Alternatives to Soft Dressings: A Review
December 2013 Issue
Postoperative management of lower-limb amputation is critical to a patient's long-term outcome.1,2,3,4 The purpose of dressings is to help meet the goals of postoperative management: healing, providing protection from outside trauma, managing pain, initiating early weight bearing, controlling edema while properly shaping the residual limb, preventing flexion contractures, regaining preoperative functional level, minimizing depression, and executing the proper care of the contralateral limb.1,2,3,4,5 However, there is a lack of consensus regarding the best choice of postoperative dressing. The options include soft dressings, immediate postoperative prostheses (IPOPs), removable rigid dressings (RRDs), ZipperCasts (ZCasts), and air splints. Choosing the appropriate dressing for a patient can be a challenge for surgeons because there is no definitive or standard dressing.
The published literature in this area seems to be inconclusive, which complicates the dressing choice. Much of the research compares soft dressings to other postoperative options, and it has shown that RRDs, IPOPs, ZCasts, and air splints are better options when compared to soft dressings, such as postoperative socks or elastic compression bandages.10,11,13,14,15
Choudhury et al. studied the trends between physicians and their dressing preferences, analyzing three factors: the percentage of each postoperative technique used for transtibial amputations in U.S. Department of Veteran Affairs (VA) hospital, the personnel who applied the dressing, and the frequency of a dressing choice from different medical disciplines. Results showed that use of a wide range of dressings is due to different surgical strategies, but "other factors may be present that influence postoperative dressing selection such as practice conventions, training, availability of skilled staff to apply rigid dressings, or other healthcare factors."6
The majority of research revealed an inconsistency in protocol ranging from the definition of "healed" to the distinction between a success or failure.3 There is also a lack of documentation of patient comorbidities, preoperative functional level, and the surgeon's level of experience—all factors that have been shown to affect patient outcomes.3 An example of this inconsistency reported by Smith et al. in their literature review was a mortality rate ranging from 0-20 percent among the different case studies.3 Without definitive, standardized criteria, the surgeon's decision is based solely on his or her experience. With the current data, it is impractical to compare different postoperative dressings accurately.3
This literature review will synthesize the information on IPOPs, RRDs, ZCasts, and air splints found within published studies and provide unbiased information about these types of dressings.
An IPOP is a prosthesis that is applied immediately in the operating room after the patient's amputation.7 This type of preparation is only used on patients with a transtibial amputation who were active before the amputation. It consists of padding and compression socks surrounding the limb and is protected by a rigid fiberglass or plaster wrap. Within the wrap, an attachment plate is secured to connect a pylon and a foot.8
Several studies indicate an IPOP could provide both physical and psychological benefits to the patient. Burgess et al. performed an IPOP study to observe the effects of the postoperative dressing on 16 subjects. The subjects reported psychological benefits, and the researchers found that wound healing was not delayed, edema was reduced, and the amount and duration of pain decreased.9 The study authors also found constant pressure and alignment were necessary for success.9 Condon and Jordan reported the positive effects of IPOPs in a study with 37 subjects, including one subject with bilateral amputations, where the patients stood on the first postoperative day and days following as pain tolerated. The researchers found IPOPs resulted in a decreased amount of pain directly proportional to the reduction of narcotics. Condon and Jordan also found that healing, "judged by epithelial bridging of the wound between sutures, occurred without complications in 23 of the 38 amputations."10
Immediate postoperative plate for use with an IPOP. Photograph courtesy of Prosthetic Design Inc., Clayton, Ohio.
The patients were encouraged to talk about their anxieties to give the researchers a better understanding of what they were feeling. Typically patients will fall into a depression, which is accompanied by anger, a sense of helplessness and uselessness, fear of social nonacceptance, and premonition of death.10 Condon and Jordan reported in their study that the mood of the subjects was atypical in that they were less angry initially and were angry for a shorter duration as compared to their conventionally managed counterparts. A higher percentage of patients using IPOPs as a postoperative dressing ambulated in a definitive prosthesis than those who were treated with the conventional post-amputation method.10,11 The results of other high-quality studies suggest that the success with a prosthesis could be due to positive psychological effects and a safe healing environment. IPOP patients also benefit from the reduction of edema as well as having a good environment in which the residuum can heal.2,11
One criticism of IPOPs is that they require a trained prosthetist for removal and application. However, Smith found tissues heal fastest and with the least pain when they are undisturbed.2 A second critique of IPOPs comes from the surgeon's inability to see and monitor the wound as it heals.2,3,8 Although it is believed that trauma can occur within a cast, there are no reports of trauma under these circumstances in published articles.3 One problem associated with early weight bearing is due to the lack of research. There is no set criteria regarding IPOP use time, which creates skewed results among studies.3
Smith et al. report that most of the current documentation of IPOPs is too inconsistent to make a definitive conclusion on the criteria for a particular dressing that will optimize a patient's recovery. More research on IPOPs is needed to obtain consistent data.
Flo-Tech IPOP socket system designed by Robert Brown Sr. Photograph courtesy of Flo-Tech O&P Systems, Trumansburg, New York.
A prosthetic team fits the RRD on the patient after the amputation surgery has taken place and the patient's condition is stable. The patient dons several postoperative socks, and then a cast is taken. The practitioner wraps fiberglass around the cast to form the socket. The RRD cast is suspended by a stockinette and a cuff above the knee.
This postoperative dressing method is beneficial in maintaining adequate fit and function and offers the ease of applying additional socks to control edema.11,12,13 RRDs are removable and allow nurses, physicians, and patients to view the wound.5,13,14 The removable nature of the RRD can be beneficial in a number of ways, but only with a properly trained and compliant rehabilitation staff and patient. It is imperative that the staff and patient are properly educated on how to don and doff the device as well as when to add and remove socks to provide a better fit. Proper education and compliance can often eliminate the need for a trained prosthetic team to be present for removal and application.5 Nawijn found RRDs are better for healing and volume reduction in the residual limb.14 Deutsch et al. completed a study that compared RRDs to soft dressings in a cohort of 50 patients with transtibial amputation. The researchers found the incision sites healed two weeks faster with RRDs than with soft dressings.12,15 Another study comparing the post-transtibial amputation use of soft dressings to RRDs was conducted by Muller, using a 16-subject cohort. The study reported no significant difference in residual-limb volume measurements between the RRD group and the soft dressing group but did find significant results of an overall decrease in volume in the RRD group.6 A study by Taylor et al. also reported on the comparison of soft dressings versus RRDs. Using a 37-patient cohort, they found that patients using RRDs as a postoperative dressing received their first prosthetic cast sooner and spent less time in the hospital but had no difference in their rehabilitation time when compared to other dressing types.17,18
There have been criticisms of both the claimed advantages of RRDs and the RRDs themselves. Wu et al. completed a case study of 28 patients that compared the healing rates of patients using RRDs versus traditional soft dressings.5 They found the residual limbs of the RRD group healed in half the time of the residual limbs of their counterparts who had soft dressings.5 However, Smith et al. noted in their review that this case report lacks statistical significance and a consistent outcome measure, both possible sources of bias. RRDs do not immobilize the knee, which can allow for flexion contractures to develop.12 According to Baker, if applied too loosely, the RRD will permit swelling; if it is too tight, it will lead to anterior tibial or patellar skin necrosis.18 And if left off for more than 15 minutes, the residual limb will swell and the RRD cannot be reapplied.12 There are many studies that look at RRDs and compare them to semi-rigid dressings or soft dressings. These studies all conclude that the RRD is the better option.
In the research for this review, there was no available information on ZCasts in recent literature. Therefore, the authors contacted the distributor, who was unable to provide any updated objective outcomes data for the product. See photo below for description of ZCast usage.
The ZCast can be used alone as an RRD or with the addition of a pylon and foot as an IPOP. Photograph courtesy of O&P Solutions, Dayton, Ohio.
Air splints were originally introduced as an emergency solution to stabilize fractures and have been successfully used as pressure bandages for transtibial and transfemoral amputees.22,23,24 They were first modified by J. M. Little, MD, MS, FRACS, for post-amputation use to overcome the previously discussed weaknesses of RRDs.20,21 An air splint consists of a plastic pneumatic bag and a rigid aluminum frame.22 A foot can be attached to allow for early ambulation. Some have a zipper for easier removal and wound access.23 A towel is wrapped around the thigh to absorb perspiration and prevent maceration of the skin.24 This device has also been used as both an immediate, and a temporary prosthesis.22 It is normally applied two to ten days after surgery although it can be put on immediately.
Several studies and literature reviews have discussed the benefits of the air splint, including its lighter weight compared to other postoperative dressings.25 Palsule and Desai studied the air splint's ability to be used as a rehabilitation tool following amputation. The reported effects were a decrease in the distal and mid-girth of the amputated limb, a decrease in edema, the ability to weight bear, a decrease in pain perception, no knee contractures or wound infection, and residual limb shrinkage. They found the air splint effective in creating compression and also in allowing for early ambulation when the splint had a foot attached. An increase in weight bearing using the air splint was also reported. These factors may be the reason edema was decreased in the residual limbâ€"compression kept the blood circulating, preventing swelling of the limb. None of the patients had infection at the wound site, and no knee contractures were reported since the splint kept the knee in extension. The splint was taken off after four hours to allow the knee to move. The researchers also discovered that there was a "significant decrease in limb girth measurements," which was particularly valuable to the elderly subjects.21 Palsule and Desai also studied which load bearing position was best. They determined that deformation of the residual-limb soft tissue occurred sooner when the weight was initiated on the forefoot portion of the prosthesis as opposed to weight on the heel.21
Potential benefits of the air splint are the easy application process that requires little training for the rehabilitation team to don and doff, the decreased risk of knee-flexion contracture, and the ability to release air out of the splint for greater patient comfort.22,24,25 The air splint has also been proven to work for both transfemoral and transtibial amputations.22 Bonner and Green have successfully used a type of air splint on more than 200 patients who had undergone a transtibial amputation.25
One criticism of the air splint is the concern about air leakage. According to the Palsule and Desai study, air leakage could occur if the rehabilitation team or the patient did not exercise caution against pricking the splint, although the leakage was not sudden. The air splint was also uncomfortable for most of the patients in the study, particularly in warm climates.21 Monga et al. reported a possibility of necrosis caused by the inner air splint pressure although no cases have been reported. They also found that it "tended to reduce the suspension of the prosthesis particularly in above knee amputees."23
No recent studies have been prepared on the air splint. Most of the documentation about air splints comes from other literature reviews. Subsequently, there is not enough documentation from studies to form an opinion on this dressing.
While many studies have been conducted on alternatives to soft dressings, there is not a definitive conclusion on which type produces optimal outcomes. A better conclusion could be reached with a study directly comparing IPOPs, RRDs, ZCasts, and air splints. There is also a lack of information on the ZCast with which to compare it to the other dressings. Overall, more research is needed to compare these dressings for there to be a set standard.
Deborah Kinor, MEE, was a clinical researcher at Dayton Artificial Limb Clinic and a production co-op at Prosthetic Design Inc. (PDI), both in Dayton, Ohio, for four co-operative education terms. Erin Sutton, BME, has been a clinical researcher at Dayton Artificial Limb Clinic and a research and development co-op at PDI for the last three years. Erica Gaussa (University of Dayton) is a development co-op at PDI.
- Sanders, G. 1986. Postoperative management. In Lower limb amputations: A guide to rehabilitation, ed. B. May, 358-61. Salem: F.A. Davis Company.
- Smith, D. 2004. General principles of amputation surgery. In Atlas of amputations and limb deficiencies: Surgical, prosthetic, and rehabilitation principles, ed. D. Smith, J. Michael, and J. Bowker, 3rd ed., 27-8. Rosemont: American Academy of Orthopaedic Surgeons.
- Smith, D. G., L. V. McFarland, B. J. Sangeorzan, G. E. Reiber, and J. M. Czerniecki. 2004. Postoperative dressing and management strategies for transtibial amputations: A critical review. Journal of Prosthetics and Orthotics 16 (3S): 15-25.
- U.S Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guideline for rehabilitation of lower limb amputation. Washington DC: Department of Veterans Affairs, Department of Defense; Washington DC, 2008.
- Wu, Y., R. D. Keagy, H. J. Krick, J. S. Stratigos, and H. B. Betts. 1979. An innovative removable rigid dressing technique for below-the-knee amputation. Journal of Bone & Joint Surgery 61-A (5):724-9.
- Choudhury, S. R., G. E. Reiber, J. A. Pecoraro, J. M. Czerniecki, D. G. Smith, and B. J. Sangeorzan. 2001. Postoperative management of transtibial amputations in VA hospitals. Journal of Rehabilitation Research & Development 38 (3): 293-8.
- Bowker, J. Surgical management. 2004. In Atlas of amputations and limb deficiencies: Surgical, prosthetic, and rehabilitation principles, ed. D. Smith, J. Michael, and J. Bowker, 3rd ed., 497-9. Rosemont: American Academy of Orthopaedic Surgeons.
- Hutson. C., T. Dillingham, and A. Esquenazi. 1998. Rehabilitation of the lower limb amputee. In Rehabilitation of the Injured Combatant, vol. 1, by B. Zajtchuk, 96-100. Washington DC: Office of the Surgeon General at TMM Publications Borden Institute.
- Burgess, E. M, R. L. Romano, and J. E. Traub. 1965. Immediate post-surgical prosthetic fitting. Bulletin of Prosthetics Research Fall:42-51.
- Condon, R. E., and P. H. Jordan. 1969. Immediate postoperative prostheses in vascular amputations. Paper presented at the annual meeting of the American Surgical Association, Cincinnati, OH. Subsequently printed in Annals of Surgery 9:435-44.
- Rheinstein, J., C. J. Wong, and J. E. Edelstein. 2006. Postoperative Management. In Prosthetics and patient management: A comprehensive clinical approach, ed. K. Carroll and J. E. Edelstein, 20-2. Thorofare: Slack Incorporated.
- Deutsch, A., R. D. English, T. C. Vermeer, P. S. Murray, and M. Condous. 2005. Removable rigid dressings versus soft dressings: A randomized, controlled study with dysvascular, trans-tibial amputees. Prosthetics and Orthotics International 29 (2):193-200.
- Ladenheim, E., Oberti-Smith, K., and G. Tablada Results of managing transtibial amputations with a prefabricated polyethylene rigid removable dressing. Journal of Prosthetics and Orthotics 2007; 19:2-4.
- Woodburn, K. R, S. Sockalingham, H. Gilmore, M. Condie, C. Ruckley, et al. 2004. A randomised trial of rigid stump dressing following trans-tibial amputation for peripheral arterial insufficiency. Prosthetics and Orthotics International 28 (1): 22-7.
- Mooney, V., J. P. Harvey, E. McBride, and R. Snelson. 1971. Comparison of postoperative stump management: Plaster vs. soft dressings. Journal of Bone & Joint Surgery 53 (2): 241-9.
- Muller, M. 1982. Comparison of removable rigid dressings and elastic bandages in preprosthetic management of patients with below-knee amputations. Physical Therapy 62:1438-41.
- Taylor, L., S. Cavenett, J. Stepien, and M. Crotty. 2008. Removable rigid dressings: A retrospective case-note audit to determine the validity of post-amputation application. Prosthetics and Orthotics International 32:223-30.
- Baker, W. H., R. W. Barnes, and D. G. Shurr. 1977. The healing of below-knee amputations: A comparison of soft and plaster dressings. American Journal of Surgery 133 (6):716-8.
- Johannesson, A., G. U. Larsson., T. Öberg, and I. Atroshi. 2008. Comparison of vacuum-formed removable rigid dressing with conventional rigid dressing after transtibial amputation: Similar outcome in a randomized controlled trial involving 27 patients. Acta Orthopaedica 79 (3):361-9.
- Murdoch, G. 1983. The postoperative environment of the amputation stump. Prosthetics and Orthotics International 7 (2):75-8.
- Palsule, S., and O. Desai. 2004. Early post-operative rehabilitation with a pneumatic weight-bearing temporary prosthesis. Indian Journal of Occupational Therapy 36 (1):17-21.
- Kay, H. W. 1975. Wound dressings: Soft, rigid, or semirigid? Orthotics and Prosthetics 29 (2):59-68.
- Monga, T. N., D. C. Symington, P. Lowe, and N. Elkin. 1985. Load bearing and suspension characteristics of airsplint as a temporary prosthesis. Prosthetics and Orthotics International 9 (2):100-4.
- Sher, M. H. 1974. An alternative to the immediate postoperative prosthesis. Archives of Surgery 108 (5):746-7.
- Rausch, R. W., and A. A. Khalili. 1985. Air splint in preprosthetic rehabilitation of lower extremity amputated limbs. A clinical report. Physical Therapy 65 (6):912-4.