What is the role of shaping and rigid splinting in post-operative care for a below-knee amputation (BKA)?

From the Guidelines

Shaping and rigid splinting are crucial components of post-operative care for below-knee amputations (BKAs), primarily serving to control edema, protect the residual limb, and prepare it for prosthetic fitting. Immediately after surgery, a rigid dressing or removable rigid dressing (RRD) should be applied to the residual limb, typically consisting of plaster or fiberglass casting material. This rigid splinting should remain in place for 5-7 days post-surgery, providing compression to minimize swelling and protecting the surgical site from trauma. After the initial rigid dressing is removed, shaping of the residual limb begins using elastic bandages or compression socks (typically 20-30 mmHg compression), applied in a figure-eight pattern to create a conical shape. Alternatively, a silicone liner or shrinker sock can be used, which should be worn 23 hours per day, removing only for wound care and bathing. Proper shaping prevents the development of a bulbous end and facilitates better prosthetic fit. The compression therapy should continue for 4-8 weeks post-surgery or until the residual limb volume stabilizes. Early rigid splinting also allows for safer early weight bearing when appropriate, typically beginning 2-3 weeks post-operatively with a temporary prosthesis. These interventions are crucial because they address the natural tendency of the residual limb to develop edema, which can delay healing, increase pain, and complicate prosthetic fitting if left unmanaged, as suggested by the American Academy of Orthopaedic Surgeons clinical practice guideline summary for limb salvage or early amputation 1. Some key points to consider in the management of BKAs include:

• The use of a protective device that allows mobilization by 2 to 4 weeks postoperatively, as recommended by the diagnosis and treatment of acute achilles tendon rupture study 1
• The importance of patient physiology and mortality risk in the decision to pursue limb salvage versus amputation, as highlighted in the american academy of orthopaedic surgeons clinical practice guideline summary for limb salvage or early amputation 1
• The need for careful consideration of the level of amputation, taking into account vascular, reconstructive, and rehabilitation issues, as discussed in the 2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1 However, the most recent and highest quality study, the american academy of orthopaedic surgeons clinical practice guideline summary for limb salvage or early amputation 1, provides the best guidance for the role of shaping and rigid splinting in post-operative care for BKAs.

From the Research

Role of Shaping and Rigid Splinting in Post-Operative Care for BKA

• Shaping and rigid splinting play a crucial role in the post-operative care of below-knee amputation (BKA) patients, as they help in reducing edema, pain, and facilitating wound healing 2, 3.
• The use of a removable rigid dressing, such as a below-the-knee plaster cast held by a suspension stockinette to a supracondylar plastic cuff, has been shown to be an effective method for postoperative, pre-prosthetic, and prosthetic care of BKA patients 2.
• Rigid splinting has also been found to reduce the incidence of pre-tibial skin breakdown and distal edema, produce fast stump shrinkage, and shorten the time to ambulatory discharge with a temporary prosthesis 2.
• Immediate rigid-cast prosthetic fitting after BKA has been advocated by some researchers, as it reduces edema and postoperative pain, and permits the patient to stand at from one to two days postoperatively 3.
• However, the use of immediate fit prostheses (IPOP) instead of soft stump dressings has not been shown to have a significant bearing on postoperative hospitalization time, functional recovery, postoperative pain, morbidity, and mortality in amputees 4.

Benefits of Rigid Splinting

• Reduces edema and pain 2, 3
• Facilitates wound healing 2, 3
• Reduces the incidence of pre-tibial skin breakdown and distal edema 2
• Produces fast stump shrinkage 2
• Shortens the time to ambulatory discharge with a temporary prosthesis 2
• Permits the patient to stand at from one to two days postoperatively 3

Comparison with Soft Dressings

• The use of IPOP instead of soft stump dressings has not been shown to have a significant bearing on postoperative hospitalization time, functional recovery, postoperative pain, morbidity, and mortality in amputees 4.
• However, the use of IPOP has been found to result in a higher percentage of patients ultimately ambulating with prostheses 4.