Post-Operative Management of TT Amputations

The most recent issue of the Journal of Rehabilitation Research and Development contains an excellent review article about post-operative management of transtibial amputations by Doug Smith MD and colleagues. This is a particularly timely topic since the American Academy of Orthotists and Prosthetists just concluded a Consensus Conference on this aspect of clinical practice.

As many readers already know, cost containment pressures have pretty well eliminated the coordination of post-operative care from amputation through prosthetic gait training for most new amputees. The surgery is followed by discharge as soon as the patient appears to be medically stable, and inpatient gait training is rarely authorized. Prosthetic fitting is almost always on an outpatient basis, and the care during the interval between the surgery and prosthetic fitting varies widely across the country.

As the review article notes, "Current protocols are based on local practice, skill, and intuition." But, in the Managed Care environment, statements about what professionals think are best for patients have less and less impact. Until it can be proven to be detrimental, only the lowest cost treatment alternative is likely to be authorized today. This reimbursement climate creates a market for commercial prefabricated post-operative devices, while discouraging custom made or individualized solutions. There is insufficient evidence to determine whether this trend is to the amputee's advantage or not.

Smith et al have taken the first step in challenging this status quo by undertaking a systematic review of the existing literature on post-operative management following transtibial amputation. [The complete text is posted online at www.vard.org or can be downloaded as a PDF file by clicking on www.vard.org.] One of the most common outcomes from a literature search is a much better understanding of the limitations in previous research and a clearer idea of what can be done to improve future results. This article is quite valuable in that regard.

The great majority of prior publications have been descriptions of individual clinical experience. Not only are such reports often subjective, but since the definition of "success" or "failure" of a particular post-operative method varied widely, it is difficult or impossible to compare the results from one group to another. In addition to the lack of standardized end points, the reviewers found that there were no standard criteria for selection of a particular management strategy. Together, these two flaws decrease the value of much of the prior literature in determining the best approach for today's amputees.

Smith et al identified 10 studies [from the hundreds reviewed] that included controlled trials comparing two or more post-operative techniques, and summarized their results in two tables that are reproduced below. They classified the type of post-operative management being investigated into one of the following five classes:

1. Soft Dressings [e.g., gauze bandaging or elastic wrapping]
2. Thigh Level Rigid Dressings [e.g. a mid-thigh or longer plaster cast]
3. Immediate Post Operative Prostheses [e.g. a mid-thigh plaster cast with pylon & foot attached]
4. Short Removable Rigid Dressings [e.g. custom dressings that allow knee flexion, such as the Wu cast]
5. Prefabricated Pneumatic Prostheses [e.g. inflatable bladder-in-rigid-container commercial systems]

Table 2 PDF and Table 3 PDF These tables summarize the outcomes of various post-operative protocols following transtibial amputation, based on 10 controlled trials reported in the literature.

The decision made by the DMERC medical directors a few years ago to stop Medicare funding for removable rigid dressings on an outpatient basis has denied most patients access to this post-operative treatment in recent years, despite a number of favorable articles in the literature regarding the efficacy and cost-effectiveness of RRDs. Interestingly, one of the primary conclusions reached by Smith and colleagues was that "the literature supports that rigid plaster cast dressings result in significantly accelerated rehabilitation times and significantly less edema compared to soft dressings". They go on to note, "If the main effect of rigid dressings [with prosthesis attached] is to decrease the time until full rehabilitation is reached and patient discharge, the cost savings could be enormous."

The discussion section of this paper contains a number of well thought out caveats and recommendations. They conclude with the following comments:

"Further controlled, randomized studies are needed to directly compare different types of post-TTA management strategies. This will not be easy. Future studies will need to consistently define their outcome measures, detail rates, and the impact of complications; use a more sensitive measurement of post-operative pain; and quantify any savings of health care use and rehabilitation costs."

Smith and co-authors are to be congratulated for summarizing the current situation concisely, and for pointing the way to improving the situation in the future by conducting appropriately controlled studies. Anyone with an interest in post-operative management of transtibial amputations will benefit from reading this article in detail. Hopefully funding agencies and research teams will heed these findings and use them as a platform to help us obtain definitive answers to these fundamental questions.

Reader Comments: Read all user comments Asociacion Japonesa de Ortesistas y Protesistas? Ciudad de Mexico 12 de Julio, 2003. Estimado John Michael, CPO, FAAOP, FISPO: ¿conoce usted la direccion de la pagina, dentro de internet, de la Asociacion o Sociedad Japonesa de Ortesistas y Protesistas? Nos interesa ingresar y revisar su... read more - Alberto E. Castillo Moreno O.P.   7/12/2003 Re: Asociacion Japonesa de Ortesistas y Protesistas? I've not kept current with the Japanese P&O associations, so you might want to ask Eifi Tazawa who to contact. You can reach him at eiji@tazawa.co.jp. Contact information for the Japan Society for P&O is posted online at http://www.medtra... read more - John Michael   7/12/2003 Reference about Lower Limb Orthoses - eletronic version - Hi Mr John Michael, I'm a orthotist from Brazil, a frequent visitor of your Corner. I'm learning more about our practice and i'd like to know the complete reference of Lower Limb Orthoses used on school in the Dominican Republic. ... read more - Cristiano Sena   7/7/2003 Re: Reference about Lower Limb Orthoses - eletronic version - Nice to hear that you visit the Corner often. If I understand your question correctly, you are looking for the complete citation for the posted text. Unfortunately, I don't have any information beyond what is contained on the PDF file. T... read more - John Michael   7/9/2003 Tecnica Zinio.com Ciudad de Mexico 6 de Julio, 2003. Estimado John Michael, CPO, FAAOP, FISPO: el día de ayer tuve la oportunidad de leer en mi PC una revista deportiva mediante la tecnica ZINIO.COM Con esta tecnica online tuve la capacidad de hojear cad... read more - Alberto E. Castillo Moreno O.P.   7/6/2003 Re: Tecnica Zinio.com Interesting question, Sr. Castillo- So far as I can tell, ZINIO.COM is a new online venture that relies on paid subscriptions to stay in business. For that reason, they will almost certainly need to feature only mass circulation periodica... read more - John Michael   7/6/2003