Prosthetic limbs
Early prosthetic fitting right after lower-limb amputation: evidence and recommendations
Should people stand and walk on a temporary prosthesis as early as possible after a lower-limb amputation? A review of the evidence, international guidance and cautions.
After a lower-limb amputation, people are often told to wait for the residual limb to “mature” before a prosthesis is made. But a growing body of evidence suggests that standing and walking early on a temporary prosthesis brings clear benefits for rehabilitation, general health and even treatment costs.
This article summarises international studies and the guidance of developed countries in plain language, and states the limits of the evidence openly, so patients and families have a basis for discussion with the treating team.
A plain-language summary
The core difference: on the early pathway the patient stands and walks within the first weeks, so the body does not have time to weaken while waiting for a prosthesis. In simple terms:
- The prosthesis arrives months sooner. Studies from the Netherlands, the US, Sweden and New Zealand show that groups managed with a rigid dressing or an early-fitting protocol received a prosthesis about 2.5 weeks to 2 months earlier than with traditional care.
- Fewer joint and residual-limb complications. Early fitting went with less knee flexion contracture and, in one US study, fewer revisions of the residual limb.
- Healthier and longer lives (associated, not necessarily caused). People prescribed and fitted with a prosthesis early had lower mortality in large studies in the US and Switzerland.
- Better morale. Prosthesis users have better body-image, anxiety and depression scores than non-users.
- Lower cost for families and society. In the US, receiving a prosthesis in the first 3 months went with about 25% lower total first-year health costs and almost half as many emergency visits.
To be frank: the quality of the evidence is not high. The 2019 Cochrane review concluded that the benefit of rigid versus soft dressings is uncertain because trials were small and biased. Most mortality and cost data are observational, so part of the benefit may reflect that people fitted early were healthier to begin with. International guidance is therefore to fit early for suitable people, assessed by a multidisciplinary team, not to fit everyone early.
Concepts to tell apart
In the literature “early fitting” is not one technique but a family of solutions, ordered by when weight-bearing starts:
| Solution | Timing | Short description |
|---|---|---|
| Immediate postoperative prosthesis (IPOP) | In the operating theatre; standing from day 1 | A plaster or rigid socket around the residual limb attached to a pylon and foot; controlled partial weight-bearing |
| Removable rigid dressing (RRD) | From a few days after surgery | A rigid shell protecting the limb, compressing oedema and preventing knee contracture; no weight-bearing, prepares for early fitting |
| Early walking aids (PPAM aid, AMA, Femurett) | About 1–3 weeks, once the wound is stable | Shared walking frames with an air-bag around the residual limb; used in therapy sessions, common in the UK |
| Temporary / preparatory prosthesis | A few weeks after surgery, once the wound heals | An individual socket that can be adjusted as the limb shrinks; patient walks daily |
| Definitive prosthesis | When limb volume is stable (usually a few months after surgery) | A finished socket for long-term use |
| Late fitting | 6–12 months or more | Waiting for the limb to “mature” in soft elastic bandages, with no weight-bearing training meanwhile |
In this article “early fitting” includes the first four rows; what they share is that the patient stands and walks on the amputated limb within the first weeks rather than many months.
Evidence on rehabilitation: earlier prosthesis, fewer complications
The clearest and most repeated benefit of early fitting is a shorter time from surgery to having a prosthesis to walk on.
- Time to prosthesis. A retrospective study in three Dutch hospitals (149 below-knee amputees): the rigid-dressing/early-fitting group received a first prosthesis after a mean of 50 days versus 110 days with elastic bandaging (van Velzen et al., 2005). In the US, a prefabricated rigid dressing cut the time to casting for a prosthesis from about 84 to 58 days. In Sweden a new below-knee guideline reduced time to prosthesis from 103 to 76 days (Karolinska Institutet). The multicentre CROCS-BKA study in New Zealand (759 cases) found the removable rigid dressing group fitted about 17 days (median) sooner (RACS 2024).
- Early walking aids. In the UK, the earlier and more often a PPAM aid is used during the inpatient stay, the faster the milestones of referral, casting, prosthesis delivery and discharge are reached (Lee et al., Prosthet Orthot Int 2023). The HEART randomised trial (UK) showed that both early walking aids (PPAM and AMA with a knee joint) significantly increased walking speed during recovery, with no difference between them (Mazari et al.).
- Local complications. In the Dutch study early fitting reduced the risk of knee flexion contracture and did not increase residual-limb complications, but did increase pressure sores elsewhere (for example on the sound heel) (van Velzen 2005). A US analysis (72 people) found similar systemic and wound complication rates in the IPOP group but significantly fewer revisions of the residual limb (5.4% in the IPOP group); the authors suggest considering IPOP for every suitable candidate (Ali et al., Ann Vasc Surg 2013).
- Function. A Swedish cohort study summarised that long waits from amputation to fitting have been shown to harm walking ability and long-term prosthesis use. An Iranian study of older people with diabetes found the soft-dressing group needed on average 148 more days to reach the same independence in daily activities and definitive prosthesis as the IPOP group.
General health, mind and quality of life
Standing and walking early helps patients avoid the “immobility spiral”: prolonged bed rest leads to weak muscles, contracted joints, reduced heart-lung endurance, falls and depression, and these in turn make later training with a prosthesis harder.
- Mortality. In older US veterans, those prescribed a prosthesis within 1 year of amputation had a lower 3-year risk of death, even after adjusting for age, amputation level and comorbidity; the earlier the prescription, the lower the risk. The authors themselves stress this is an association, not causation, because sicker patients are often delayed (JRRD 2015). In Switzerland, among above-knee amputees for vascular disease, being fitted with a prosthesis was an independent factor for better 5-year survival (HR 0.306, about 70% lower risk of death) (Ann Phys Rehabil Med 2023).
- Mind. A Turkish study of 92 lower-limb amputees found significantly different body-image and anxiety–depression scores between prosthesis users and non-users (Turk J Phys Med Rehab 2014). IPOP studies describe the psychological benefit of waking after surgery already with a “leg” and standing from the first days. The US VA/DoD guideline recommends mental-health assessment at every stage and peer support as early as possible.
- Quality of life and independence. In Finland, 1 year after fitting, 85% of below-knee and 72% of above-knee amputees could walk at least indoors, and 88% still lived in their own homes (Helsinki, Prosthet Orthot Int 1990).
- An honest caveat. A Mayo Clinic study using accelerometers found that people with an IPOP after below-knee amputation were still sitting or lying about 88% of the time in the first 6 weeks (Samuelsen et al., Am J Phys Med Rehabil 2017). An early prosthesis therefore works only when combined with an active training programme.
Family finances, the health system and the community
Early fitting costs more at the start (materials, staff, a temporary prosthesis), but US data show lower total first-year costs, because patients have fewer complications, fewer readmissions and fewer falls.
- Health costs. The IMPACT study of 510 lower-limb amputees (US national insurance data): receiving a prosthesis within 0–3 months went with about 25% lower total direct health costs over 12 months, saving about USD 25,000 per person compared with no prosthesis. Receiving one at months 4–9 had total costs similar to no prosthesis even after counting the prosthesis itself (Am J Phys Med Rehabil 2020).
- Emergency care and falls. IMPACT 2, on the same database: receiving a prosthesis in the first 3 months reduced the likelihood of an emergency visit by 48% (OR 0.52); people who fell were 2.8 times as likely to go to the emergency department (PM&R 2021).
- Length of stay. The UK early-walking-aid pathway shortened time to inpatient discharge (Lee 2023).
For families and society, every month a patient walks sooner is a month relatives do not have to take leave to care for them, with less risk of a care-home admission and a better chance of returning to work. Note that the IMPACT studies were carried out by a prosthetics company (Hanger) with the University of North Carolina, on US commercial insurance data; absolute figures cannot be applied directly to Vietnam, but the trend “earlier costs less” can be used as an argument.
Below the knee and above the knee
Most of the highest-quality evidence is for below-knee amputation; above the knee the “early” principle still applies but mostly through early walking aids and temporary prostheses, with IPOP rarely used.
| Below knee (transtibial) | Above knee (transfemoral) | |
|---|---|---|
| Common early solutions | IPOP, removable rigid dressing, PPAM/AMA, temporary prosthesis | PPAM aid, Femurett, temporary prosthesis with a lockable knee |
| Level of evidence | Many trials and cohorts; Cochrane 2019 includes 9 trials (436 people) and remains uncertain | Few direct comparisons; mainly cohorts and case series |
| Key benefit | Prevents knee flexion contracture, reduces oedema, shortens time to prosthesis | Prevents hip flexion contracture, preserves endurance, early check of who can walk with a prosthesis |
| Walking 1 year later (Helsinki) | 85% walk at least indoors | 72% walk at least indoors |
| Survival | Early prosthesis prescription linked to lower mortality (VA, US) | Being fitted linked to better 5-year survival (Lausanne) |
In older above-knee amputees the Femurett helps decide whether the person can use a prosthesis before a definitive one is made, avoiding a “try and see” approach; the PPAM aid is preferred right after surgery because it controls oedema better. Above-knee amputation costs more energy to walk, so the longer a patient lies in bed the harder it is to regain strength; this is a strong clinical reason for early training even though trial data are few.
Advantages and disadvantages
Early fitting helps most suitable patients, but it carries real risks and needs a skilled team.
| Advantages of early fitting | Disadvantages and risks of early fitting |
|---|---|
| Shortens time to prosthesis by about 2.5 weeks to 2 months | Needs an experienced orthotic engineer and surgeon; a poorly applied cast can cause pressure sores |
| Compresses oedema, shapes the residual limb | Hard to inspect the wound under a fixed cast (IPOP), so infection can be missed |
| Reduces knee/hip flexion contracture | More pressure sores elsewhere (van Velzen 2005) |
| Fewer revisions of the residual limb (Ali 2013) | Weight-bearing too early or too much can open the wound in people with limb ischaemia |
| Preserves muscle strength, endurance and balance | Risk of falls during training if unsupervised |
| Positive psychological effect, early return of the feeling of “being able to walk” | Higher initial cost than a soft dressing; several socket changes as the limb shrinks |
| Linked to lower mortality, health costs and emergency visits | Trial evidence still weak (Cochrane 2019) |
What does late fitting (6–12 months) offer? A volume-stable limb, so fewer socket changes, a lower starting cost and no special technique. But the price is many months of immobility, joint contracture, loss of strength, a risk of never using a prosthesis, and no lower first-year cost (IMPACT).
Who needs caution or is not yet suited to early weight-bearing
- Severe limb ischaemia, or a wound at high risk of breaking down. A 2018 PM&R review notes that about 82% of amputations are for ischaemic disease; for this group the authors prefer a removable rigid dressing without weight-bearing (Reichmann, Stevens et al.).
- Uncontrolled residual-limb infection needing a second operation.
- Heart failure, severe lung disease, or dementia that prevents following instructions.
- Classic IPOP has mainly been reserved for below-knee amputees who were actively walking before surgery.
For these patients “early” still means: a removable rigid dressing, exercise, balance training and an assessment of prosthetic potential as soon as the wound allows.
Recommendations in developed countries
The major guidelines agree on the direction “start early, with a multidisciplinary team”, although the strength of recommendation is modest because the evidence is not strong.
| Country / organisation | Document | Content related to early fitting |
|---|---|---|
| US — VA/DoD | Clinical practice guideline for rehabilitation of lower-limb amputation 2017, updated 2024–2025 (26 recommendations) | Suggests a rigid or semi-rigid dressing as early as possible after below-knee amputation; early peer support; mental-health assessment at every stage; consider direct transfer to inpatient rehabilitation |
| UK — BSRM | Amputee and Prosthetic Rehabilitation – Standards and Guidelines, 3rd edition (2018) | A prosthetic rehabilitation centre model with primary rehabilitation immediately after surgery |
| UK — BACPAR (physiotherapy association) | Pre- and post-operative guidance; PPAM aid guidance (2008) | The PPAM aid is the standard early walking aid after below-knee amputation; early use shortens time to prosthesis |
| Netherlands | Evidence-based multidisciplinary guideline 2012, updated 2020 | States that practice still varies on when the first prosthesis is fitted and gives standardising recommendations |
| Canada — CADTH | Rapid review on prosthetic sockets | Notes a guideline recommending a postoperative prosthesis as early as possible after below-knee amputation |
| Sweden | New below-knee amputation guideline in hospital | After adoption, time to prosthesis fell from 103 to 76 days |
| France, Switzerland (French-speaking) | Standard rehabilitation pathway | Three phases: pre-fitting, temporary prosthesis, definitive prosthesis; the temporary prosthesis allows early walking and reduces limb volume |
Note: we could not find a specific recommendation from the Haute Autorité de Santé (France) on the timing of prosthetic fitting; the French row above reflects the practice pathway, not a document of that body.
How certain is it, and what does it mean in practice?
The most reasonable conclusion: early fitting is supported by many consistent studies and by international guidance, but no large, high-quality trial has proved it conclusively.
| Question | Certainty | Note |
|---|---|---|
| Does early fitting shorten time to prosthesis? | Moderate | Many cohorts agree; Cochrane still rates it very low because of bias |
| Fewer joint contractures, fewer revisions? | Low – moderate | Retrospective cohorts (van Velzen, Ali) |
| Lower mortality? | Low (association only) | Healthier people are fitted earlier; causation cannot be inferred |
| Lower health and emergency costs? | Low – moderate | US insurance data, sponsored by a prosthetics company |
| Better mood and quality of life? | Low | Mostly prosthesis versus no prosthesis, with few early-versus-late comparisons |
Practical suggestions for patients, families and payers in Vietnam
- Assessment right after surgery by a multidisciplinary team (surgery, rehabilitation, orthotic engineer, physiotherapy, psychology) to decide who is suited to early fitting.
- For below-knee amputees with a stable wound: a removable rigid dressing in the first week, walking practice with an early walking aid or temporary prosthesis once the wound allows.
- For above-knee or high-risk patients: exercise, prevention of hip contracture and balance training immediately; a temporary prosthesis once eligible.
- An adjustable socket, or replacing the socket as the limb shrinks, rather than waiting for the limb to stabilise completely before making a prosthesis.
- Track results with standard measures (for example TUG, AMP, time from surgery to prosthesis) to build Vietnamese data.
The studies in this article were read through abstracts and summary pages; open the full text before citing formally in a publication. This article is for information and does not replace advice from a specialist.
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If you or a family member is about to have, or has just had, a lower-limb amputation, contact us early for advice on the rehabilitation pathway and the right time to fit a prosthesis. Hotline +84 985 211 888.
References
- Kwah LK, Webb MT, Goh L, Harvey LA. Rigid dressings versus soft dressings for transtibial amputations. Cochrane Database Syst Rev 2019;(6):CD012427.
- van Velzen AD và cs. Early treatment of trans-tibial amputees: retrospective analysis of early fitting and elastic bandaging. Prosthet Orthot Int 2005.
- Ali MM và cs. A contemporary comparative analysis of immediate postoperative prosthesis placement following below-knee amputation. Ann Vasc Surg 2013;27(8):1146–53.
- Schon LC và cs. Benefits of early prosthetic management of transtibial amputees: a prospective clinical study of a prefabricated prosthesis. Foot Ankle Int 2002;23(6):509–514.
- Samuelsen BT và cs. The impact of the immediate postoperative prosthesis on patient mobility and quality of life after transtibial amputation. Am J Phys Med Rehabil 2017;96(2):116–119.
- Reichmann JP, Stevens PM và cs. Removable rigid dressings for postoperative management of transtibial amputations: a review of published evidence. PM&R 2018;10:516–523.
- Lee J và cs. Impact of PPAM aid use on the time to prosthetic limb delivery in patients with unilateral transtibial amputation. Prosthet Orthot Int 2023;47(3):258–264.
- Mazari FAK và cs. Hull Early walking aid for Rehabilitation of Transtibial amputees — randomized controlled trial (HEART).
- Miller TA, Wurdeman SR và cs. Impact of time to receipt of prosthesis on total healthcare costs 12 months postamputation. Am J Phys Med Rehabil 2020.
- The role of earlier receipt of a lower limb prosthesis on emergency department utilization. PM&R 2021.
- Early receipt of a prosthesis linked to lower mortality in older veterans. J Rehabil Res Dev 2015;52(4).
- Prosthetic fitting associated with better survival at 5 years after above-knee amputation due to vascular insufficiency. Ann Phys Rehabil Med 2023.
- Pohjolainen T và cs. Prosthetic use and functional and social outcome following major lower limb amputation. Prosthet Orthot Int 1990.
- Atay IM và cs. The prevalence of prosthesis use with the effects on body image, depression, anxiety and self-esteem in lower-extremity amputations. Turk J Phys Med Rehab 2014;60(3):184–187.
- VA/DoD Clinical Practice Guideline for Rehabilitation of Individuals with Lower Limb Amputation, 2017; cập nhật 2024.
- Amputee and Prosthetic Rehabilitation – Standards and Guidelines, 3rd ed. BSRM, London 2018.
- Fard B và cs. Amputation and prosthetics of the lower extremity: the 2020 Dutch evidence-based multidisciplinary guideline. Prosthet Orthot Int 2023;47(1):69–80.
- Femurett adjustable prosthesis in the assessment and walking training of new above-knee amputees. Prosthet Orthot Int 1989.
- Hình ảnh minh họa / Illustrations: dungcuchinhhinh.vn (website của Lê Hoàn Prosthetics & Orthotics)
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