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Post-Op Management Options Cameron Ward B.P&O. Overview What is needed in post op management? What is needed in post op management? A quick look at oedema.

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Presentation on theme: "Post-Op Management Options Cameron Ward B.P&O. Overview What is needed in post op management? What is needed in post op management? A quick look at oedema."— Presentation transcript:

1 Post-Op Management Options Cameron Ward B.P&O

2 Overview What is needed in post op management? What is needed in post op management? A quick look at oedema. A quick look at oedema. Comparing the options? Comparing the options? Something “new” Something “new” Compression therapyCompression therapy

3 What is needed in post op management? - Multi-disciplinary team Optimal recovery and rehabilitation after amputation requires a multi-disciplinary approach. It is important that all personnel involved in the treatment of the amputee, obtain knowledge of each others professions and working procedures. Occupational therapist Prosthetist Rehabilitation Consultant Physio- therapist Nurse Orthopaedic surgeon The Amputee

4 What is needed in post op management? - Aims Ensure good wound healing Ensure good wound healing Reduce oedema in residual limb Reduce oedema in residual limb Pain reduction Pain reduction Shape residuum Shape residuum Protection of residuum from external stresses Protection of residuum from external stresses Prevent contractures Prevent contractures Prepare for prosthetic management/ambulation Prepare for prosthetic management/ambulation

5 Wound Healing - oedema Inflammatory response Inflammatory response Oedema exudate formsOedema exudate forms Fluids from the medullary bone bleeding, tissue exudate and blood loss form oedema exudate Fluids from the medullary bone bleeding, tissue exudate and blood loss form oedema exudate Harmful effects of oedema: Delays wound healing Delays wound healing Increases interstitial pressureIncreases interstitial pressure Increased risk of infection Increased risk of infection Induces the onset of pain Induces the onset of pain

6 Harmful effects of Oedema Amputees often predisposed to edema: Amputees often predisposed to edema: Pre existing vessel diseasePre existing vessel disease Decreased capacity for venous returnDecreased capacity for venous return Incision to vessels Incision to vessels Cut muscles Cut muscles ImmobilityImmobility

7 Stump Volume 1 week post op- volume is at its peak 1 week post op- volume is at its peak 1-2 weeks – decreased edema and some tissue atrophy 1-2 weeks – decreased edema and some tissue atrophy 2-3 weeks edema resolved, tissue atrophy 2-3 weeks edema resolved, tissue atrophy If you can limit volume in initial week If you can limit volume in initial week ↓ the rate change over time (same volume reached after 3 months) ↓ the rate change over time (same volume reached after 3 months) ↑ wound healing ↑ wound healing

8 What are the options: Nothing Nothing Soft dressings: Soft dressings: Elastic BandagingElastic Bandaging Juzo / stump shrinkersJuzo / stump shrinkers Rigid dressings Rigid dressings Thigh level rigid plaster dressing without immediate prosthesisThigh level rigid plaster dressing without immediate prosthesis IPOP – Immediate Post op ProsthesisIPOP – Immediate Post op Prosthesis Removable Rigid Dressing (RRD) Removable Rigid Dressing (RRD) Compression therapy/RRD Compression therapy/RRD

9 Soft dressings Advantages ease of application ease of application accessibility to the wound accessibility to the wound Low initial cost Low initial cost

10 Soft dressings Disadvantages High local or proximal pressures impair skin survival and healing High local or proximal pressures impair skin survival and healing Likelihood of gauze falling off Likelihood of gauze falling off ↑ ed chance of knee flexion contracture ↑ ed chance of knee flexion contracture ↑ ed pain →↑ ed bedrest, ↓ mobility ↑ ed pain →↑ ed bedrest, ↓ mobility ↑ ed hospital stays →↑ risk of pulmonary complications, stokes, pneumonia ↑ ed hospital stays →↑ risk of pulmonary complications, stokes, pneumonia ↑ ed health care costs due to ↑ ed hospital stays ↑ ed health care costs due to ↑ ed hospital stays

11 Shrinkers Vs Bandaging Bandaging Bandaging application is unreliableapplication is unreliable Dangerous in terms of pressure distribution (Puddifoot and associates showed elastic wrap to have the greatest range of pressures and the highest readings)Dangerous 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 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 dressings Significantly shorter rehab times compared to soft gauze dressings Protects the residual limb →↓ es revision surgery Protects the residual limb →↓ es revision surgery ↓ es edema, pain and healing times ↓ es edema, pain and healing times ↑ es tolerance to weight bearing/early ambulation ↑ es tolerance to weight bearing/early ambulation Holds knee in extension → prevents flexion contracture Holds knee in extension → prevents flexion contracture

13 Thigh level rigid plaster dressing Disadvantages More difficult to apply More difficult to apply Requires skilled surgical/prosthetic/rehab team Requires skilled surgical/prosthetic/rehab team ↑ ed cost (short term) ↑ ed cost (short term) ↓ ed access for wound inspection ↓ ed access for wound inspection Inability to adjust fit Inability to adjust fit Immobilises knee into extension Immobilises knee into extension

14 Thigh level rigid plaster dressing with IPOP Advantages Simular benefits of no IPOP plus: Simular benefits of no IPOP plus: ↑ stimulation of circulation ↑ stimulation of circulation Weightbearing within 24 hours Weightbearing within 24 hours ↓ es edema (by ↑ ing pressure and pumping action of muscles) ↓ es edema (by ↑ ing pressure and pumping action of muscles) ↓ ed time to custom prostheses ↓ ed time to custom prostheses Fewer surgical revisions Fewer surgical revisions Emotional/ self imaging benefits Emotional/ self imaging benefits Rapid healing Rapid healing

15 Thigh level rigid plaster dressing with IPOP Disadvantages Difficult to inspect wound Difficult to inspect wound Tissue damage – mechanical trauma (particularly vascular patients) Tissue damage – mechanical trauma (particularly vascular patients) Need a dedicated team/ highly skilled Need a dedicated team/ highly skilled Unskilled application could lead to disaster Unskilled application could lead to disaster Difficult to control early weight bearing Difficult to control early weight bearing Healing rate studies have shown Ambulate healing rates to be 20% less than non- ambulant Healing 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 dressings Significantly less oedema compared to soft dressings Enhanced wound healing; Enhanced wound healing; Limited oedema formationLimited oedema formation Immobilisation of soft tissuesImmobilisation of soft tissues Healing on average 3 weeks earlier than soft dressing management Healing on average 3 weeks earlier than soft dressing management Healing more rapid than IPOP Healing more rapid than IPOP Ability to remove and inspect wound Ability to remove and inspect wound Patient learns donning and doffing Patient learns donning and doffing Permits knee flexion Permits knee flexion Ability to adjust fit Ability to adjust fit

17 RRD vs Elastic Bandages Easier to apply Easier to apply Remain secure Remain secure Better stump shrinkage and shaping Better stump shrinkage and shaping No pressure problems No pressure problems Stump protection Stump protection ↓ ed Length of Stay (LOS) in accute hospital ↓ ed Length of Stay (LOS) in accute hospital Average of 9 days instead of 14Average of 9 days instead of 14

18 Rehabilitation Prostheses Plaster interims - Physios Plaster interims - Physios Moulded directly onto stumpsMoulded directly onto stumpsLimitations Socket design Socket design Basically walking on a castBasically walking on a cast No modifications can be madeNo modifications can be made Volume adjustments restricted to socksVolume adjustments restricted to socks Materials (weight, strength etc) Materials (weight, strength etc) Huge medico legal issuesHuge medico legal issues Different amputation levels Different amputation levels Heavy patients Heavy patients

19 Plaster vs prostheses Evaluation of service - MECRS Criteria Admissions Admissions L.O.S L.O.S No. of sockets No. of sockets 2 nd definative 2 nd definative in 1 st year PlasterProstheses %0

20 MECRS service delivery model Acute Hospital RRD fitted day 0 RRD fitted day 0 Days 0-7 acute Days 0-7 acuteRehabilitation Day 7 onwards Day 7 onwards Continue wearing RRD Continue wearing RRD Day 21 fit shrinker Day 21 fit shrinker Day 23 fit Rehab prostheses Day 23 fit Rehab prostheses

21 “Postoperative dressing and management strategies for transtibial amputations: A critical review” Douglas G.Smith et al Consensus on the most effective postoperative management strategies for TTA is lacking however: Consensus on the most effective postoperative management strategies for TTA is lacking however: Rigid dressings have been shown to significantly Rigid dressings have been shown to significantly ↓ edema compared to soft dressings ↓ edema compared to soft dressings ↓ rehab times compared to soft dressings ↓ rehab times compared to soft dressings ↓ time to initial gait training compared to soft dressings ↓ time to initial gait training compared to soft dressings

22 Compression Therapy A silicone liner is used for edema and volume control and for shaping of the residual limb A silicone liner is used for edema and volume control and for shaping of the residual limb allows the prosthetic treatment to start earlier. Three objectives are achieved in this phase: Three objectives are achieved in this phase:

23 1. Stretching of the soft tissue distally

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. Due to the decreasing thickness of the liner walls.

26 Compression Therapy Time of use and measure- ments are documented Time of use and measure- ments are documented Size of the liner is changed when necessary to maintain continuous compression Size of the liner is changed when necessary to maintain continuous compression Guidelines Guidelines Day 1 2 x 1h Day 2 2 x 2h Day 32 x 3h Day 4 and further.. 2 x 4h

27 Compression Therapy Oedema control Graded compression assists with oedema management Graded compression assists with oedema management The same level of compression is achieved regardless of who applies the liner The same level of compression is achieved regardless of who applies the liner In traditional care, both the compression and the quality of the dressing vary, depending on who performs the treatment.In 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. Improved pain control through the increased proprioception.

28 Compression Therapy Improved wound healing Reduction of oedema Reduction of oedema Provides occlusive environment Provides occlusive environment Considered standard treatment of leg ulcers Considered standard treatment of leg ulcers Prevents tissue dehydration and cell death Prevents tissue dehydration and cell death Provides barrier to bacteria Provides barrier to bacteria Decreases risk of infection Decreases risk of infection

29 Compression Therapy Further Benefits Shaping of residuum to give optimal shape for prosthetic fitting Shaping of residuum to give optimal shape for prosthetic fitting Thus reducing prosthetic complicationsThus reducing prosthetic complications Facilitates early mobilization Facilitates early mobilization Silicone speeds up maturation of residuum and helps smooth scar Silicone speeds up maturation of residuum and helps smooth scar

30 Case Study: Mr B – 2/2/04 WARNING on next slide

31 Mr B – 4/2/02

32 Mr B 12/2/04 Once the stitches were removed and there was no infection found a silicone liner was used to assist with the continuation of healing. Once the stitches were removed and there was no infection found a silicone liner was used to assist with the continuation of healing.

33 Mr B - 3/3/04 Healing improved as the “hardness” of the distal end reduced Healing improved as the “hardness” of the distal end reduced Patient reported pain reduction. Patient reported pain reduction.

34 Mr B – Today!

35 Launceston General Hospital Pilot Trial May 2003 Prem Anandam Full pilot trial can be found on:

36 QUESTIONS?

37 For related Post Op references or any further information please contact me at APC prosthetics or Thank you

38 Thank You


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