Presentation on theme: "Early Limb Loss Care: Wound Care Options Reviewed Jeff Ericksen, MD."— Presentation transcript:
Early Limb Loss Care: Wound Care Options Reviewed Jeff Ericksen, MD
Objectives 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.
Objectives Outline benefits associated with particular techniques. Review evidence basis for particular methods.
Early Wound Care Goals in the Pre-Prosthetic Phase Incision protection for trauma and contamination. Edema control. Body image influence? Social interaction?
Edema control Balance 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.
Edema Control Early 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?
Postoperative Dressings Immediate postoperative Rigid fitted socket vs. pneumatic system +/- prosthetic components for weight bearing Delayed fitted rigid removable dressing +/- prosthetic components for weight bearing Soft dressing Controlled environment
Early Prosthetic Fitting von Bier in 1893 used temp prosthetics in early days after surgery, allowed mobilization Wilson reported plaster-of-Paris socket with prosthetic components for American Expeditionary Force on WWI Western Front
Picture source: Lower Extremity Amputation by Moore & Malone 1989
Early 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
Immediate PostOperative Prosthesis (IPOP) or Immediate Postsurgical Prosthetic Fitting (IPPF) Berlemont 1950s Weiss 1963: 6 th International Prosthetic Course in Copenhagen & then guest lecture at UCSF & US Naval Hospital Oakland.
PRS Beginnings Berlemonts tour stimulated VA Prosthetic & Sensory Aids Service to support Prosthetics Research Study in Seattle. Ernest Burgess, MD Varied approaches at many centers, PRS evaluated Weiss techniques in Poland. Much educational work ensued with technique dissemination.
Immediate Fit Principles Technique is critical Goal = rapid wound healing and limb maturation Must yield perfect fit for stump in socket Wound observation limited Immediate post-surgical placement with attention to total contact principles and biomechanics
IPPF Principles…. Avoid proximal constriction, no patellar shelf, no popliteal compression, no ischial tuberosity weight bearing Suspension with close anatomic fit & auxiliary systems Duplication of permanent system is goal for function
IPPF Reported Benefits Accelerated wound healing by edema prevention/control Pain reduction from edema prevention Mechanical barrier Early mobilization reduces immobility complications of thromboembolic disease and muscle weakness/deconditioning
IPPF Reported Benefits Phantom pain reduction? Improved psychological response to limb loss Earlier definitive prosthesis & return to lifestyle and employment Shorter hospital stay?
Research Support for IPOP/IPPF
Supportive Work Several 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.
Unsupportive Work Retrospective series with few IPOP subjects after BKA described with higher wound problems and conversion to AKA. Discussion considered technique & experience of team.
Burgess 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.
Mooney et al 1971 JBJS 182 DM patients had BKA procedures over 2 year period (med age 66) Alternating dressing system each 2 months on DM ward USC Medical Center 45: soft dressing with fig 8 ACE 34: plaster shell 40: plaster with pylon in OR
USC Results 41% soft dressings failed to make definitive prosthesis stage = failure 22% AKA revision 35% plaster shells failure 6% AKA revision 26% plaster shell with pylon failure 12% AKA revision 12/182 AKA revision total
USC Shell and shell with pylon use gave 6-8 week quicker use of definitive prosthesis Concluded that rigid dressing facilitated healing but immediate ambulation adversely impacted healing
Golbranson 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 healing Concluded rigid dressing most efficacious on BK patients for edema and contracture prevention
Golbranson… Immediate & early ambulation highly benficial psychological effect Prevents complications of inactivity in older patients Rapid shrinkage early on Prosthetist the most important link in program
Golbranson 1 st 18 mo of project, 32 patients with daily cast removal to visualize wound 1 st week post-op with rapid swelling, most needed return of cast within 1 minute to fit again Rapid swelling tendency ended after 2 weeks
Kane et al 1980 The Am Surgeon 52 BKA procedures: 34 IPOP, 18 soft Soft dressing group older, similar disease rates IPOP: 21% necrosis, 21% wound infection, 26% revision, 12% died within 30 days Soft dressing: 17% necrosis, 33% infection, 44% revision, 11% died No signif differences
Kane…. No pain med use difference, hospitalization difference 56% IPOP patients able to use prosthetic vs. 22% soft dressing patients Though no signif IPOP effects, temp to 137 F noted on cast inner surface as plaster set Skin burn potential?
Folsom et al 1992 Am J Surgery 65 of 167 LE amputations had IPOP Cleveland VAMC 86% achieved independent ambulation Surgery to ambulation interval 15.2 days BKA 9.3 AKA 15% IPOP did not complete 9% withdrew, 6% died
Pinzur et al 1989 Orthopedics 38 consecutive BKA patients had Jobst pneumatic prosthetic device applied immediately 34 vasc mean age trauma mean age 34.5 Ambulated as soon as clinically feasible Daily wound inspection
Pinzur 76.3% wound healing and progression to temporary limb before d/c Weight bearing 4.7 days vasc group 5 days trauma group Pneumatic system duration 8.3 days vasc 10.8 days trauma
Pinzur D/C home 9 days vasc & 11 days trauma 4 infection/wound dehiscence patients Povidine dressings & continued with pneumatic system, all healed 86.8% total success to early prosthetic limb fit and use 3 AKA revisions
Pinzur Concluded traditional IPOP approach fails due to shearing as edema resorbs & volume reduces Pneumatic system accommodates volume changes in early phase Easy access to wound Reduced labor & skill set needed in surgical setting is appealing
Cohen et al 1974* Surgery Reported 97 consecutive LE amputations for ischemia but only 9 IPOP patients IPOP group 2 healed in plaster 3 AKA revisions 5/6 BKA IPOP group (83%) walked at f/u
Cohen Concluded: 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 technique Acknowledged inexperience with technique
Baker et al 1977 Am J Surg Compared soft to rigid dressings on 51 patients No significant difference found between healing in the two groups Significant shortening of hospitalization and rehabilitation times
IPOP Pros/Cons Advantage: excellent edema control protects residual limb against trauma Disadvantage: lack of easy wound access requires technical skill in application immediate weight bearing effect on wound healing?
IPOP Pros/Cons The 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?
Rigid Removable Dressing First developed by Dr. Wu at Northwestern in 1978 Adapted as a standard of care in vascular surgery textbooks Used for below knee amputations only
Wu et al 1979 JBJS Below knee plaster cast with supracondylar plastic cuff suspension Edema control, protection and inspection were goals Offered as an alternative to the standard early rigid dressings such as IPOP dressings.
Wu twenty one below knee amputations in 19 pts treated with the RRD, timing? compared with thirty patients admitted prior with elastic bandaging Healing time inferred from temporary prosthetic order in chart Rehab time = amputation to d/c with temp prosthesis
Wu Table courtesy M Huang, MD
Mueller 1982 Physical Therapy 15 subjects with 16 below knee amputations Age mean 73, all vascular, 12 DM randomly assigned to elastic bandaging and RRD RRD showed significant decrease in limb volume versus elastic bandaging no skin breakdown noted initial cost only slightly higher than elastic bandaging
Other RRD reports Wu, Clinical Prosthetics and Orthotics, 1987 case of open wound healed with RRD Richter, Archives of PM & R, 1988 case report in a patient with wound dehiscence healing of wound without further surgery using RRD
Recent data A Biomechanical Study of Two Postoperative Prostheses for Transtibial Amputees: A Custom-Molded and a Prefabricated Adjustable Pneumatic Prosthesis
Bourcher et al Foot & Ankle International Cadaver study of transtibial stump in pneumatic prefab system (Air-Limb TM,Aircast Co.) compared to custom molded rigid system (ICEX TM, OSSUR) Strain gage measurement of skin flap motion forces medial and lateral aspect Knee stabilized with IM rod 12 fresh cadaver limbs frozen, then thawed before testing protocol
Bourcher Medial mean motion IPOP mm ICEX 1.63 mm Med max opening IPOP 1.5 mm static ICEX 3.6 mm static IPOP 1.7 mm dyn ICEX 2.9 mm dyn Lateral mean motion IPOP -.54 mm ICEX -.03 mm Max lat opening IPOP 1.1 mm static ICEX 1.24 mm static IPOP 0.33 mm dyn ICEX 1.7 mm dyn
Boucher Negative values implies wound compression or closure Positive maximum values indicates wound opening Only statistically significant difference between IPOP and ICEX systems was mean medial strain measurement with cyclic loading: mm vs mm.
Boucher Concluded 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.
Boucher Acknowledged lack of post surgical edema influence in simple biomechanical measure. Argued pneumatic system offered more uniform distal pressure, easier to use and was standardized.
My conclusions The 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 patients changing anatomy appears to be critical in vascular and DM amputation wound healing.
Conclusions There 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.