Presentation on theme: "Early Limb Loss Care: Wound Care Options Reviewed"— Presentation transcript:
1Early Limb Loss Care: Wound Care Options Reviewed Jeff Ericksen, MD
2Objectives Review goals of acute residual limb care in leg amputation. Review history of acute wound care methods.Emphasis on immediate postoperative casting methods, rigid dressings, semi-rigid dressings and soft dressings.
3Objectives Outline benefits associated with particular techniques. Review evidence basis for particular methods.
4Early Wound Care Goals in the Pre-Prosthetic Phase Incision protection for trauma and contamination.Edema control.Body image influence?Social interaction?
5Edema controlBalance of intrinsic or intra-stump pressure with extrinsic or extra-stump pressure.Excess edema = wound healing impairment and tissue tension at incision.Excess external pressure with hypoperfusion risk.
6Edema ControlEarly edema control effort inhibits intrinsic pressure buildup.Assumption: Edema reduction techniques do not compromise capillary bed perfusion if adequate arterial supply available?Do most limb loss patients have “adequate arterial supply” for the level?
10Postoperative Dressings Immediate postoperativeRigid fitted socket vs. pneumatic system+/- prosthetic components for weight bearingDelayed fitted rigid removable dressingSoft dressingControlled environment
11Early Prosthetic Fitting von Bier in 1893 used temp prosthetics in early days after surgery, allowed mobilizationWilson reported plaster-of-Paris socket with prosthetic components for American Expeditionary Force on WWI Western Front
12Picture source: Lower Extremity Amputation by Moore & Malone 1989
14Early Prosthetic Fit Popular For War Injuries European field hospitals in World Wars used plaster sockets with simple pegs for wt. bearing.Techniques lost favor after wars ended.Fewer traumatic injuries
15Immediate PostOperative Prosthesis (IPOP) or Immediate Postsurgical Prosthetic Fitting (IPPF) Berlemont 1950’sWeiss 1963: 6th International Prosthetic Course in Copenhagen & then guest lecture at UCSF & US Naval Hospital Oakland.
16PRS BeginningsBerlemont’s tour stimulated VA Prosthetic & Sensory Aids Service to support Prosthetics Research Study in Seattle.Ernest Burgess, MDVaried approaches at many centers, PRS evaluated Weiss techniques in Poland. Much educational work ensued with technique dissemination.
17Immediate Fit Principles Technique is criticalGoal = rapid wound healing and limb maturationMust yield perfect fit for stump in socketWound observation limitedImmediate post-surgical placement with attention to total contact principles and biomechanics
18IPPF Principles….Avoid proximal constriction, no patellar shelf, no popliteal compression, no ischial tuberosity weight bearingSuspension with close anatomic fit & auxiliary systemsDuplication of permanent system is goal for function
19IPPF Reported Benefits Accelerated wound healing by edema prevention/controlPain reduction from edema preventionMechanical barrierEarly mobilization reduces immobility complications of thromboembolic disease and muscle weakness/deconditioning
20IPPF Reported Benefits Phantom pain reduction?Improved psychological response to limb lossEarlier definitive prosthesis & return to lifestyle and employmentShorter hospital stay?
22Supportive WorkSeveral retrospective and prospective studies noting improvement in outcomes in traumatic cases as well as vascular and infectious.Salvage reports for infected or failed BKA limbs.
23Unsupportive WorkRetrospective series with few IPOP subjects after BKA described with higher wound problems and conversion to AKA.Discussion considered technique & experience of team.
24Burgess et al 1968 Clin Orth & Rel Res 3 year period, 167 LE amputations, nearly 50% vascular and diabetes as risks.Reported the technique was effective, stressed the continual upgrading and assessment of surgical and wound care system fabrication techniques.
25Mooney et al 1971 JBJS182 DM patients had BKA procedures over 2 year period (med age 66)Alternating dressing system each 2 months on DM ward USC Medical Center45: soft dressing with fig 8 ACE34: plaster shell40: plaster with pylon in OR
26USC Results41% soft dressings failed to make definitive prosthesis stage = failure22% AKA revision35% plaster shells failure6% AKA revision26% plaster shell with pylon failure12% AKA revision12/182 AKA revision total
27USCShell and shell with pylon use gave 6-8 week quicker use of definitive prosthesisConcluded that rigid dressing facilitated healing but immediate ambulation adversely impacted healing
28Golbranson et al 1968 Clin Orthopaedics & Rel Res Navy Oakland Hospital – 112 amputations studied (21 vascular, 2/3 smokers)73% walked day 1, 85% by day 2 – vascular patients delayed until wound healingConcluded rigid dressing most efficacious on BK patients for edema and contracture prevention
30Golbranson…Immediate & early ambulation “highly benficial” psychological effectPrevents complications of inactivity in older patientsRapid shrinkage early onProsthetist the most important link in program
32Golbranson1st 18 mo of project, 32 patients with daily cast removal to visualize wound1st week post-op with rapid swelling, most needed return of cast within 1 minute to fit againRapid swelling tendency ended after 2 weeks
33Kane et al 1980 The Am Surgeon 52 BKA procedures: 34 IPOP, 18 softSoft dressing group older, similar disease ratesIPOP: 21% necrosis, 21% wound infection, 26% revision, 12% died within 30 daysSoft dressing: 17% necrosis, 33% infection, 44% revision, 11% diedNo signif differences
34Kane…. No pain med use difference, hospitalization difference 56% IPOP patients able to use prosthetic vs. 22% soft dressing patientsThough no signif IPOP effects, temp to 137 F noted on cast inner surface as plaster setSkin burn potential?
35Folsom et al 1992 Am J Surgery 65 of 167 LE amputations had IPOP Cleveland VAMC86% achieved independent ambulationSurgery to ambulation interval15.2 days BKA9.3 AKA15% IPOP did not complete9% withdrew, 6% died
36Pinzur et al 1989 Orthopedics 38 consecutive BKA patients had Jobst pneumatic prosthetic device applied immediately34 vasc mean age 60.94 trauma mean age 34.5Ambulated as soon as “clinically feasible”Daily wound inspection
37Pinzur76.3% wound healing and progression to temporary limb before d/cWeight bearing4.7 days vasc group5 days trauma groupPneumatic system duration8.3 days vasc10.8 days trauma
38Pinzur D/C home 9 days vasc & 11 days trauma 4 infection/wound dehiscence patientsPovidine dressings & continued with pneumatic system, all healed86.8% total success to early prosthetic limb fit and use3 AKA revisions
39PinzurConcluded traditional IPOP approach fails due to shearing as edema resorbs & volume reducesPneumatic system accommodates volume changes in early phaseEasy access to woundReduced labor & skill set needed in surgical setting is appealing
40Cohen et al 1974* SurgeryReported 97 consecutive LE amputations for ischemia but only 9 IPOP patientsIPOP group2 healed in plaster3 AKA revisions5/6 BKA IPOP group (83%) walked at f/u
41CohenConcluded: “the high failure rate for IPOP in our institution has caused us to question the wisdom of this technique.”Noted high inner surface temperatures with plaster techniqueAcknowledged inexperience with technique
42Baker et al 1977 Am J SurgCompared soft to rigid dressings on 51 patientsNo significant difference found between healing in the two groupsSignificant shortening of hospitalization and rehabilitation times
43IPOP Pros/Cons Advantage: excellent edema control protects residual limb against traumaDisadvantage:lack of easy wound accessrequires technical skill in applicationimmediate weight bearing effect on wound healing?
44IPOP Pros/ConsThe immediate wound issues may be effect of the benefit of IPOP, edema prevention and rapid resorption leading to volume reduction and poor fit.Motion and thus shear forces when weight bearing as fit reduces.Is there a compromise?
45Rigid Removable Dressing First developed by Dr. Wu at Northwestern in 1978Adapted as a standard of care in vascular surgery textbooksUsed for below knee amputations only
46Wu et al 1979 JBJSBelow knee plaster cast with supracondylar plastic cuff suspensionEdema control, protection and inspection were goalsOffered as an alternative to the standard early rigid dressings such as IPOP dressings.
48Wu twenty one below knee amputations in 19 pts treated with the RRD, timing?compared with thirty patients admitted prior with elastic bandagingHealing time inferred from temporary prosthetic order in chartRehab time = amputation to d/c with temp prosthesis
49Table courtesy M Huang, MD WuTable courtesy M Huang, MD
50Mueller 1982 Physical Therapy 15 subjects with 16 below knee amputationsAge mean 73, all vascular, 12 DMrandomly assigned to elastic bandaging and RRDRRD showed significant decrease in limb volume versus elastic bandagingno skin breakdown notedinitial cost only slightly higher than elastic bandaging
51Other RRD reports Wu, Clinical Prosthetics and Orthotics, 1987 case of open wound healed with RRDRichter, Archives of PM & R, 1988case report in a patient with wound dehiscencehealing of wound without further surgery using RRD
52Recent data“A Biomechanical Study of Two Postoperative Prostheses for Transtibial Amputees: A Custom-Molded and a Prefabricated Adjustable Pneumatic Prosthesis”
53Bourcher et al Foot & Ankle International Cadaver study of transtibial stump in pneumatic prefab system (Air-LimbTM,Aircast Co.) compared to custom molded rigid system (ICEXTM, OSSUR)Strain gage measurement of skin flap motion forces medial and lateral aspectKnee stabilized with IM rod12 fresh cadaver limbs frozen, then thawed before testing protocol
54Bourcher Medial mean motion Lateral mean motion IPOP -0.49 mm ICEX 1.63 mmMed max openingIPOP 1.5 mm staticICEX 3.6 mm staticIPOP 1.7 mm dynICEX 2.9 mm dynLateral mean motionIPOP -.54 mmICEX -.03 mmMax lat openingIPOP 1.1 mm staticICEX 1.24 mm staticIPOP 0.33 mm dynICEX 1.7 mm dyn
55Boucher Negative values implies wound compression or closure Positive maximum values indicates wound openingOnly statistically significant difference between IPOP and ICEX systems was mean medial strain measurement with cyclic loading: mm vs mm.
56BoucherConcluded pneumatic IPOP had less wound edge separation than rigid device in loading simulation of fresh cadaver residual limbs.Hypothesized that medial separation difference vs. lateral may be due to difference in soft tissue between wound and bone, more muscle laterally.
57BoucherAcknowledged lack of post surgical edema influence in simple biomechanical measure.Argued pneumatic system offered more uniform distal pressure, easier to use and was standardized.
58My conclusionsThe research has been limited and certainly not reproduced.Technique seems very important for use of early rigid dressings, particularly with weight bearing efforts.We can all agree that early edema control makes sense but how much and how “specific” the control is for the patient’s changing anatomy appears to be critical in vascular and DM amputation wound healing.
59ConclusionsThere is no cookbook approach to residual limb management and prosthetic fitting.Early weight bearing may be associated with increased wound compromise but that conclusion is not well supported but is clinically conservative.