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?