Guidance for the multi disciplinary

team on the management of post-

operative residuum oedema in lower
limb amputees.

Authors: Elizabeth Bouch, Katie Burns, Elizabeth Geer, Matthew Fuller and Anna Rose

Acknowledgements: Penny Broomhead, BACPAR and University of Bradford

 Introduction
Guidance development
This guidance is designed for use by the multi-disciplinary team, working with lower limb
amputees. It provides recommendations based on evidence gained from the literature to
aid decision making regarding non-pharmacological oedema management post
operatively and to inform best practice.

It has been developed from work originally completed as part of a Post graduate
certificate from Bradford University and has been endorsed by the British Association of
Chartered Physiotherapists in Amputee Rehabilitation (BACPAR) to support and enhance
the other evidence based guidance produced by this professional network (Appendix 3);
BACPAR is a professional network and a Chartered Society of Physiotherapy (CSP)
affiliated organisation. BACPAR aims to promote best practice in the field of amputee and
prosthetic rehabilitation, through evidence and education, for the benefit of patients and
the profession. It is committed to research and education, providing a network for the
dissemination of best practice in pursuit of excellence and equity whilst maintaining cost
effectiveness.

This document has been produced by practising physiotherapists and occupational

therapists who are members of the Chartered Society of Physiotherapy and British
Association of Occupational Therapists and who hold registration with the Health and
Care Professions Council (HCPC). No sponsorship or funding was received during the
development of this guideline and no conflicts of interest have been declared by the
authors.

All decisions on the application of oedema control modalities should be made jointly by
the multidisciplinary team. The residuum should also be regularly reassessed and
measurements documented in order to ascertain the clinical effectiveness of the chosen
oedema control modality.

Within the current literature there are various methods of oedema control described,
with wide variation in their application and a lack of clarity on the timing of such
applications. The guidance presents current evidence and is intended as a resource to
guide application of best practice and to assist decision making. It should be used to
support clinical judgement. Further research is needed to substantiate the guideline with
regards to the timing and application of modalities.

Background
Oedema control methods should ideally be safe, easy to apply, remain secure, prevent
skin breakdown, provide limb shrinkage and shaping, be painless and cost effective. 6,7

Oedema occurs post operatively following lower limb amputation surgery due to the
trauma and handling of tissues during surgery.12,20,29 In normal tissues, volume is
controlled by the complex interplay of fluid transfer across capillary membranes and
lymphatic re-absorption. Usually equilibrium is maintained unless pathology or trauma 20,

BACPAR post operative oedema guidance Page 1

such as amputation, occurs. This swelling remains due to post amputation inactivity29 and
a lack of muscle tone in the residuum.29

The presence of post-operative oedema can cause the following complications to

patient’s rehabilitation;
 Delayed healing time12,18
 Pain1,20
 Delayed mobility1,3
 Increased time to start of prosthetic phase of rehabilitation 15,16,18
 Increase in length of hospital stay16
 Poor stump shaping and maturation10

Literature Review
Evidence was gathered from a thorough review of available literature in November 2010
using a search of multiple databases: AMED, BNI (British Nursing Index), CINAHL,
Cochrane, EMBASE, Medline, NHS EVIDENCE, OT Seeker, PEDro, Pubmed and hand
searches of relevant literature reference lists. Limits were applied to exclude minor
amputation, upper limb amputations, hip disarticulations and hemi pelvectomy, children
and non-human studies. The inclusion criteria included major lower limb amputations,
human adults and papers written in the English language.

A list of all methods of oedema control was compiled by the guidance development group
(GDG) all working in the field of vascular surgery and amputee rehabilitation.

Search terms generated from this list were; Elevat*, Swelling, Stump AND Board,
Shrinker, Sili* AND/OR Sleeve, Heal*, Femurett*, Exercise, Juzo, Tubi, Flowtron *,
Wound, Elastic AND/OR band*, Compres*, PPAM, EWA, Sock, Volume, POP, Plaster of
Paris, Rigid AND dressing.

117 articles were identified by the literature search, 73 were excluded by abstract. Of the
remaining 44 articles, 39 were appraised using the Scottish Intercollegiate Guidelines
Network (SIGN) methodology checklists28, by two GDG members, as recommended by the
National Institute of Health and Clinical Excellence (NICE)26 and assigned a level of
evidence (Appendix 1). This appraisal tool was selected as the GDG were familiar with its
use from previously published guidelines relating to lower limb amputees 21. The
remaining five articles could not be appraised as their methodological design did not have
an appropriate corresponding checklist; these include OrthoEurope 27 & manufacturers
guidance24. These articles were included in the guideline’s additional reference list, as
they provide a depth of explanation to the guideline recommendations. The evidence
base for each modality was assigned an overall grade of recommendation based on the
quality of research available. (Appendix 2)

Robust evidence was found to support the use of Rigid dressings, Pneumatic Post
Amputation Mobility Aid (PPAM aid), compression socks, wheelchair stump boards and to
discourage the use of elastic bandage wrapping.

BACPAR post operative oedema guidance Page 2

 Methods of Oedema Control
Rigid Dressings
A rigid or semi rigid dressing applied to a trans-tibial residuum to contain and further
prevent formation of post-operative oedema.

Grade of
recommendation

B
Types available

 Rigid removable (extending above the knee or remaining below knee, eg fibreglass
sock)
 Vacuum formed manufactured by Ossur
 Rigid non removable (eg Plaster of Paris)
 Semi rigid (extending above the knee or remaining below knee).

These techniques require specialist skills and materials. Costs vary depending on design
and supplier.

Application

When

 Immediate post-operative/theatre4,8,9,12,14,15,18,19
 0-3 days post-operative5

Who

 Multi-disciplinary team members need to have documented training prior to

application of rigid dressings 11,23
 Surgeon8,9

Duration

 The literature is unclear on the duration of use of rigid dressings but the GDG
suggest use until fitting of a prosthesis or until stump volumes have stabilised.
 Rigid Dressings

Kept on for 7 days, checked and reapplied for further 14 days19

Dressing changed every 7 days15

5-7 days then replaced with compression therapy9
 Rigid Removable Dressings

Continuous (to be removed for wound inspection)7,8,11

5-7 days then swapped to standardised compression therapy8

BACPAR post operative oedema guidance Page 3

Benefits

 Reduction in oedema1,7,8,11,12,14,15,18
 Reduced healing time4,12,15,18
 Reduced time to prosthetic casting3,7,8,9,12,15,19
 Reduced incidence of fixed flexion deformities at the knee15
 Physically protects the stump from external trauma4
 Removable rigid dressings permits regular residuum inspection7,8
 Able to apply earlier than other modalities such as stump shrinkers 7

Further Considerations

 Further reduction in oedema with addition of polymer gel sock5 or compression

sock under rigid dressing
 Various designs are available, however there is no consensus as to which is
best.1,12,14
 Multi-disciplinary team members need to have documented training prior to
application of rigid dressings23
 This technique requires specialist materials and cost varies.

BACPAR post operative oedema guidance Page 4

Pneumatic Post Amputation Mobility Aid (PPAM aid)
An early walking aid consisting of a pneumatic sleeve extending from groin to below
amputation residuum enclosed by a frame cage.

Grade of
recommendation

D
Types available

Ortho Europe - trans-tibial and trans-femoral bags available with 3 heights and 2
circumferences of frames available.

Application

When

 Can be used from 5 days post-operative pending a satisfactory wound inspection27

 From 6 days post-operative13
 If used prior to 10 days post-operative, time to casting is significantly reduced3

Who

 Used by therapist trained in the correct and safe application 2

Duration

 Inflation time is increased from 5 minutes to up to 2 hours twice a day27

Frequency

 Everyday25,27
 The GDG suggest use of the PPAM aid until fitting of a prosthesis or until stump
volumes have stabilised.

Benefits

 Reduction of oedema3,13,25
 Improves limb shaping13
 Can be used as an assessment tool for prosthetic limb potential2,25
 Allows commencement of early walking preventing deterioration of postural
muscles13

Further Considerations

 Can be used for trans-femoral, through-knee and trans-tibial amputations25

 Can cause delayed healing if used incorrectly25
 Only to be used partially weight bearing and not bilaterally25

BACPAR post operative oedema guidance Page 5

Compression Socks
A conical, graduated, sock like compression garment for residual limbs.

Grade of
recommendation

D
Types available

Manufactured by Juzo and Otto Bock. Available for trans-tibial and trans-femoral
amputations in a variety of lengths and circumferences.

Application

When

 Within 10 days post-operative3

Who

 No evidence is documented in the literature to suggest who should measure and

fit a compression sock.

Duration

 A regime for wearing a compression sock is not documented in current literature

or manufacturer’s instructions.

Benefits

 Reduction in oedema1,2,10
 Reduced time to prosthetic casting3
 Easy donning and doffing10
 Helps to shape into cylindrical shape for casting10

Further Considerations

 Compression socks should be used in preference to elastic bandage wrapping 2

 Trans-femoral and trans-tibial socks available24
 Compression sock size selection as per manufactures’ guideline24
 Bespoke compression socks can be ordered from the manufacturers
 Frequent donning and doffing of socks in the early post op stages can create
excessive distraction pressure over the distal end therefore the GDG suggest the
use of a bandage applicator for ease of application and to reduce this effect.
 Manufactures’ guidance does not say when compression socks can be initially
applied.

BACPAR post operative oedema guidance Page 6

Wheelchair Stump Boards

A detachable wheelchair accessory to allow elevation of the residuum when seated in

the wheelchair.

Grade of
recommendation

D
Types

 Kings Mark II
 Different types available from different wheelchair manufacturers

Application

When

 Within a week post-operative17

Who

 No literature documents who should provide the stump boards but it is suggested
by the GDG that this is done by the professional responsible for providing and
organising a loan/permanent wheelchair.

Duration

 Literature does not state how long a stump board should be used for but the GDG
group suggest their use whenever the patient is in the wheelchair without a
prosthesis.

Benefits

 Reduces formation of dependent oedema17

 Reduced formation of fixed flexion deformities at the knee 17
 Increased patient comfort17
 Protection of the residuum against injury17

Further Considerations

 Primarily used with trans-tibial amputations, but may be appropriate in trans-

femoral or through-knee amputations where the residuum length exceeds the seat
depth17

BACPAR post operative oedema guidance Page 7

Elastic Bandage Wrapping
Figure of eight elastic bandaging technique, consisting of oblique turns that alternately
ascend and descend after encircling the lower limb. The greatest pressure is applied at
the distal end and allows several degrees of compression of the residual limb to control
oedema. 10

The evidence available6 is against the use of elastic bandages therefore information
regarding types available and their application is not included in this guideline.

Elastic bandage wrapping has been used as the control group in comparison with rigid
dressings and was demonstrated to be less effective in oedema reduction1,11,15,18

Elastic bandaging is unreliable and dangerous in terms of pressure and pressure

distribution6

Conclusion
Based on the best current available evidence rigid/semi rigid dressings should be used
when expertise, time and resources allow; the benefits are well documented in the
literature. The PPAM aid, compression socks and stump boards have been shown to have
some evidence base for oedema control and may be used in addition or in the absence of
rigid dressings dependant on clinical judgement. However, these modalities are not
necessarily primarily intended for use for oedema control. Their advantages include
preparation for prosthetic rehabilitation, reduction in flexion deformities and
maintenance/improvement in muscle tone and are important components of amputee
rehabilitation. Compression socks and the PPAM aid are the only tools available for trans-
femoral amputees.

Although compression socks are widely used3 as a form of oedema control there is very
limited evidence on aspects such as timing of application, who should assess
appropriateness and the frequency it should be worn for. It is suggested that further
research is required in order to offer more clarity for clinicians in these areas.

BACPAR post operative oedema guidance Page 8

 References
1. Blake, D.J., Benedetti, G.E., Brielmaier, S.M, Coniglio, L.A., Czerniecki, J., Fergason, J.,
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S., Sigford, B.J., Velez, D.J. and Weber, M. (2007) Department of Veterans Affairs -
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rigid dressings verses soft dressings: a randomized, controlled study with dysvascular,
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below-knee amputation stump bandages: elastic bandaging, the puddifoot dressing and a
pneumatic bandaging technique compared. British Journal of Surgery, 62(12), pp.982-986.
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and elastic bandage in reducing the residual limb volume of below knee amputees.
Journal of the Medical Association of Thailand, 91(9), pp.1441-1446. 1+
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formed removable rigid dressing with conventional rigid dressing after transtibial
amputation. Acta Orthopaedica, 79(3), pp.361-369. 2+
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Atroshi, I. (2010) Outcomes of a standardized surgical and rehabilitation program in
transtibial amputation for peripheral vascular disease: a prospective cohort study.
American Journal of Physical Medicine and Rehabilitation, 89(4) pp.293-303. 2+
10. Louie, S.W., Lai, F.H., Poon, C.M., Leung, S.W., Wan, I.S. and Wong, K. (2010) Residual limb
management for persons with transtibial amputation: comparison of bandaging technique
and residual limb sock. Journal of Prosthetics and Orthotics, 22(3), pp.194-201. 1+
11. Mueller, M.J. (1982) Comparison of removable rigid dressings and elastic bandages in
preprosthetic management of patients with below-knee amputations. Physical Therapy,
62(10), pp.1438-1441. 2+
12. Nawijn, S.E., Van Der Linde, H., Emmelot, C.H. and Hofstad, C.J. (2005) Stump
management after trans-tibial amputation: a systematic review. Prosthetics and Orthotics
International, 29(1), pp.13-26. 1+
13. Redhead, R.G., Davis, B.C., Robinson, K.P. and Vitali, M. (1978) Post-amputation
pneumatic walking aid. British Journal of Surgery, 65, pp.611-612. 3

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 14. Smith, D.G., McFarland, L.V., Sangeorzan, B.J., Reiber, G.E. and Czerniecki, J.M. (2003)
Postoperative dressing and management strategies for transtibial amputations: a critical
review. Journal of Rehabilitation Research and Development, 40(3), pp.213-224. 1+
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Additional Reference List

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traumatic oedema in lower legs using intermittent pneumatic compression. Scandinavian
Journal of Rehabilitation Medicine, 20(1), pp.25-28.
21. Brett, F., Burton. C., Brown. M., Clark, K., Duguid, M., Randell. And Thomas. D. (2012) Risks
to the contra-lateral foot of unilateral lower limb amputees: A therapist’s guide to
identification and management. BACPAR. Available from:
http://www.csp.org.uk/sites/files/csp/secure/ka-final_contra_foot_guideline.pdf
[accessed on 20th April 2011].
22. Ham, R. and Whittaker, N. (1984) The kings amputee stump board: a new design.
Physiotherapy, 70(8), pp.300.
23. Hickok, R.J. and Zimmerman, J.P. (1972) What are the legal implications for a physical
therapist applying an immediate postoperative rigid dressing, a cast change, or a
preparatory plaster of Paris prosthesis to an amputee under the order and supervision of
a physician? Physical Therapy, 52(3), pp.330-331.
24. Juzo JUZO-Varin soft-in two-way stretch compression stump shrinkers.
25. Lien, S. (1992) How are Physiotherapists using the vessa pneumatic post-amputation
mobility aid? Physiotherapy, 78(5), pp.318-322.
26. National Institute for Health and Clinical Excellence (2009) The Guideline Manual 2009
[online]. London: National Institute of Health and Clinical Excellence (NICE). Available
from:
http://www.nice.org.uk/aboutnice/howwework/developingniceclinicalguidelines/clinicalg
uidelinedevelopmentmethods/GuidelinesManual2009.jsp [accessed 5th April 2011].
27. Ortho Europe. Introducing PPAM Aid the pneumatic post-amputation mobility aid.
Hampshire: Ortho Europe. Available from: http://www.ortho-
europe.com/products/PPAM/ppam-aid-brochure-2010.pdf [accessed 19th March 2011].

BACPAR post operative oedema guidance Page 10

 28. Scottish Intercollegiate Guidelines Network (2008) SIGN 50: A Guideline Developer’s
Handbook [online]. Edinburgh: Scottish Intercollegiate Guidelines Network (SIGN).
Available from: http://www.sign.ac.uk/guidelines/fulltext/50/index.html [accessed 30th
March 2011].
29. Varghese, G., Hindle, P., Zilber, S., Perry, J.E. and Redford, J.B. (1981) Pressure applied by
elastic bandages: a comparative study. Orthotics and Prosthetics, 35(4), pp.30-36.

BACPAR post operative oedema guidance Page 11

 Appendix 1
Levels of evidence
1++ High quality meta-analyses, systematic reviews of Randomised Controlled Trials
(RCTs), or RCTs with a very low risk of bias.

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of

bias.

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort or studies. High quality
case control or cohort studies with a very low risk of confounding or bias and a
high probability that the relationship is causal

2+ Well-conducted case control or cohort studies with a low risk of confounding or

bias and a moderate probability that the relationship is causal

2- Case control or cohort studies with a high risk of confounding or bias and a
significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

Appendix 2
Grades of Recommendations
A At least one meta-analysis, systematic review, or RCT rated as 1++, and directly
applicable to the target population; or A body of evidence consisting principally
of studies rated as 1+, directly applicable to the target population, and
demonstrating overall consistency of results.

B A body of evidence including studies rated as 2++, directly applicable to the

target population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+

C A body of evidence including studies rated as 2+, directly applicable to the target
population and demonstrating overall consistency of results; or Extrapolated
evidence from studies rated as 2++

D Evidence level 3 or 4; or Extrapolated evidence from studies rated as 2+

BACPAR post operative oedema guidance Page 12

 Appendix 3
BACPAR evidence based guidance
 Evidence based clinical guidelines for the physiotherapy management of adults
with lower limb prostheses.
http://bacpar.csp.org.uk/publications/evidence-based-clinical-guidelines-
physiotherapy-management-adults-lower-limb-p

 Clinical guidelines for the pre and post operative physiotherapy management of
adults with lower limb amputation.
http://www.csp.org.uk/sites/files/csp/secure/BACPAR_guidelines_lower_limb_am
putation_2006.pdf

 Guidance for falls prevention in lower limb amputees.

http://www.csp.org.uk/sites/files/csp/secure/falls_prevention_lowerlimb_ampute
es.pdf

 Risks to the contra-lateral foot of unilateral lower limb amputees – guideline.

http://www.csp.org.uk/sites/files/csp/secure/ka-final_contra_foot_guideline.pdf

All BACPAR and jointly produced publications are available to download from the BACPAR
website http://bacpar.csp.org.uk/publications

BACPAR post operative oedema guidance Page 13

 Appendix 4
Guideline Development Group (GDG)
Elizabeth Bouch is a Senior Specialist Physiotherapist working in amputee rehabilitation at
Central Manchester Foundation Trust. Elizabeth qualified as a physiotherapist in 2004 and
completed her junior rotations at Central Manchester Foundation Trust. In 2007 she
obtained a static senior post working with amputees and commenced the senior specialist
role in 2009. Elizabeth specialises in Intermittent Claudication, acute amputee
rehabilitation and early prosthetic rehabilitation both in an outpatient and community
setting. In 2011 Elizabeth completed a post graduate certificate in amputee rehabilitation
at The University of Bradford and is currently working to complete a masters in amputee
rehabilitation at The University of Bradford.

Katie Burns is an Expert Practitioner Occupational Therapist working in vascular and

amputee rehabilitation at The James Cook University Hospital in Middlesbrough. Katie
qualified as an Occupational Therapist in 2004 at Teesside University. Following a
graduate rotation Katie secured a senior position in vascular and amputee rehabilitation
in 2007 and commenced the expert practitioner role in 2008. In 2011 Katie completed a
post graduate certificate in amputee rehabilitation at The University of Bradford. Katie is
now working towards a masters in evidence based practice at Teesside University.

Matthew Fuller is a highly specialised physiotherapist in vascular surgery and amputee

rehabilitation working at Guys and St Thomas' NHS Foundation Trust. Matthew qualified
as a physiotherapist in 2000 from the University of East London. Matthew has worked
within vascular and acute amputee rehabilitation since 2006. Firstly he held senior
physiotherapist posts within a regional prosthetic centre working with pre-prosthetic,
prosthetic rehabilitation and established amputees before moving to the vascular surgery
department at St Thomas' Hospital in 2010. In 2011 Matthew completed a post graduate
certificate in amputee rehabilitation at The University of Bradford and has held the post
of Public Relations Officer on the executive committee of The British Association of
Physiotherapists in Amputee rehabilitation (BACPAR) for the last 3 years.

Lizzie Geer is a senior vascular physiotherapist working in vascular and amputee

rehabilitation at The Heart of England NHS Foundation Trust. Lizzie qualified as a
physiotherapist in 2006 from Birmingham University. She has worked in vascular and
amputee rehabilitation since 2008 and specialises in pre and immediate post operative
amputee care. In 2011 Lizzie completed a post graduate certificate in amputee
rehabilitation from The University of Bradford and is currently working towards obtaining
a masters in professional development at Salford University.

Anna Rose is a senior physiotherapist leading vascular, amputee and renal therapy at The
Royal London Hospital within the North East London Vascular network. Anna graduated in
2001 from Oxford Brookes University. After completing Band 5 rotations and in-patient
Band 6 rotations at large teaching hospitals, Anna specialised in vascular and amputee
management in 2008. In 2011 Anna completed a post graduate certificate in amputee
rehabilitation at The University of Bradford.

BACPAR post operative oedema guidance Page 14