Early Limb Loss Care: Wound Care Options Reviewed

1. Early Limb Loss Care: Wound Care Options Reviewed Jeff Ericksen, MD

2. 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.

3. Objectives • Outline benefits associated with particular techniques. • Review evidence basis for particular methods.

4. Early Wound Care Goals in the Pre-Prosthetic Phase • Incision protection for trauma and contamination. • Edema control. • Body image influence? • Social interaction?

5. 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.

6. 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?

7. Edema Factors • Perfusion flow, venous pressure, interstitial tissue pressure, capillary bed leakage, serum osmotic factors (protein).

10. 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

11. 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

12. Picture source: Lower Extremity Amputation by Moore & Malone 1989

14. 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

15. 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.

16. 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.

17. 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

18. 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

19. 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

20. IPPF Reported Benefits • Phantom pain reduction? • Improved psychological response to limb loss • Earlier definitive prosthesis & return to lifestyle and employment • Shorter hospital stay?

21. Research Support for IPOP/IPPF

22. 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.

23. 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.

24. Burgess et al 1968Clin 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.

25. 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 ACE • 34: plaster shell • 40: plaster with pylon in OR

26. 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

27. 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

28. 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

30. 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

31. Edema Reduction

32. Golbranson • 1st 18 mo of project, 32 patients with daily cast removal to visualize wound • 1st week post-op with rapid swelling, most needed return of cast within 1 minute to fit again • Rapid swelling tendency ended after 2 weeks

33. Kane et al 1980The Am Surgeon • 52 BKA procedures: 34 IPOP, 18 soft • Soft 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% died • No signif differences

34. 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?

35. 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 BKA • 9.3 AKA • 15% IPOP did not complete • 9% withdrew, 6% died

36. Pinzur et al 1989Orthopedics • 38 consecutive BKA patients had Jobst pneumatic prosthetic device applied immediately • 34 vasc mean age 60.9 • 4 trauma mean age 34.5 • Ambulated as soon as “clinically feasible” • Daily wound inspection

37. Pinzur • 76.3% wound healing and progression to temporary limb before d/c • Weight bearing • 4.7 days vasc group • 5 days trauma group • Pneumatic system duration • 8.3 days vasc • 10.8 days trauma

38. Pinzur • D/C home • 9 days vasc & 11 days trauma • 4 infection/wound dehiscence patients • Povidine dressings & continued with pneumatic system, all healed • 86.8% total success to early prosthetic limb fit and use • 3 AKA revisions

39. 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

40. Cohen et al 1974*Surgery • Reported 97 consecutive LE amputations for ischemia but only 9 IPOP patients • IPOP group • 2 healed in plaster • 3 AKA revisions • 5/6 BKA IPOP group (83%) walked at f/u

41. 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 technique • Acknowledged inexperience with technique

42. 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

43. IPOP Pros/Cons • Advantage: • excellent edema control • protects residual limb against trauma • Disadvantage: • lack of easy wound access • requires technical skill in application • immediate weight bearing effect on wound healing?

44. 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?

45. 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

46. 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.

48. Wu • twenty one below knee amputations in 19 pts • treated with the RRD, timing? • compared with thirty patients admitted prior with elastic bandaging • Healing time inferred from temporary prosthetic order in chart • Rehab time = amputation to d/c with temp prosthesis

49. Wu Table courtesy M Huang, MD

50. Mueller 1982Physical Therapy • 15 subjects with 16 below knee amputations • Age 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