A New Paradigm of Postoperative Amputation Care

By Miki Fairley

Michael Pinzur, MD, has a guiding philosophy: "Think outside the box." In discussing the American healthcare system, Pinzur says, "It's a bad system, but it's the best around." To arrive at the ultimate goal of optimal patient outcomes, Pinzur believes the healthcare professional should look through a wide-angled lens at the entire picture, rather than narrowly focus on one aspect - and think outside the box.

Considering the whole-picture view is important in strategizing what is the best care for each individual patient, Pinzur believes.

Pinzur, who is a professor of Orthopaedic Surgery and Rehabilitation at Loyola University Medical Center, Maywood, Illinois, urges, "Look at the biology, the technology, and the system," - and how these apply to patient care. "Think about the whole process, not just the specifics."

Biology can apply to both your patient's medical condition, and treatment goals - and how these can be best achieved. Technology involves prosthetic devices to help achieve treatment goals. However the system and factoring it into your patient care is highly complex and involves what is available to the patient in care options and what is affordable for him.

In discussing amputation postoperative care with The O&P EDGE, Pinzur discussed that marvelous weight bearing organ, the foot, with its 26 bones (the feet contain about one quarter of all the bones in the human body) to accept weight bearing, absorb shock, and adapt to differing terrain. In a lower-limb amputation, all this is lost, with only a limited ability to replace it.

"With an amputation, we now have a much smaller surface area and limited cushioning and adaptability compared to that organ uniquely adapted for weight bearing - the foot," says Pinzur. So a new development he would like to see is something that would bring the residual limb up to the level of the natural foot.

If it weren't for the problem of infection, Pinzur feels that the osseointegration technique pioneered by Rickard Branemark, MD, is the best current solution, since it eliminates stabilization and interface issues.

Even though the ideal solution doesn't yet exist, the first step toward better postoperative care and successful prosthesis use begins with good surgery, Pinzur points out. "I'd like to see surgeons do better surgery and understand the principles of how you create a terminal organ of weight bearing. If the prosthetist gets a bad limb, he or she spends a significant amount of effort and design adapting to the problems. When prosthetists get a good limb, it makes their job easier and they can take more advantage of new technology."

Pinzur routinely performs bone-bridge surgeries on traumatic amputees and believes the technique does create a better residual limb for weight bearing and prosthetic use. However, he stresses the need for scientific evidence to support treatment theories. "I have my theories as to how people bear weight, but its not proved. We don't yet know through scientific studies how patients bear weight in a prosthesis. The studies that we have are based on computer simulations, so we really don't know how people actually bear weight."

Pinzur continues, "I'm a proponent of immediate weight bearing, but there is no evidence that in the long term people who immediately weight bear do better than those who start their weight bearing later. Those of us who believe in it say people don't decondition as much, don't get contractures, and receive psychological benefits. But this is not evidence-based."

Prosthetic Priorities

After surgery, prosthetic technology and design enter the picture. The most important need is for an intimate fit, Pinzur stresses. He looks at a prosthesis from a fresh perspective. "Think of the prosthesis as a big shoe. Think how you feel if the shoe is sloppy, loose, and doesn't fit right. Also, many people like gym shoes better than leather shoes because they're softer and more cushioned. So you want a prosthesis that is snug, cushioned, stays attached, and effectively transmits the load of weight bearing."

Applying the shoe concept to an immediate postoperative prosthesis (IPOP), Pinzur notes that the classic IPOP includes a plaster cast. "Now would you rather walk in a plaster shoe or a soft, cushioned shoe?"

An intimate fit is highly important, since shear forces - rather than pressure as such - are what cause skin breakdown, Pinzur says. "What happens when you wear hard leather shoes and your heel starts moving up and down? You get a blister. So if the limb pistons up and down in the socket, that produces shear which breaks down the wound. So what we want in an IPOP is one that will rapidly adapt to changes in the limb's geographic shape and volume, dissipate weight over the whole surface area, and is cushioned and intimately fitting to protect the wound from shear and pressure."

Weight Bear Early - Or Not?

Taking a big-picture view has led Pinzur to conclusions that, at first glance, may seem counterintuitive. For instance, he believes in early weight bearing for older patients with diabetes or other medical conditions more so than with young, otherwise healthy persons with amputations due to trauma, tumors, or congenital anomalies.

"Statistically, when you do a BK amputation on a person with diabetes and vascular disease, they have a high likelihood of being dead in two years. When I do an amputation on a little old lady with diabetes, I don't want her to have to sit around in a wheelchair for 50 percent of the time she has left. She'll get weak and have flexion contractures and won't become a prosthetic user." Although early ambulation increases the risk of wound breakdown and complications, Pinzur would rather take this risk and have these types of patients ambulate early and have more quality of life.

However, Pinzur sees the opposite situation with healthy, younger amputees. They have the probability of becoming long-term prosthetic users, so an optimum residual limb is a prime consideration. "I'm aggressive with IPOPs for the older people. But I can do the same exact surgery on a 24-year-old who's had a motorcycle accident, and I tend to not have him fit with a prosthesis right away. What's the difference? It's best not to run the risk of wound problems, because it's crucial for him in the long term to have an excellent residual limb." The recovery timeline from surgery to prosthetic use with the timing of each step in the process is different with these two different patient populations, Pinzur notes.

Timeline, Team Considerations

A team environment, such as is generally found in university medical centers, ideally provides a seamless transition from surgery to prosthetic fitting. It's about the timeline - what has to be achieved at each step before going on to the next step - and looking at the process as a whole. The timeline would vary depending on the patient - and the desired end result. Vascular surgeons perform about 80-90 percent of all amputations in the US, since most amputations are due to dysvascular conditions, Pinzur observes. Successful surgical wound healing is the vascular surgeons goal. "However, I feel that amputation is just the first step in the process," he says. "To me, the end result is successful prosthetic use."

Recovery timelines, with their related treatment algorithms and decision trees, would be much different, for instance, for the older dysvascular patient than a youngster undergoing an elective transtibial amputation to correct a congenital anomaly. Says Pinzur, "If we think of an overall timeline, algorithm, and decision tree - the biology of the healing, the technology of the prosthesis, together with the timeline for recovery - we have established a whole new paradigm for addressing these issues."

Impacts on IPOP Use

However, the "real-world" environment - reimbursement issues, health professionals' "territorial" issues, and allocation of limited resources - can derail the ideal scenario. If a surgeon puts an IPOP on a patient after surgery, that goes into their DRG and the hospital eats the cost, which doesn't sit well with hospital administrators. "I've taken a patient that could be profitable for the hospital and made them a money loser," Pinzur says.

Also, insurance plans tend to pay for only a limited number of prostheses, so if the surgeon puts an IPOP on a patient in the operating room and the plan only pays for one prosthesis, the insurance won't pay for the definitive prosthesis.

A vascular surgeon, who is mainly interested in successful wound healing, would not likely promote a technique that could endanger the wound. When the vascular surgeon thinks the wound is safe, he sends the patient to a physiatrist. If the physiatrist prescribes an IPOP or early postoperative prosthesis (EPOP) and there's a wound complication, the physiatrist gets the blame, and the surgeon has to fix the damage, so the physiatrist would be hesitant to use an IPOP and take the risk.

External regulations are another factor. "If your mother has a hip replacement, wouldn't you like her to go to a rehab center?" Pinzur asks rhetorically. However, with Medicare, if you are a surgeon doing a certain number of hip replacements, and you send more than a small percentage to a rehab center, the center may be de-certified.

Allocating Limited Resources

Medical care is expensive, and allocation of resources is a large issue. No individual, organization, or even nation has unlimited resources, and choices have to be made, Pinzur points out. The public has to decide what it wants, look at the big picture, and consciously consider how to allocate available resources. Pinzur draws an analogy with an individual considering buying a BMW or a Chevette. Both will fulfill his basic transportation needs. However, he may want the BMW and decide to buy it and live in a smaller house. Or he may decide to buy a bigger house and drive the Chevette. His priorities will determine his allocation of his resources.

Ideal Scenario

In the ideal scenario, professionals in each rehab discipline would be on the same page, work as a team, be unaffected by issues of practice territory and income relative to other disciplines, regulations that impede the process, resource allocation issues, and be driven by the recovery timeline and the desired outcome for the patient. Pinzur sums it up concisely: "A lot of our failures are due to the failure of our systems. If we could make our systems better, we could make a lot of our patients' recoveries better." 

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Table Of Contents - April 2005

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