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

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

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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Plaster vs prostheses Evaluation of service - MECRS 32 54 108 59 4 2 87% 0 Criteria Admissions L.O.S No. of sockets 2nd definative in 1st year

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

“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

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:

1. Stretching of the soft tissue distally

2. Compression of the wound surfaces along the suture lines.

3. An even compression that decreases proximally Due to the decreasing thickness of the liner walls.

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

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.

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

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

Case Study: Mr B – 2/2/04 WARNING on next slide

Mr B – 4/2/02

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.

Mr B - 3/3/04 Healing improved as the “hardness” of the distal end reduced Patient reported pain reduction.

Mr B – Today!

Launceston General Hospital Pilot Trial May 2003 Prem Anandam Full pilot trial can be found on: www.monash.edu.au/rehabtech/

QUESTIONS?

For related Post Op references or any further information please contact me at APC prosthetics. 02-9890-8123 or cameron@advcancedprosthetic.com.au Thank you

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