Vol. 40 No. 3, May/June 2003
Pages 213 — 224
Postoperative dressing and management strategies for transtibial amputations: A critical reviewDouglas G. Smith, MD; Lynne V. McFarland, PhD, MS; Bruce J. Sangeorzan, MD; Gayle E. Reiber, PhD, MPH; Joseph M. Czerniecki, MDDepartment of Orthopedics and Sports Medicine, University of Washington, Seattle, WA; Prosthetic Research Study, Seattle, WA; Amputee Coalition of America, Knoxville, TN; Department of Health Services, University of Washington, Seattle, WA; Department of Veterans Affairs (VA) Health Services Research and Development, Seattle, WA; VA Center of Excellence for Limb Loss Prevention and Prosthetics Engineering and VA Rehabilitation Research and Development, Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WAAbstract — Postamputation management is an important determinant of recovery from amputation. However, consensus on the most effective postoperative management strategies for individuals undergoing transtibial amputation (TTA) is lacking. Dressings can include simple soft gauze dressings, thigh-high rigid cast dressings, shorter removable rigid dressings, and prefabricated pneumatic dressings. Postoperative prosthetic attachments can be added to all but simple soft dressings. These dressings address the need to cleanly cover a fresh surgical wound, but not all postoperative dressings are designed to facilitate the strategic goals of preventing knee contractures, reducing edema, protecting from external trauma, or facilitating early weight bearing. The type of dressing and management strategy often overlap and are certainly interrelated. Current protocols and decisions are based on local practice, skill, and intuition. The current available literature is challenging, and difficulties include variations in healing potential, in comorbidity, in surgical-level selection, in techniques and skill, in experience with postoperative strategies, and with poorly defined outcome criteria. This paper reviews the published literature and compares measures of safety, efficacy, and clinical outcomes of the various techniques. Analysis of 10 controlled studies supported only 4 of the 14 claims cited in uncontrolled, descriptive studies.The literature supports that rigid plaster cast dressings result in significantly accelerated rehabilitation times and significantly less edema compared to soft gauze dressings, and prefabricated pneumatic prostheses were found to have significantly fewer postsurgical complications and required fewer higher-level revisions compared to soft gauze dressings. No studies directly compared pneumatic prostheses with rigid dressings, and no reports compared all types of dressings within one study. In conclusion, the literature and evidence to date is primarily antidotal and insufficient to support many of the claims. Future randomized trials on TTA dressing and management strategies are clearly needed to collect the evidence needed to best guide clinicians with the decision.Key words: air splint, immediate postoperative prosthesis, pneumatic postoperative prosthesis, soft dressings, transtibial amputation.