Post-Op Management Options

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Post-Op Management Options
Cameron Ward B.PO
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Overview

• What is needed in post op management?
• A quick look at oedema.
• Comparing the options?
• Something new
• Compression therapy

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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.
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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

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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

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Harmful effects of Oedema

• Amputees often predisposed to edema
• Pre existing vessel disease
• Decreased capacity for venous return
• Incision to vessels
• Cut muscles
• Immobility

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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

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What are the options

• Nothing
• Soft 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

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Soft dressings Advantages

• ease of application
• accessibility to the wound
• Low initial cost

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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

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Shrinkers Vs Bandaging

• 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

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Thigh level rigid plaster dressingAdvantages

• 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

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Thigh level rigid plaster dressingDisadvantages

• 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

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Thigh level rigid plaster dressing with
IPOPAdvantages

• 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

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Thigh level rigid plaster dressing with
IPOPDisadvantages

• 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

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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

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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

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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

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Plaster vs prosthesesEvaluation of service -
MECRS

• Plaster
• Prostheses
• 32 54
• 108 59
• 4 2
• 87 0

• Criteria
• Admissions
• L.O.S
• No. of sockets
• 2nd definative
• in 1st year

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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

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Postoperative dressing and management strategies
for transtibial amputations A critical
reviewDouglas 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

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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

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1. Stretching of the soft tissue distally
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2. Compression of the wound surfaces along the
suture lines.
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3. An even compression that decreases proximally

• Due to the decreasing thickness of the liner
  walls.

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Compression Therapy

• Time of use and measure- ments are documented
• Size of the liner is changed when necessary to
  maintain continuous compression

• Guidelines
• Day 1 2 x 1h
• Day 2 2 x 2h
• Day 3 2 x 3h
• Day 4 and further.. 2 x 4h

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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.

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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

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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

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Case Study Mr B 2/2/04WARNING on next slide
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Mr B 4/2/02
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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.

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Mr B - 3/3/04

• Healing improved as the hardness of the distal
  end reduced
• Patient reported pain reduction.

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Mr B Today!
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Launceston General Hospital Pilot Trial

• May 2003
• Prem Anandam
• Full pilot trial can be found on
• www.monash.edu.au/rehabtech/

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QUESTIONS?
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For related Post Op references or any further
information please contact me at APC
prosthetics.02-9890-8123or cameron_at_advcancedpro
sthetic.com.au
Thank you
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Thank You