Presentation on theme: "Use of TEC system for amputees and other innovations in early management of the amputee Dr F Kohler 19th August 2005."— Presentation transcript:
1Use of TEC system for amputees and other innovations in early management of the amputee Dr F Kohler 19th August 2005
2Advantages of early fitting of prosthesis 1. Quicker stump maturation2. Preservation of muscle tone3. Prevention of contractures4. Facilitates gait retraining5. Eliminates bad walking habits
3Goals of Post-operative Management of residual limbs 1) Primary wound healing2) Prevention of oedema3) Facilitation of stump shrinkage4) Prevention of stump trauma5) Patient education6) Prevention of contractures
4Timing for prosthetic treatment (A) temporary prosthesis ordered when(1) wound appears healed(2) sutures have been removed(3) stump is no longer oedematous(B) definite prosthesis(1) stump is no longer oedematous and measurements are stable over a period of time.
5Current best practice1. General conditions permitting the patient stands on day 1 or 2 post-operative for 1 to 5 minutes.2. This is delayed in debilitated disorientated or obese patients and bed exercises are substituted.3. Weightbearing is encouraged from day 1 or 2 but limited to less than 20kg (further restriction may be necessary).4. Full weightbearing from when the wound is healed.5. Ambulatory training commences when the patient can stand for > 5 minutes. (weightbearing restricted to 10kg).
6GENERAL OUTLINE (preoperatively) Pre-operative ConsultationExplanation of programmePsychosocial issuesUpper limb/contra lateral limb exercise programmeMobilisation with aids
7Perioperative Bed exercise programme Psychosocial aspects Plan early home visitEducation of process
8Postoperative (1) Day 2-3 - sit out of bed Day stand and commence mobility training.Day commence transfer practice.About 1 week - home visit.
9Postoperative (2) Week 2 Progress to mobilising with aids Simultaneously may learn wheelchair independence, especially if TF amputee.Self care retraining
10Postoperative (3) Week (3) Home visit with patient if requiredStump bandaging if surgeon is happyDischarge home if possibleTransfer to rehabilitation unit if required.- no home support- unsuitable home environment
11Postoperative (4) After Week 3 Stump bandagingTemporary plaster prostheses as requiredProsthetic training, usually as outpatientDefinitive prosthesis about 3-4 months post amputation
13DefinitionTEC stands for Total Environmental Control referring to the total skin contact, and the pressure relieving properties of the system.3
14Components of the TEC system The system consists of TEC linerTEC stump socketTEC retainer4
15TEC Liner (1) made of urethane has flow properties to decrease pressure areasliner ‘flows’ from areas of high pressure to areas of lower pressures to even out pressure on the stumppre-shapedavailable in four different sizescomes with or without cover5
21Advantages 1) Stump protection 2) Earlier and better stump shaping 3) Enhances stump healing by assisting with management of oedema4) Earlier mobilisation5) Ease of review11
22Disadvantage of TEC System May not fit well on all stumps as premoulded, not individualisedMay not fit well secondary to the stump changes.Cost, about $1000 per prosthesis and liner.
23Implications (1)Since it has been used, 2 patients who have had a significant fall onto their stump have not sustained any wound breakdown, unlike the 3 patients before use of TEC system, who required stump revision for 1 patient, conversion to above knee amputation for 2 patients.12
24Implications (2)Patients can now get up about day 7, compared to day prior to use of thisearlier mobilisation results in earlier dischargepossibly a shorter time to definitive prosthesis13
25Economics Cost: Approximately $1000 per system can be sterilised and reused - 2,3 or more times.Savings: Unspecified, but likely to be manytimes the outlay. Currently studying to quantify savingsSignificant improvement in patient wellbeing.14
27Look at my new Flex-Foot Barnaby is a 12-year-old horse from the UK.Happily, pioneering surgery and assistance from Dorset Orthopaedic meant Barnaby didn't have to be put down following an infection in his foot.
28ICEXICEX 100 is an integral part of the Icelandic Direct Casting (IDC) system, the unique direct casting system to make customized carbon fiber sockets directly onto the residual limb.The direct casting system allows prosthetists to produce well fitting sockets time and time again.
29ICEX 2ICEX 100Superior comfort and fit IDC provides a Total Surface Bearing ICEX socket through even pressure distributionStrong and durable The ICEX 100 carbon fiber braid fits users of all activity levels upt to 100 kg. in weightLightweight Carbon fibers are the strongest and most lightweight casting material available
32Polymer impregnated sock Thin thermoplastic/silicone type sockLightweight removable rigid dressingDecreases shear forcesGood stump compressionResults suggest that stump stability for fitting of prosthesis is decreased from 17 to 12 days
33Patients with TEC protector (1) JK: 55 year old lady- bilateral PVD, malunion following trauma- lives in caravan- etoh abuser with cerebellar signs- ® TT amputation 8/12/99- Transfer to rehab. 22/12/99- stump protector fitted 5/1/2000- Independently mobile with prostheses and crutches- quad stick including steps on discharge 24/1/2000- ongoing outpatient PT & support- now needs three distal pads in prosthesis
34Patients with TEC protector (2) DR: 86 year old lady living alone at home (self care unit). PVD; IHD; # (L) wrist whilst on gate leave 12/11(l) TT amputation 27/7, slow to heal, bed rest 3/52.Home to daughter’s house, independent with mobility on pick up frameAwaiting wound healing on 10/9/99Admit to Braeside Rehab 21/10/99 and TEC liver.TEC prostheses fitted 25/10 - mobilising up to 150m outside with 2 crutches by 12/11Had fall whilst transferring into car 14/11Discharged home 24/11
35Patients with TEC protector (2) DR: 86 year old lady living alone in self care unit; PVD; IHD; # (L) wrist whilst on gate leave 12/11(l) TT amputation 27/7, slow to heal, bed rest 3/52.Home to daughter’s house, independent with mobility on pick up frame while awaiting wound healing on 10/9/99Admit to Braeside Rehab 21/10/99 and TEC liver.TEC prostheses fitted 25/10 - mobilising up to 150m outside with 2 crutches by 12/11Had fall whilst transferring into car 14/11Discharged home 24/11definitve fitted mid Decemberstill fitting well on last review 7/2/2000
36TEC Patients (3) Mrs. MD - IDDM Bilateral TT amputations (L) 11/11/99 Poor wound healing - skin graft on left; slow healing on right; MRSA infectionperipheral neuropathyCCF, IHDTransferred to Rehab 5/1/2000- primary goal: Wheelchair independence achieved by 25/1.- Whilst awaiting home modifications (R) wound healed and a plaster prostheses was fitted on 27/1- 28/1 standing practice and swivel transfers.
37MD (2) 11/2 left TEC prostheses fitted 14/2 mobilised with prostheses x 2, FASF and assist x 215/2 - discharged
38MD (3) 11/2 (l) TEC prostheses 14/2 mobilised with prostheses x 2, FASF and assist x 215/2 - discharged
39TEC Patients (4) Mr AL, PVD, heavy smoker, lives on first floor (R) TT amputation 27/9Fall 19/10 and placed on bed rest28/10 mobilised with stump protector only4/11 discharge home on cruchesReadmitted 21/11 with abscess(R) TF amputation 17/12Admit rehab 10/1D/c Home 21/1on crutches
40TEC Patients (5) Mr RC vasculopath, diabetic,obese (R) TF amputation 17/8Fall end of August resulting in wound dehiscence and resuturingStump protector only fitted early SeptemberTransferred to Rehab St Elsewhere wthout stump protector on 22/9fall on 29/9 requiring resuturing (R) TT amputation 30/9
41RC (2) Transfer to Rehab 7/10 commence prosthetic training 15/10 stump ooze increasing 22/10recommence prosthetic training 28/10independent with rollator frame 22/11home mods required; discharge 3/12definitive prosthesis fitted in January 2000
42TEC Patients (6) Mr RK: PVD, AAA, smoker (R) TT amputation 21/10 Stump protector only fitted 2/11Discharged home 2/11 hopping with PUF17/11 mobilised with temporary TEC prosthesis25/11 progressed to Canadian crutches13/1 Definitive prosthesis fitted4/2 minor adjustment to definitve prosthesis
43Traditional (local) timing for prosthetic treatment (A) temporary prosthesis ordered when(1) wound appears healed(2) sutures have been removed(3) stump is no longer grossly oedematous(B) definite prosthesis(1) stump is no longer oedematous and measurements are stable over a period of two to four weeks
44Local StudyRetrospective analysis of first 30 patients with TEC prosthesis and a sample of amputee patients for two years prior to using the TEC system.
45Study Aim Compare retrospective samples of patients by: Age Time taken to first get out of bedTime taken to first mobiliseTime taken to first temporary prosthesisTime taken to mobilising independentlyTime taken to discharge and or transfer to a rehabilitation unitTime taken to definitive prosthesisNumber of falls and consequences of falls
46Method Retrospective chart analysis Patient identification by - 1) referral book2) consult sheets3) case conference lists
47Inclusion criteria Transtibial amputation previously walking cognitively able to participate with rehabilitation programme
48Exclusive criteria Grossly incomplete data severe dementia Other: morbidities excluding participation in rehabilitation programmestump revision
49Results (1) TEC used in 30 patients 6 patients no data available - transferred to other hospital soon after TEC issue24 patients for analysis
50Results (2) Comparison Group 40 - 8 deleted because of lacking data 32 remaining for analysis
54Falls outcomes with TEC TEC liner not worn 10 days lost due to bruisingPatient fell while not wearing TEC resulting in wound breakdown, required re-suturing and three weeks to heal2 falls in one patient, one resulting in no complications, one resulting in a fractures armPatient developed fractured ribsNo stump damage
55Falls outcomes without TEC wound breakdown requiring one weeks bed rest and three weeks to healwound breakdown and subsequent infection requiring conversion to AKAno complications3 patients developed bruising to stump from fall delaying prosthetic fitting by 10 days or more
56Analysis (1) Data not normally distributed Mann-Whitney test used for statistical analysisNot significant were:time to first get out of bedtime to first mobilisingtime to dischargetime to transfer to rehabilitation unit
57Analysis (2) Highly significant differences for: first mobilising with prosthesisindependent with prosthesisApproaching significance:Temporary Prosthesis first issued (0.057)
58ConclusionTec stump protectors result in improved patient outcomes as measured by earlier independence in prosthetic mobilityThere was a decreased incidence of serious stump trauma in patients who used the TEC protector.There is no evidence from this study that there were significant other effects on patient management
59Economic Consequences of Falls Difficult to determine accurately but the stump revision required after the fall in the patient not wearing a TEC protector sways the costs markedly against not using a TEC liner or other protective device.So far only 2 events with stump damage in the TEC protectorsAt a hospitalisation cost of around $700 or more per day the cost/benefit ratio of TEC protectors seems favourable.
60DiscussionNeed for further studies/greater numbers to fully evaluate outcomes.Need to review patient and staff satisfaction/acceptabilityChanges in surgeons expectations.No TEC=no mobilisationCost of protectors and who pays?Reuse of protectors and effect on cost.Other possible effects on results.
61Prosthetist involvement in making of temporary prosthesis This group consisted of amputees who were transferred to the Braeside inpatient rehabilitation unit from May 2003 onwards. The prosthetist reviewed the patients and made their temporary prosthesis while they were inpatients at Braeside. The data was collected prospectively.
62Results (1)A total of 11 transtibial amputees were treated in the prosthetist group. One patient discharged themselves against medical advice and was excluded from the analysis as many of the end points were not met. This patient had progressed quite well prior to discharge. This left ten patients who were analysed as part of the study.
671961 Berlemont:immediate prosthetic limb replacement on the operating tableapplied plaster of paris following debridement of the infected and septic stumpweight bearing allowed early in the post-operative period1963 Weiss - modified and improved the technique using it for closed lower extremity amputations and surgical stump revisions
68Burgess & Romanoindicated that immediate post surgical prosthetic fitting had a significant positive effect on the plan of managementconfirmed as useful treatment by Moore (1968), Condon & Jordan (1969)Lim et al suggested the success was due to the rigid dressing, rather than early mobilisationSormiento (1970) recommended that full weightbearing be prohibited for at least 2 weeks after amputation.
69Kiah et al (1970) demonstrated faster wound healingdecreased complication ratereduced hospital length of stayThis was as a consequence of using rigid dressings without prostheticGerhardt & Assoc. (1970) advocated the use of an immediate post-operative fitting to achieve better soft tissue healing in addition to help control post surgical oedema, reduce pain and prevent the complications of inactivity.
70Mooney & co-workers (1971) demonstrated that application of a functional, mechanical stress by means of progressive controlled weightbearing is beneficial in the soft tissue healing of the stump wound.- also demonstrated that early ambulation (< 1 month) post-operative) provided some physical or mental advantages to the patients, which allowed them to become functional prosthetic users to a greater degree
71Cohen et al (1974)This immediate post-operative prosthesis technique had a tenfold increased incidence of wound complicationNicholas et al (1976) showed that the rigid dressing resulted in 100% healing of stumps by primary intention, compared to 78% primary healing in their conventional dressings (published figures 60-80%)
72Mid 1970s it was generally felt that immediate post-operative prosthesis should be reserved for patients undergoing amputations for trauma or tumour, and the occasional good risk artheroschlerotic amputee.Generally weightbearing is allowed from about 2 weeks post operation
73Baker et al in 1977 showed that plaster dressing significantly shortened hospitalisation and enabled earlier rehabilitation. The patients with soft dressings, almost uniformly had stump oedema despite wrapping with an elastic bandage, the persistence of which postponed the beginning of gait training.
74They allowed protective/partial weightbearing on parallel bars/crutches as early as the first post-operative day, but did not hesitate to discontinue weightbearing if the patient was unable to control weightbearing.They demonstrated that maintenance of knee range of motion, stair climbing, walking up and down ramps, and standing up and sitting down were facilitated by this process, especially in the geriatric patient.
75Wu & Assoc. (1979 &1980) first described a removable rigid dressing technique The below-the-knee removable rigid dressing is a below-the-knee plaster cast held by a suspension stockinette to a supracondylar plastic cuff. Being removable, it permits frequent observation and progressive shrinkage of the stump (by adding socks), and eliminates the need of elastic stump bandaging.
76In addition, it still maintains the advantages of immobilisation of soft tissue (to reduce pain and facilitate wound healing) and prevention of trauma to the stump as does the conventional rigid dressing.It has significantly reduced the incidence of pre-tibial skin breakdown and distal oedema, produced fast stump shrinkage, and shortened time to ambulatory discharge with a temporary prosthesis by ninety days.Bacon et al (1986) described a detachable cast pylon technique for rigid dressing.The pylon could be removed at night, with the rigid dressing left insitu
77Rehabilitation time following amputation (Wu et al 1979) Average time to healing (days)Average time to ambulatory discharge (days)Control group109.5191.4Removable rigid dressing46.2101.8
78Stump trauma (1991) Behan et al U.S. Retrospective review of below knee amputees for 14 years23 suffered trauma to their stumps80% of the trauma was as a result of a fall11 patients required above knee amputation
79Plaster Pylon Technique Harrington et al 1984 &1991used a rigid plaster dressing applied in theatre to mid thigh levelthe patient is allowed to mobilise immediately with walker or crutchesat one week plaster is changed and a copper tube pylon is added to the castthe patient is then allowed to partial weightbear or fully weightbear
80Plaster Pylon Techniques Results (56 patients) Average time for wound healing (days)Average time for mobilisation with temporary prosthesisPlaster Pylon Group40.4108.4Soft bandage Group98.4200.1
81Open stump woundsStudy by Vigier (France) et al 1999 Plaster cast socket with silicone sleeve versus elastic compression 28 subjects per groupAverage healing time (days)Walking with prosthesisDischargePlaster cast71.263.599.8Elastic compression96.873.3129.9
82Preformed temporary sockets First suggested by Foort in 1970Further advocated by McDougall in 1977 who used transparent plastic sockets with foam/rubber pads. Three different diameters were available.This resulted in improved outcomes including healing of stumps which had been thought to require revision(Case series of 650)
83Other types of temporary prosthesis 1. Shrink plastic film (s film)Dowie, 1975 S.A.one case reportwalking at 3/52 post operatively2. Air splint Burraclough et al Sydney5 patients from 10 used the air splint with pylon and foot attached prior to changing to a conventional temporary prosthesis
84Other types of temporary prosthesis (cont’d) 3. Prefabricated plastic limb - Kraker D, , USAplastic, hollow form fitted over the conventional plaster dressing and cut to size.Usually applied about day 8 post operatively.Average definitive prosthetic fitting at 7.7 weeks(54 days)
85Other types of temporary prosthesis (cont’d) 4. Otto Bock Prefab5. TEC6. Definitive type
86Advantages of Rigid dressings 1. Control oedema2. Support circulation3. Minimises inflammatory reaction4. Simplified nursing care5. Positive effect on stump shaping6. Decreased painful phantoms
87Disadvantages of rigid dressings 1) inability to observe the stump except at cast change2) inability to produce progressive stump shrinkage except at cast change3) length of time needed during periodic cast removal and re-application4) need for an experienced prosthetist (physiotherapist) at completion of surgery5) resource intensive
88Contraindications to Rigid Dressing 1. Local infection at the site of amputation2. Large oedematous stump in which technical application and appropriate anchoring would present a problem