1. Craig Evans Physiotherapist Rankin Park Limb Centre
Walking the Wounded
Craig Evans
Physiotherapist
Rankin Park Limb Centre

2. AROC RPC Results summarised (Rees, Baines and Dunne 2015)
Admission:
RPC has increased complexity of patients
Increased comorbidities
Increased patients with carer and support
Decreased admission FIM’s
Inpatient:
Increased LOS ( Due to external service issues )
Decreased complications ( RPC good nursing care )
Discharge:
Lower FIM scores
Increased FIM change
Increased services at home but increased discharge to home
Overall as compared to our national benchmarks: We have a lower admission and discharge FIM score and longer LOS than the benchmarks but we are getting more of our patients home with increased services and carers other than Residential placement.

3. Episodes of care at RPC

4. FIM change over 10 + years

5. Average Age change over the years

6. More FIM data…

7. Overall admissions

8. From AROC we know… AROC Data (FY 12/13 – 15/16) National RPC
Start Rehab Phase “Delayed Wound” (completed Start phase data collection)
32%
(63%)
43%
(98%)
LOS (Start phase)
- Pre- prosthetic
- Delayed wound
35.9 days
34.6 days
30.1 days (n=38, 40%)
40.7 days (n=40, 43%)

10. There’s a lot more to amputees than a stump.
Home – environment / access and help / services
Psychosocial – motivation, participation, depression, anxiety, future, coping, perception amongst the community / by staff / family
Physical health – heart / lungs / nutrition / diabetes / bone health / deconditioned / intact limb at high risk
Prosthesis / function – walking, falls, a step in the right direction
Not listed Pain.

11. What presents…
Underlying everything can be Pain.

12. What Is needed for wound healing?
Happy healthy cells!
Remove oedema and slough
Moist vs dry
Circulation – O2 and nutrition
Approximate wound edges
Prevent adherent scarring

13. Wound Healing The phases of wound healing are: • Hemostasis
• Inflammation
• Proliferation or Granulation
• Remodeling or Maturation

14. A building analogy…

15. Different dressings and materials

16. Negative Pressure Wound Therapy
POSITIVES
Collection of exudate away from wound
low frequency dressings
“Anatomically clean” – reduce exposure to infection.
Low odour
Promotes granulation
Approximates wound
Increased perfusion.

17. Negative Pressure Wound Therapy
NEGATIVES
Wound maceration
Retention of dressings
Wound infection
“suction rash”
Interfere with mobility
Noisy – sleep probs
Prosthesis issues?
Cost?

18. Negative Pressure Wound Therapy
Cochrane review (Dumville et al 2015) – NPWT on second intention wounds(SIW).
2 studies
Lack of evidence or adverse effects
New study – shock, anguish, frustration, powerlessness (McCaughan, 2015)
RCTs aren’t everything…
2 studies reviewed / qualified out of a possible 32 full text articles:
1 compared NPWT with alginate dressings in groin wounds
1 compared NPWT with a silicone dressing

19. Wound Research… 1000s! No 2 wounds are the same – comparison issues
Need to use different dressings at different times.
Consensus is difficult
There is so much research out there you could invariably find something that says what you were using was the right thing to do!
But is it good research?
Does it compare apples with apples?
Often we need to use different things at different times and what works for one wound might not work for the next.
Need to use clinical judgement.

20. Other considerations…
Circulation / Perfusion / Oxygen
Problems with O2 delivery will affect wound healing:
Ordinary Hb levels
Poor functioning Respiratory or Cardiac systems – poor ventilation perfusion matching, lung disease, reduced LVEF
Poor skin and muscle perfusion – shunt to capillary beds feeding these areas. TcPO2

22. Other considerations…
Depression linked with lower prosthetic use rates post discharge (?)
Exercise may help mood
Pain
Home environment / accessibility
Can a prosthesis be fitted?

23. Early Prosthetic fitting…
IPOPs – since ?1980s / earlier? More recently found to have similar complications, less revision surgery required (Ali et al 2013)
Active suction sockets (Traballesi et al 2012)
Ali – retrospective study, high risk of bias but made it in annals of vascular surgery journal!
Traballesi – Used Vacuum assisted socket systems as a primary prosthesis vs standard suction socket systems. Better mobility as rated using LCI at end of 12 weeks rehab, used prosthesis for longer at 2 months follow up. Groups were same at 6 month follow up. Small numbers though

24. Early Prosthetic fitting…
Use of NPWT concurrently with prosthesis (Fuller et al 2011)

25. Silicone Liners (Larsson and Johannesson,1997)
Figure 6 – stretching of the soft tissue distally
Figure 7 – approximation and compression of the wound edges
Figure 8 – Graduated compression from distal to proximal (even compression that decreases proximally)
Distal cup provides increased protection

26. Nothing to lose… BK1
This is a case example from 2007 of a gentleman who was trialled with a silicone liner and prosthesis soon after the first photo was taken. The limb at that stage was on the verge of requiring a revision but ended up healing with careful wound management in combination with silicone liner and prosthetic use. It required a big team effort!
No NPWT
Cast on the day of the first photo, fitted 4 days after.
2nd photo is 1 month after fitting.
Last one 2 months post fitting.

27. Walking helps… Active exercise – increases CO and BP
Wound compressed in socket +/- ? Silicone
“Squeezes” out the “bad stuff”
Cyclical Pumping – blood flow, reduces oedema
Good for the psyche
Better function

28. Case Study: BK2 49 yo male Amputation: (R) TTA 17/6/16
B/G: T2DM; Obesity; PVD – (L) TTA 2014; H/T; Depression; eMRSA
Post op complications: Hb 78, multiple debridements + VAC, depression.
Rehab adm 4/8/16

29. Case BK2: 9/8/16

30. Case BK2: 29/8/16 Maceration to the wound edges.
In subsequent days with a change in foam and tracking up the leg with a view to still doing some weight bearing – rash developed

31. Case BK2: 16/9/16 no prosthesis.
The cost for the NPWT for this gentleman whilst in rehab was: ~$1520 (26 days total, 7 dressing changes)
If it were normal dressings? Not sure
Cost to mental health?
Cost of bed days?
Would it have been different with no NPWT?

32. Strict prosthetic protocol

33. Case BK2: 20/9/16 (Prosthesis)

34. Case BK2: 26/9/16 Discharge!!!

35. Strict prosthetic protocol

36. Case BK2: 28/9/16 – 1st OP visit

37. Case BK2: 5/10/17
5/10/16

38. Case BK2: 5/10/16

39. Case BK2: 2/11/16

40. Amputee mortality / survival rates
Kulkarni Pande and Morris (2006) “Survival rates in dysvascular lower limb amputees.” International Journal of Surgery (2006) 4:
English Cohort (n=201)
Interestingly bilateral amputee survival rates were better than unilateral.

41. Amputee mortality / survival rates
WA study diabetic patients between 1990 and All amputations included from digits to limbs.

42. Prosthetic fitting for delayed wounds
Doesn’t always go right.
Meticulous
Monitoring wound and fit
Strict protocol
Who are the best candidates?
Who are the best candidates?
Can monitor wound and fit – Cognition
Potential to increase Oxygen delivery?
At risk of depression and isolation if they don’t get going
Exudating wounds – not dry and crusty
?Sweat – indicates skin perfusion.
Nothing to lose – potential for revision.
Pain free.
Components

43. References
AJ Hayes et al (2011). “Risk equations to predict life expectancy of people with Type 2 diabetes mellitus following major complications: a study from Western Australia.” Diabet. Med. 28, 428–435 (2011)
Kulkarni Pande and Morris (2006) “Survival rates in dysvascular lower limb amputees.” International Journal of Surgery (2006) 4:
Larsson and Johannesson (1997)?
Dumville JC, Owens GL, Crosbie EJ, Peinemann F, Liu Z. Negative pressure wound therapy for treating surgical wounds healing by secondary intention. CochraneDatabaseof SystematicReviews 2015, Issue 6. Art. No.: CD DOI: / CD pub2.
MM Ali et al (2013). “ A contemporary comparative analysis of immediate postoperative prosthesis placement following below-knee amputation.” Annals of Vascular Surgery 27(8): , 2013 Nov.
Traballesi et al (2012). “Residual limb wounds or ulcers heal in transtibial amputees using active suction socket system. A randomised controlled study.” European journal of physical & rehabilitation medicine 48(4): Dec.
M Fuller et al (2011). “A novel approach to wound management and prosthetic use with concurrent vacuum-assisted closure therapy.” Prosthetics and Orthotics International 35(2): 246-9, 2011 Jun