages of immobilisation of soft tissue (to reduce pain and facilitate wound healing) and prevention of trauma to the stump as does the conventional rigid dressing.
It has significantly reduced the incidence of pre-tibial skin breakdown and distal oedema, produced fast stump shrinkage, and shortened time to ambulatory discharge with a temporary prosthesis by ninety days.
Bacon et al (1986) described a detachable cast pylon technique for rigid dressing.
The pylon could be removed at night, with the rigid dressing left insitu

77. Rehabilitation time following amputation (Wu et al 1979)
Average time to healing (days)
Average time to ambulatory discharge (days)
Control group
109.5
191.4
Removable rigid dressing
46.2
101.8

78. Stump trauma (1991) Behan et al U.S.
Retrospective review of below knee amputees for 14 years
23 suffered trauma to their stumps
80% of the trauma was as a result of a fall
11 patients required above knee amputation

79. Plaster Pylon Technique
Harrington et al 1984 &1991
used a rigid plaster dressing applied in theatre to mid thigh level
the patient is allowed to mobilise immediately with walker or crutches
at one week plaster is changed and a copper tube pylon is added to the cast
the patient is then allowed to partial weightbear or fully weightbear

80. Plaster Pylon Techniques Results (56 patients)
Average time for wound healing (days)
Average time for mobilisation with temporary prosthesis
Plaster Pylon Group
40.4
108.4
Soft bandage Group
98.4
200.1

81. Open stump wounds
Study by Vigier (France) et al 1999 Plaster cast socket with silicone sleeve versus elastic compression 28 subjects per group
Average healing time (days)
Walking with prosthesis
Discharge
Plaster cast
71.2
63.5
99.8
Elastic comp
ression
96.8
73.3
129.9

82. Preformed temporary sockets
First suggested by Foort in 1970
Further advocated by McDougall in 1977 who used transparent plastic sockets with foam/rubber pads. Three different diameters were available.
This resulted in improved outcomes including healing of stumps which had been thought to require revision
(Case series of 650)

83. Other types of temporary prosthesis
1. Shrink plastic film (s film)Dowie, 1975 S.A.
one case report
walking at 3/52 post operatively
2. Air splint Burraclough et al Sydney
5 patients from 10 used the air splint with pylon and foot attached prior to changing to a conventional temporary prosthesis

84. Other types of temporary prosthesis (cont’d)
3. Prefabricated plastic limb - Kraker D, , USA
plastic, hollow form fitted over the conventional plaster dressing and cut to size.
Usually applied about day 8 post operatively.
Average definitive prosthetic fitting at 7.7 weeks
(54 days)

85. Other types of temporary prosthesis (cont’d)
4. Otto Bock Prefab
5. TEC
6. Definitive type

86. Advantages of Rigid dressings
1. Control oedema
2. Support circulation
3. Minimises inflammatory reaction
4. Simplified nursing care
5. Positive effect on stump shaping
6. Decreased painful phantoms

87. Disadvantages of rigid dressings
1) inability to observe the stump except at cast change
2) inability to produce progressive stump shrinkage except at cast change
3) length of time needed during periodic cast removal and re-application
4) need for an experienced prosthetist (physiotherapist) at completion of surgery
5) resource intensive

88. Contraindications to Rigid Dressing
1. Local infection at the site of amputation
2. Large oedematous stump in which technical application and appropriate anchoring would present a problem