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【medical-news】Postoperative management of lower extremity
Postoperative management of lower extremity amputations.
Goldberg T.
ProsthetiCare Fort Worth, 1550 West Rosedale Street, Suite 100, Fort Worth, TX 76104, USA. TGOLDBERG@sbcglobal.net
Postoperative management of the lower extremity amputation continues to evolve as a crucial first step in amputee rehabilitation. Although the major goals of early rehabilitation remain fairly constant, external forces continually pressure the rehabilitation team to complete these goals within shorter time frames. The atmosphere of rapid rehabilitation for amputees stresses return to normal function as quickly as possible. Early ambulation is the obvious goal for most new amputees.
PMID: 16517350 [PubMed - indexed for MEDLINE]
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Postoperative Management of Lower Extremity Amputations
Tim Goldberg, CP, LPO
ProsthetiCare Fort Worth, 1550 West Rosedale Street, Suite 100, Fort Worth, TX 76104, USA
Postoperative management of the lower extremity amputation continues to evolve as a crucial first step in amputee rehabilitation. Although the major goals of early rehabilitation remain fairly constant, external forces continually pressure the rehabilitation team to complete these goals within shorter time frames. The atmosphere of rapid rehabilitation for amputees stresses return to normal function as quickly as possible. Early ambulation is the obvious goal for most new amputees.
Immediate postamputation concerns remain unchanged. Wound healing and edema control are the first steps to restoring function. In addition to the standard wound dressing, a compressive stump shrinker should be applied as soon as possible after surgery. Additionally, the application of a removable rigid dressing (RRD) has proved beneficial in protecting the surgical wound and in promoting wound healing. The protective environment of the rigid dressing minimizes trauma to the wound in case of a fall on the amputated limb and provides controlled compression to aid in the reduction of edema.
Rigid dressings historically have been used as an intricate part of an early weight-bearing device, the immediate postoperative prosthesis (IPOP). The traditional IPOP for transtibial amputation consists of a nonremovable plaster cast with an alignable, removable pylon and foot (Fig. 1). This technique was developed in the 1950s by Berlemont et al [1] and gained fairly wide acceptance during the next several decades. In 1979, Wu et al [2] introduced the RRD, which de-emphasized immediate ambulation, but did allow for early partial weight bearing. The RRD provided the protective qualities of an IPOP-type cast, but did not allow for bipedal ambulation (Fig. 2).
In recent years, various manufacturers have developed prefabricated postoperative prosthetic devices. Typically marketed as ‘‘adjustablepostop/preparatory’’ prostheses, these devices are modular by design and can be used with an assortment of foot or knee components. Consisting of an inner bivalved, adjustable socket and external frame, this device is relatively simple to fit (Figs. 3 and 4). Various iterations are available ranging from air-cast type sockets with removable knee immobilizers to transfemoral applications. These devices provide off-the-shelf expediency, but lack the intimate fit required for prolonged ambulation and for even compression.
Fig. 1. Traditional plaster immediate postoperative prosthesis.
The prefabricated IPOP provides a ready platform for early partial weight bearing, but is lacking in other areas. Because of the generic sizing(S-M-L) and fitting techniques employed in their use, these devices by definition cannot provide an intimate custom socket fit. Uneven support of the residual limb occurs, and the risk for complications is increased. Excessive distal weight bearing and ‘‘bell clapping’’ or ‘‘hammocking’’ of the residual limb are common problems with poorly fitted IPOPs. Any of these conditions can compromise wound healing quickly.
Fig. 2. Plaster removable rigid dressing.
More recent efforts have been made to combine a custom casting/fitting technique with the off-the-shelf IPOP technology to provide a low-cost, custom- made postoperative prosthesis. With input from Mark Bussell, MD, CPO (personal communication, 2002), a simple, effective hybrid has emerged. In January 2002, a 20-year-old man had a left transtibial amputation secondary to injuries sustained in an automobile accident. Three days postoperatively, it was decided to fit this patient with an IPOP. Because of his large body size, he could not be fitted with a conventional prefabricated device. Instead, he was fitted with a stump shrinker and a plaster RRD. Three days later, after significant reduction of edema in his residual limb, he was recasted. The external frame portion of a prefabricated IPOP with suspension belt, pylon, and foot was applied over the RRD (Fig. 5). The patient was able to toe-touch ambulate using a rolling walker immediately on donning the IPOP (Fig. 6). He continued early gait training with this device. One month and one cast change later, he was fitted with his standard preparatory prosthesis. Several other cases were treated in a similar manner, all with good results.
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作者:admin@医学,生命科学 2010-10-18 05:11
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