Orthotics and Prosthetics Rehabilitation Engineering Centre

General Post-Operative Amputation Management Guidelines General Post-Operative Residual Limb Management Considerations General Considerations in the Application of a Compression Bandage Upper/Limb Prosthetic Guidelines - Lower/Limb Prosthetic Guidelines Lower/Limb Prosthetic Gait Training Guidelines

I. Immediate Post-Operative Stage
(1 to 21 days post amputation - sutures in place)

A. Primary Goals:

1. Promote healing and protection of the operative incision line with sterile dressings.
2. Minimize soft tissue edema for improvement of circulation to the operative site.

B. Recommended Control Options:

1. Introduce the use of an elastic compression bandage over the sterile dressings.
2. Introduce the use of a rigid cast over sterile dressings.

II. Early Post-Operative Stage
(21 to 42 days post amputation - sutures removed)

A. Primary Goals:

1. Continue to promote healing and protection of the operative incision line.
2. Encourage initial soft tissue atrophy in preparation for the development of a preparatory prosthesis.
3. Begin developing soft tissue endurance if medically appropriate.

B. Recommended Control Options:

1.Continue use of an elastic compression bandage over the sterile dressings.
2. Introduce use of a prosthetic residual limb compression sock.
3. Initiate friction massaging of residual limb if medically appropriate.

III. Late Post-Operative Stage
(42 days and beyond - operative site healed)

A. Primary Goals:

1. Maximize further soft tissue atrophy in preparation for the development of the initial preparatory prosthesis.
2. Maximize further soft tissue endurance in preparation for the development of the initial preparatory prosthesis.

B. Recommended Control Options:

1. Continue with use of the prosthetic compression sock.
2. Introduce the preparatory prosthesis to begin physical rehabilitation and developing functional use.

Sterile Dressing
A sterile dressing must be in place during the immediate and early post-operative stages until the incision line is adequately healed and no drainage is present from the residual limb.

Rigid Cast Dressing
A rigid cast dressing is sometimes used during the immediate post-operative stage in place of an elastic compression bandage for edema control and protection of the operative site.

The initial rigid cast dressing is generally not removable by the patient or hospital staff and is not changed by the attending surgeon until sutures or surgical clips are to be removed.

Elastic Compression Bandage
An elastic compression bandage with a sterile dressing is more commonly used during the immediate post-operative stage for edema control and protection of the operative site.

An elastic compression bandage and sterile dressing is generally removed and reapplied daily during the immediate post-operative stage.

An elastic compression bandage should be removed and reapplied a minimum of three (3) times per day following the immediate post-operative stage and removal of all surgical clips and sutures in order to maximize soft tissue edema control

Elastic compression bandages are normally kept in place at all times except during bathing.

Prosthetic Compression Sock
The use of a prosthetic compression sock is not generally recommended for use until the incision line is adequately healed, and there are no areas of open drainage. This is to avoid soft tissue trauma to the distal incision line while pulling compression socks into place.

Prosthetic compression socks are normally kept in place at all times except during bathing or use of a prosthesis for approximately the first three (3) months following the amputation to maximize soft tissue edema control.

A compression bandage is commonly used for the control of residual limb post-operative soft tissue edema or swelling. As a general rule, a 4" wide bandage is most appropriate for amputations below-the-knee and a 6" wide bandage is most appropriate for amputations above-the-knee.

The following general guidelines should be followed in the application of the bandage to the residual limb:

1. Elastic compression bandages must be applied to gradually give less compression from the distal end proximally.

2. Excessive compression tightness, proximal to the distal end, will restrict circulation and lead to increased distal end edema.

3. Elastic compression bandages should always be applied in a "figure-of-eight" spiral fashion. This helps to prevent excessive proximal compression and provides sufficient compression over the extreme distal end of the limb.

I. Primary Purpose

A. To achieve optimum independent functional use and tolerance of the prosthesis consistent with the patient's physical condition and level of amputation

II. Primary Goals

A. Develop confidence and acceptance to prosthetic use

B. Develop knowledgeable functional use of the prosthesis

C. Develop residual limb tolerance to prosthesis

D. Develop basic concepts of functional use and control of the prosthesis

III. Primary Objectives

A. Provide positive reinforcement of the potential for independent functional use of the prosthesis

B. Enhance the patient's knowledge of the normal physical aspects of his/her residual limb

1. Soft tissue skin care
2. Soft tissue edema
3. Soft tissue atrophy
4. Soft tissue abrasions
5. Soft tissue neuromas
6. Soft tissue hypersensitivity
7. Soft tissue scars
8. Phantom limb sensations
9. Phantom limb pain

C. Enhance the patient's knowledge of appropriate care and use of the prosthesis

1. Proper donning and doffing
2. Proper fitting assessment
3. Proper use of prosthetic socks

D. Toughen the residual limb soft tissue for optimum tolerance to use of the prosthesis

1. Soft tissue friction massaging
2. Gradually increase endurance wearing time

E. Enhance the patient's knowledge of appropriate control of the components of the prosthesis

1. Actuation of the terminal device (Hand/Hook)
2. Actuation of the wrist mechanism
3. Actuation of the elbow mechanism
4. Movement of the passive mechanical components
5. Understanding of Bowden cable control concepts
6. Understanding of myoelectric control concepts
7. Understanding of switch control concepts

F. Optimize functional use of the prosthesis

1. Independent use of the terminal device for grasp and release of objects
2. Independent use of the wrist mechanism for appropriate positioning of the terminal device
3. Independent use of the elbow mechanism for lifting and positioning of the terminal device
4. Independent use of the shoulder mechanism for positioning of the elbow and terminal device

I. Primary Purpose

A. To achieve optimum independent functional use and tolerance of the prosthesis consistent with the patient's physical condition and level of amputation

II. Primary Goals

A. Develop confidence and acceptance to prosthetic use

B. Develop knowledgeable functional use of the prosthesis

C. Develop residual limb tolerance to weight bearing

D. Develop basic concepts of prosthetic gait and stability

E. Develop unassisted independent ambulation skills

III. Primary Objectives

A. Provide positive reinforcement of the potential for independent functional ambulation

B. Enhance the patient's knowledge of the normal physical aspects of his/her residual limb

C. Enhance the patient's knowledge of appropriate care and use of the prosthesis

1. Proper donning and doffing
2. Proper fitting assessment
3. Proper use of prosthetic socks

D. Toughen the residual limb soft tissue for optimum tolerance to use of the prosthesis

1. Soft tissue friction massaging
2. Gradually increase endurance wearing time
3. Gradually increase weight bearing time
4. Gradually increase ambulation time

E. Enhance the patient's knowledge of appropriate gait and stability with the prosthesis

1. Stance phase weight bearing transfer
2. Stance phase hip and knee control
3. Swing phase hip and knee control
4. Swing phase toe clearance
5. Swing and stance phase stride length control
6. Negotiation of steps, inclined and declined surfaces

F. Optimize functional prosthetic gait and stability

1. Independent ambulation in parallel bars
2. Independent ambulation with a walker
3. Independent ambulation with a quad cane
4. Independent ambulation with a single pole cane
5. Independent unassisted ambulation

Initial Gait Training Phase

Primary Goal: To develop the patient's residual limb tissue tolerance and initial knowledge of normal prosthetic gait for independent ambulation within parallel bars.

The patient should not progress beyond this phase until his/her residual limb is sufficiently stable enough to tolerate 50% weight bearing and he/she demonstrates sufficient control of the basic concepts of normal gait along with independent ambulation, balance and stability in the parallel bars.

Secondary Gait Training Phase

Primary Goal: To further develop the patient's residual limb tissue tolerance to increased weight bearing and further develop independent ambulation, balance and stability with a walker.

The patient should not progress beyond this phase until his/her residual limb is sufficiently stable for tolerance of 75% weight bearing and he/she demonstrates consistent control of the basic concepts of normal gait along with independent unassisted ambulation, balance and stability in the walker.

Primary Gait Training Phase

Primary Goal: To further develop residual limb tissue tolerance for full weight bearing and independent ambulation, balance and stability with a quad or single pole cane.

The patient should not progress beyond this phase until his/her residual limb is sufficiently stable for tolerance of 100% weight bearing and they demonstrate definite control of the basic concepts of normal gait along with independent unassisted ambulation, balance and stability with a single pole cane.

Advanced Gait Training Phase

Primary Goal: To further develop unassisted independent ambulation, balance, and stability without the assistance of an external support.

The patient has achieved independent unassisted ambulation and is ready to purse all the normal ADL challenges one would expect to encounter in their environment, as well as, the resumption of their vocational and/or vocational interests.