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APOPPS Abstract

This report will introduce the Adjustable Postoperative, Protective & Preparatory System (APOPPS™ [patent #s 5,571,209 & 5,728,165]). It will present the system in detail, highlighting: the protective aspects of the FLO-TECH-TOR™ with its: unique one piece construction (providing unparalleled volume reduction), compression features which are concentrated in the medio-lateral areas of the transtibial amputation to minimize popliteal pressure, flexibility (encouraging a more comfortable healing process), early weight bearing through use of the UFOS™ and easy access to bandages for attentive wound care throughout the early pre-preparatory stages of ambulation. This report will show how converting from the post-operative early ambulation system to the VCSPS™ portion of the APOPPS™ is simple and effective.

This report will explain the rationale for its invention and discuss selection of components, A number of cases will be cited, showing: selection of appropriate sizes, donning and doffing the APOPPS™ and wear and care of the various component parts.

Finally, and most significant, this report will discuss the future of post amputation rehabilitation in today's cost cutting health care environment and how the APOPPS™ will save health care dollars by providing: protection from injury, enhanced healing and volume reduction, and a more positive emotional and mental environment allowing patients to return to productive healthy lifestyles as quickly as possible.

The APOPPS™ is a three-part adjustable socket system providing post-operative, early and preparatory prosthetic care. The FLO-TECH-TOR™ provides protection from accidental injury and allows the patient to begin controlled and monitored weight bearing. It is an early intervention treatment allowing patients to go home from a hospital with a protective device. This feature minimizes the worry of injury caused by: an accidental bump, slipping or falling on their recently amputated residuum. The likelihood of sustaining injury, caused during the transfers or injuries caused by simply trying to shift ones weight in bed, is very high. The FLO-TECH-TOR™ minimizes these kinds of incidents.

Many patients experience phantom sensations, some require treatment for the reduction of pain others for cramping. But one area of the phantom sensation phenomenon not generally addressed is the feeling that one's foot is intact.

Usually this is greeted with curiosity, even humor that one can feel a foot that is no longer a part of their body. However, I suggest this sensation leads many patients to accidental injury when, in one of their less than conscious moments, they get up and take or attempt to take a step. Still others collapse due to weakness unable to support their weight on the remaining "healthy" extremity and they reach for support from the amputated extremity. The result of this kind of incident is an impact injury to the residuum.

Injuries of this type, usually, range from mild bruises to totally compromised closures of the wound sight. The healing process is equally as varied. Some patients are able to get by with little more than pain suppressants for a few days while others require revisions to the residuum and still others develop infections resulting in drastic procedures to regain their status as a patient ready for the ambulatory rehabilitation process.

Reducing impact injuries is important because it will decrease the incidents of post amputation revisions in a population already at risk for secondary amputation (1) (2) (3).

The APOPPS™ provides the protection necessary to minimize or prevent the effects of an impact injury to the transtibial residuum while pursuing early ambulation. The FLO-TECH-TOR™ portion of the APOPPS™ features innovative one piece construction which:

• Is Anatomically-bivalved to focus volume reduction where it will produce gentle and safe results
• Provides timely compression (reducing and shaping the transtibial amputation at the pace each individual patient needs)
• Is easy to don and doff
• Is light weight
• Prevents, and reduces, flexion contractures
• Is well ventilated
• Allows easy access to bandages for observation and meticulous wound care by patient, nursing, home care providers and/or physicians (1) (4)
• Allows scheduled range of motion exercises to stimulate healing and build strength
• Allows therapists to begin a controlled weight-bearing program prior to introduction of a pylon and foot.
• Builds patient confidence by involving them in their daily regime

The anatomically bivalved socket is unique because the separation between the anterior and posterior segments, of the polyethylene-1, is shaped to provide specific rigidity to non compressible boney areas and sensitive circulatory vessels while the segments encompassing soft tissue areas of the medial and lateral sides of the residuum are flexible (5). This anatomic bivalve pattern results in a patented process, which provides flexible compression noticeably different on the medial side of the residuum than on the lateral side. It is clearly evident how the tibia remains supported and becomes more pronounced as the residuum decreases in volume.

Volume reduction is accomplished without the use of exaggerated pressure. The dressings or bandages will provide all the compression necessary while the FLO-TECH-TOR™ portion of the APOPPS™ concentrates on protection during the immediate post-operative phase of the healing process. Later as the wound is judged to be ready for a shrinker or an elastic wrap the FLO-TECH-TOR™ is used over the compression of choice continuing to provide the protection necessary to prevent or minimize the effects of an impact injury. Still later as the healing process continues the FLO-TECH-TOR™ portion of the APOPPS™ can be snugly secured providing auxiliary compression and shaping of the residuum as the patient begins a controlled weight-bearing program of daily physical therapy.

The FLO-TECH-TOR™ portion of the APOPPS™ is easy to don and doff because there is only one strap and two Neoplush^® bands the patient has to work with and because the one piece anatomic socket design opens like a clam shell allowing the residuum to be placed in to the socket with no pulling, twisting or massaging required to secure the residuum in the appropriate position.

The FLO-TECH-TOR™ portion of the APOPPS™ is so lightweight it does not require a suspension belt, in most cases. The socket is secured with a circumferential strap of webbing and Velcro^® -3 at the level of the patella tendon and the tibial tubercle and two Neoplush^® bands. One band secures the thigh while the other provides suspension, support and/or compression between the anterior and posterior segments of the below knee socket area of the FLO-TECH-TOR™ portion of the APOPPS™ focusing volume reduction in the medial and lateral fleshy areas of the residuum.

The FLO-TECH-TOR™ portion of the APOPPS™ prevents flexion contractures because its design incorporates the knee joint in the socket. The posterior portion of the socket extends 8" to 9" above the knee. The anatomically bivalved socket portion extends seven inches (7") or nine inches (9") from the mid patella tendon to the distal end. These two lengths will accommodate about 80% of all transtibial amputations. Amputations of varying lengths are accommodated by use of the APOPPS™ pads, provided with each socket. The APOPPS™ sockets are flexible to promote venous return and to permit necessary motion of the Knee. The patient should be taught to remove the FLO-TECH-TOR™ portion of the APOPPS™ several times a day to: perform wound care, examine the residuum, replace damp outer socks or shrinkers, allow care givers to replace soiled bandages and gently massage the residuum and range the knee joint.

Tissue pressure is reduced because the unique design of the APOPPS™ permits considerable ventilation from the post-operative socket (FLO-TECH-TOR™) to the preparatory socket (VCSPS™). The reduction of tissue pressures is further assured by removing the FLO-TECH-TOR™ portion of the APOPPS™ several times a day.

Every prosthetists can relate stories of patients who have fallen in the middle of the night because they forgot they had an amputation or the number of patients who because of fatigue fell out of the grip of their spouse. Most patients are injured through no fault of their own from bumps and bruises received in the course of their daily living (scrapes on wheel chair, children jumping on their lap, etc.). Prosthetists have worked closely with physicians, therapists, family members and patients to provide post injury prosthetic care which has ranged from socket adjustments to socket replacements, to revised amputations, to months of waiting for an infected wound to heal.

Clinics see patients on a regular basis whom, in many cases, are deemed ready for a preparatory prosthesis. However, the day of clinic they greet the clinic team with, "I fell last night and came down on the leg. I haven't looked at it yet but it doesn't feel right. Could you take a look and tell me if it's okay. Will I be able to get my new leg soon?" Most of the time these patients begin a slow process of healing before the prosthetic plan can be reconsidered. During this delay they are still at risk for further injury.

These kinds of occurrences, at St. Joseph's clinic in Syracuse New York, pushed me to action. Three patients were seen who had, very recently, sustained an impact injury. They were all emotionally distraught because they were not going to be able to "get going" and each of them was sent home with new wound care instructions, medication and words of caution. However, there was no prosthetic system which could offer them protection from the one thing they couldn't prevent - accidental impact injury.

Within a few weeks a prototype of the APOPPS™ was made and testing of the design features was begun. Over the next six months several patients were fitted with excellent results.

The APOPPS is fitted over the dressings and bandages. It is therefore necessary to measure over these bandages when determining the appropriate size for each patient. The FLO-TECH-TOR™ accommodates the reduction of edema and swelling and the removal of bandages because of the anatomic overlapping design.

All of these features will provide the kind of protective care each patient with a transtibial amputation needs. Surgeons can prescribe a system which preserves their fine work, keeps health care costs under control and minimizes and protects their patients from: injury, prolonged rehabilitation and additional emotional trauma. Prosthetists can begin the process of developing the kind of relationship necessary in providing prosthetic care without interruption due to injuries that can be prevented.

Physical therapists can challenge their patients to give their best efforts, knowing the likelihood of injury has been reduced. This kind of security can allow patients to attempt to comply with work at home orders with less fear of injury. Patients can continue on the rehabilitation path with peace of mind, security, protection and the benefits of shaping their residuum and building tolerance for a definitive prosthesis as they progress from the early weight bearing FLO-TECH-TOR™ portion of the APOPPS™ to the VCSPS™ (preparatory) portion of the APOPPS™.

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