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

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.
Occupational
therapist
Prosthetist
Rehabilitation
Consultant
Physio-
Nurse
Orthopaedic
surgeon
The
Amputee
It 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?
- Aims
Ensure good wound healing
Reduce oedema in residual limb
Pain reduction
Shape residuum
Protection of residuum from external stresses
Prevent contractures
Prepare for prosthetic management/ambulation

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

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

7. Stump Volume 1 week post op- volume is at its peak
1-2 weeks – decreased edema and some tissue atrophy
2-3 weeks edema resolved, tissue atrophy
If 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 Bandaging
Juzo / stump shrinkers
Rigid dressings
Thigh level rigid plaster dressing without immediate prosthesis
IPOP – Immediate Post op Prosthesis
Removable Rigid Dressing (RRD)
Compression therapy/RRD

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

10. Soft dressings Disadvantages
High local or proximal pressures impair skin survival and healing
Likelihood 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 unreliable
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

12. Thigh level rigid plaster dressing Advantages
Significantly shorter rehab times compared to soft gauze dressings
Protects the residual limb →↓es revision surgery
↓es edema, pain and healing times
↑es tolerance to weight bearing/early ambulation
Holds knee in extension → prevents flexion contracture

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

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

15. Thigh level rigid plaster dressing with IPOP Disadvantages
Difficult to inspect wound
Tissue damage – mechanical trauma (particularly vascular patients)
Need a dedicated team/ highly skilled
Unskilled application could lead to disaster
Difficult to control early weight bearing
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
Enhanced wound healing;
Limited oedema formation
Immobilisation of soft tissues
Healing on average 3 weeks earlier than soft dressing management
Healing more rapid than IPOP
Ability to remove and inspect wound
Patient learns donning and doffing
Permits knee flexion
Ability to adjust fit

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

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

19. Plaster vs prostheses Evaluation of service - MECRS
32 54
4 2
87% 0
Criteria
Admissions
L.O.S
No. of sockets
2nd definative
in 1st year

20. MECRS service delivery model
Acute Hospital
RRD fitted day 0
Days 0-7 acute
Rehabilitation
Day 7 onwards
Continue wearing RRD
Day 21 fit shrinker
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:
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 Therapy
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:

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.

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

27. Compression Therapy Oedema control
Graded compression assists with oedema management
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.
Improved pain control through the increased proprioception.

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

29. Compression Therapy Further Benefits
Shaping of residuum to give optimal shape for prosthetic fitting
Thus reducing prosthetic complications
Facilitates early mobilization
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.

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