Early Limb Loss Care: Wound Care Options Reviewed Jeff Ericksen, MD
Mar 29, 2015
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?
Edema Factors
Perfusion flow, venous pressure, interstitial tissue pressure, capillary bed leakage, serum osmotic factors (protein).
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 1950’s Weiss 1963: 6th International Prosthetic
Course in Copenhagen & then guest lecture at UCSF & US Naval Hospital Oakland.
PRS Beginnings
Berlemont’s 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 1971JBJS
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 ACE34: plaster shell40: 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 1968Clin 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
Edema Reduction
Golbranson
1st 18 mo of project, 32 patients with daily cast removal to visualize wound1st 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 1980The Am Surgeon
52 BKA procedures: 34 IPOP, 18 softSoft 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% diedNo 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 1992Am J Surgery
65 of 167 LE amputations had IPOP Cleveland VAMC
86% achieved independent ambulation Surgery to ambulation interval
15.2 days BKA9.3 AKA
15% IPOP did not complete9% withdrew, 6% died
Pinzur et al 1989Orthopedics
38 consecutive BKA patients had Jobst pneumatic prosthetic device applied immediately34 vasc mean age 60.94 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 bearing4.7 days vasc group5 days trauma group
Pneumatic system duration8.3 days vasc10.8 days trauma
Pinzur
D/C home9 days vasc & 11 days trauma
4 infection/wound dehiscence patientsPovidine 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 group2 healed in plaster3 AKA revisions5/6 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 techniqueAcknowledged inexperience with
technique
Baker et al 1977Am 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 controlprotects 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 1979JBJS
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 bandagingHealing time inferred from temporary
prosthetic order in chartRehab time = amputation to d/c with
temp prosthesis
Wu
time tohealing
time toprosthesis
control group 109.5 191.4
study group 46.2 101.8
Table courtesy M Huang, MD
Mueller 1982Physical Therapy
15 subjects with 16 below knee amputationsAge 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, 1987case of open wound healed with RRD
Richter, Archives of PM & R, 1988case report in a patient with wound
dehiscencehealing 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-LimbTM,Aircast Co.) compared to custom molded rigid system (ICEXTM, 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 -0.49 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: -0.49 mm vs. 1.63 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 patient’s 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.
Thank you for your attention!
Questions?