2 Overview What is needed in post op management? A quick look at oedema. Comparing the options?Something “new”Compression therapy
3 What is needed in post op management? - Multi-disciplinary team Optimal recovery and rehabilitation after amputation requires a multi-disciplinary approach.OccupationaltherapistProsthetistRehabilitationConsultantPhysio-NurseOrthopaedicsurgeonTheAmputeeIt is important that all personnel involved in the treatment of the amputee, obtain knowledge of each others professions and working procedures.
4 What is needed in post op management? - AimsEnsure good wound healingReduce oedema in residual limbPain reductionShape residuumProtection of residuum from external stressesPrevent contracturesPrepare for prosthetic management/ambulation
5 Harmful effects of oedema: Wound Healing - oedemaInflammatory responseOedema exudate formsFluids from the medullary bone bleeding, tissue exudate and blood loss form oedema exudateHarmful effects of oedema:Delays wound healingIncreases interstitial pressureIncreased risk of infectionInduces the onset of pain
6 Harmful effects of Oedema Amputees often predisposed to edema:Pre existing vessel diseaseDecreased capacity for venous returnIncision to vesselsCut musclesImmobility
7 Stump Volume 1 week post op- volume is at its peak 1-2 weeks – decreased edema and some tissue atrophy2-3 weeks edema resolved, tissue atrophyIf you can limit volume in initial week↓ the rate change over time (same volume reached after 3 months)↑ wound healing
8 What are the options: Nothing Soft dressings: Rigid dressings Elastic BandagingJuzo / stump shrinkersRigid dressingsThigh level rigid plaster dressing without immediate prosthesisIPOP – Immediate Post op ProsthesisRemovable Rigid Dressing (RRD)Compression therapy/RRD
9 Soft dressings Advantages ease of applicationaccessibility to the woundLow initial cost
10 Soft dressings Disadvantages High local or proximal pressures impair skin survival and healingLikelihood of gauze falling off↑ed chance of knee flexion contracture↑ed pain →↑ed bedrest, ↓mobility↑ed hospital stays →↑risk of pulmonary complications, stokes, pneumonia↑ed health care costs due to ↑ed hospital stays
11 Shrinkers Vs Bandaging application is unreliableDangerous in terms of pressure distribution (Puddifoot and associates showed elastic wrap to have the greatest range of pressures and the highest readings)Shrinkers have been shown to be more effective than bandaging in decreasing residual limb volume
12 Thigh level rigid plaster dressing Advantages Significantly shorter rehab times compared to soft gauze dressingsProtects the residual limb →↓es revision surgery↓es edema, pain and healing times↑es tolerance to weight bearing/early ambulationHolds knee in extension → prevents flexion contracture
13 Thigh level rigid plaster dressing Disadvantages More difficult to applyRequires skilled surgical/prosthetic/rehab team↑ed cost (short term)↓ed access for wound inspectionInability to adjust fitImmobilises knee into extension
14 Thigh level rigid plaster dressing with IPOP Advantages Simular benefits of no IPOP plus:↑stimulation of circulationWeightbearing within 24 hours↓es edema (by ↑ing pressure and pumping action of muscles)↓ed time to custom prosthesesFewer surgical revisionsEmotional/ self imaging benefitsRapid healing
15 Thigh level rigid plaster dressing with IPOP Disadvantages Difficult to inspect woundTissue damage – mechanical trauma (particularly vascular patients)Need a dedicated team/ highly skilledUnskilled application could lead to disasterDifficult to control early weight bearingHealing rate studies have shown Ambulate healing rates to be 20% less than non-ambulant
16 Removable Rigid Dressings (RRD) Advantages Significantly less oedema compared to soft dressingsEnhanced wound healing;Limited oedema formationImmobilisation of soft tissuesHealing on average 3 weeks earlier than soft dressing managementHealing more rapid than IPOPAbility to remove and inspect woundPatient learns donning and doffingPermits knee flexionAbility to adjust fit
17 RRD vs Elastic Bandages Easier to applyRemain secureBetter stump shrinkage and shapingNo pressure problemsStump protection↓ed Length of Stay (LOS) in accute hospitalAverage of 9 days instead of 14
18 Rehabilitation Prostheses Plaster interims - PhysiosMoulded directly onto stumpsLimitationsSocket designBasically walking on a castNo modifications can be madeVolume adjustments restricted to socksMaterials (weight, strength etc)Huge medico legal issuesDifferent amputation levelsHeavy patients
19 Plaster vs prostheses Evaluation of service - MECRS 32 544 287% 0CriteriaAdmissionsL.O.SNo. of sockets2nd definativein 1st year
20 MECRS service delivery model Acute HospitalRRD fitted day 0Days 0-7 acuteRehabilitationDay 7 onwardsContinue wearing RRDDay 21 fit shrinkerDay 23 fit Rehab prostheses
21 “Postoperative dressing and management strategies for transtibial amputations: A critical review” Douglas G.Smith et alConsensus on the most effective postoperative management strategies for TTA is lacking however:Rigid dressings have been shown to significantly↓ edema compared to soft dressings↓rehab times compared to soft dressings↓time to initial gait training compared to soft dressings
22 Compression TherapyA silicone liner is used for edema and volume control and for shaping of the residual limballows the prosthetic treatment to start earlier.Three objectives are achieved in this phase:
24 2. Compression of the wound surfaces along the suture lines.
25 3. An even compression that decreases proximally Due to the decreasing thickness of the liner walls.
26 Compression Therapy Guidelines Day 1 2 x 1hDay 2 2 x 2hDay 3 2 x 3hDay 4 and further.. 2 x 4hTime of use and measure- ments are documentedSize of the liner is changed when necessary to maintain continuous compression
27 Compression Therapy Oedema control Graded compression assists with oedema managementThe same level of compression is achieved regardless of who applies the linerIn traditional care, both the compression and the quality of the dressing vary, depending on who performs the treatment.Improved pain control through the increased proprioception.
28 Improved wound healing Compression TherapyImproved wound healingReduction of oedemaProvides occlusive environmentConsidered standard treatment of leg ulcersPrevents tissue dehydration and cell deathProvides barrier to bacteriaDecreases risk of infection
29 Compression Therapy Further Benefits Shaping of residuum to give optimal shape for prosthetic fittingThus reducing prosthetic complicationsFacilitates early mobilizationSilicone speeds up maturation of residuum and helps smooth scar
30 Case Study: Mr B – 2/2/04 WARNING on next slide