Post-Op Management Post-Op Management OptionsOptions

Cameron Cameron Ward Ward B.P&OB.P&O

OverviewOverview What is needed in post op What is needed in post op

management?management? A quick look at oedema.A quick look at oedema. Comparing the options?Comparing the options? Something “new” Something “new”

• Compression therapyCompression therapy

What is needed in post op What is needed in post op management?management?

- Multi-disciplinary team- Multi-disciplinary teamOptimal recovery and Optimal recovery and rehabilitation after rehabilitation after amputation requires a amputation requires a multi-disciplinary approach. 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.

Occupational therapist

Prosthetist

Rehabilitation Consultant

Physio-therapist

Nurse

Orthopaedic surgeon

The Amputee

What is needed in post op What is needed in post op management?management?

- Aims- Aims Ensure good wound healingEnsure good wound healing Reduce oedema in residual limbReduce oedema in residual limb Pain reductionPain reduction Shape residuumShape residuum Protection of residuum from external Protection of residuum from external

stressesstresses Prevent contracturesPrevent contractures Prepare for prosthetic Prepare for prosthetic

management/ambulationmanagement/ambulation

Wound Healing - oedemaWound Healing - oedema Inflammatory responseInflammatory response

• Oedema exudate formsOedema exudate forms Fluids from the medullary bone bleeding, tissue Fluids from the medullary bone bleeding, tissue

exudate and blood loss form oedema exudate exudate and blood loss form oedema exudate

Harmful effects of oedema:Harmful effects of oedema: Delays wound healingDelays wound healing

• Increases interstitial pressureIncreases interstitial pressure Increased risk of infectionIncreased risk of infection Induces the onset of painInduces the onset of pain

Harmful effects of OedemaHarmful effects of Oedema Amputees often predisposed to Amputees often predisposed to

edema:edema:• Pre existing vessel diseasePre existing vessel disease• Decreased capacity for venous returnDecreased capacity for venous return

Incision to vessels Incision to vessels Cut musclesCut muscles

• ImmobilityImmobility

Stump Volume Stump Volume 1 week post op- volume is at its peak1 week post op- volume is at its peak 1-2 weeks – decreased edema and 1-2 weeks – decreased edema and

some tissue atrophysome tissue atrophy 2-3 weeks edema resolved, tissue 2-3 weeks edema resolved, tissue

atrophyatrophy If you can limit volume in initial weekIf you can limit volume in initial week

• ↓ ↓ the rate change over time (same the rate change over time (same volume reached after 3 months)volume reached after 3 months)

• ↑ ↑ wound healingwound healing

What are the options: What are the options: NothingNothing Soft dressings:Soft dressings:

• Elastic Bandaging Elastic Bandaging • Juzo / stump shrinkersJuzo / stump shrinkers

Rigid dressingsRigid dressings• Thigh level rigid plaster dressing without Thigh level rigid plaster dressing without

immediate prosthesisimmediate prosthesis• IPOP – Immediate Post op ProsthesisIPOP – Immediate Post op Prosthesis

Removable Rigid Dressing (RRD)Removable Rigid Dressing (RRD) Compression therapy/RRDCompression therapy/RRD

Soft dressings Soft dressings AdvantagesAdvantages

ease of applicationease of application accessibility to the woundaccessibility to the wound Low Low initialinitial cost cost

Soft dressingsSoft dressings DisadvantagesDisadvantages

High local or proximal pressures impair High local or proximal pressures impair skin survival and healingskin survival and healing

Likelihood of gauze falling offLikelihood of gauze falling off ↑↑eded chance of knee flexion contracture chance of knee flexion contracture ↑↑ed pain →↑ed bedrest, ↓mobility ed pain →↑ed bedrest, ↓mobility ↑↑ed hospital stays ed hospital stays →↑risk of pulmonary →↑risk of pulmonary

complications, stokes, pneumoniacomplications, stokes, pneumonia ↑↑ed health care costs due to ↑ed ed health care costs due to ↑ed

hospital stayshospital stays

Shrinkers Vs BandagingShrinkers Vs Bandaging BandagingBandaging

• application is unreliableapplication is unreliable• Dangerous in terms of pressure distribution Dangerous in terms of pressure distribution

(Puddifoot and associates showed elastic wrap (Puddifoot and associates showed elastic wrap to have the greatest range of pressures and to have the greatest range of pressures and the highest readings)the highest readings)

Shrinkers have been shown to be more Shrinkers have been shown to be more effective than bandaging in decreasing effective than bandaging in decreasing residual limb volumeresidual limb volume

Thigh level rigid plaster dressingThigh level rigid plaster dressingAdvantagesAdvantages

Significantly shorter rehab times Significantly shorter rehab times compared to soft gauze dressingscompared to soft gauze dressings

Protects the residual limb →↓es Protects the residual limb →↓es revision surgeryrevision surgery

↓↓es edema, pain and healing timeses edema, pain and healing times ↑↑es tolerance to weight es tolerance to weight

bearing/early ambulationbearing/early ambulation Holds knee in extension → prevents Holds knee in extension → prevents

flexion contractureflexion contracture

Thigh level rigid plaster dressingThigh level rigid plaster dressingDisadvantagesDisadvantages

More difficult to applyMore difficult to apply Requires skilled Requires skilled

surgical/prosthetic/rehab teamsurgical/prosthetic/rehab team ↑↑ed cost (short term)ed cost (short term) ↓↓ed access for wound inspectioned access for wound inspection Inability to adjust fitInability to adjust fit Immobilises knee into extensionImmobilises knee into extension

Thigh level rigid plaster dressing with Thigh level rigid plaster dressing with IPOPIPOP

AdvantagesAdvantages Simular benefits of no IPOP plus:Simular benefits of no IPOP plus: ↑↑stimulation of circulationstimulation of circulation Weightbearing within 24 hoursWeightbearing within 24 hours

• ↓↓es edema (by ↑ing pressure and pumping es edema (by ↑ing pressure and pumping action of muscles)action of muscles)

↓↓ed time to custom prosthesesed time to custom prostheses Fewer surgical revisionsFewer surgical revisions Emotional/ self imaging benefitsEmotional/ self imaging benefits Rapid healingRapid healing

Thigh level rigid plaster dressing with Thigh level rigid plaster dressing with IPOPIPOP

DisadvantagesDisadvantages

Difficult to inspect woundDifficult to inspect wound Tissue damage – mechanical trauma Tissue damage – mechanical trauma

(particularly vascular patients)(particularly vascular patients) Need a dedicated team/ highly skilledNeed a dedicated team/ highly skilled Unskilled application could lead to disasterUnskilled application could lead to disaster Difficult to control early weight bearingDifficult to control early weight bearing Healing rate studies have shown Ambulate Healing rate studies have shown Ambulate

healing rates to be 20% less than non-healing rates to be 20% less than non-ambulant ambulant

Removable Rigid Dressings (RRD)Removable Rigid Dressings (RRD)AdvantagesAdvantages

Significantly less oedema compared to soft Significantly less oedema compared to soft dressingsdressings

Enhanced wound healing;Enhanced wound healing;• Limited oedema formationLimited oedema formation• Immobilisation of soft tissuesImmobilisation of soft tissues

Healing on average 3 weeks earlier than soft Healing on average 3 weeks earlier than soft dressing managementdressing management

Healing more rapid than IPOPHealing more rapid than IPOP Ability to remove and inspect woundAbility to remove and inspect wound Patient learns donning and doffingPatient learns donning and doffing Permits knee flexionPermits knee flexion Ability to adjust fitAbility to adjust fit

RRD vs Elastic BandagesRRD vs Elastic Bandages Easier to applyEasier to apply Remain secureRemain secure Better stump shrinkage and shapingBetter stump shrinkage and shaping No pressure problemsNo pressure problems Stump protectionStump protection ↓↓ed Length of Stay (LOS) in accute ed Length of Stay (LOS) in accute

hospitalhospital• Average of 9 days instead of 14Average of 9 days instead of 14

Rehabilitation ProsthesesRehabilitation Prostheses Plaster interims - PhysiosPlaster interims - Physios

• Moulded directly onto stumpsMoulded directly onto stumps

LimitationsLimitations Socket designSocket design

• Basically walking on a castBasically walking on a cast• No modifications can be madeNo modifications can be made• Volume adjustments restricted to socksVolume adjustments restricted to socks

Materials (weight, strength etc) Materials (weight, strength etc) • Huge medico legal issuesHuge medico legal issues

Different amputation levelsDifferent amputation levels Heavy patientsHeavy patients

Plaster vs prosthesesPlaster vs prosthesesEvaluation of service - MECRSEvaluation of service - MECRS

CriteriaCriteria AdmissionsAdmissions L.O.SL.O.S No. of socketsNo. of sockets 22ndnd definative definative

in 1in 1stst year year

PlasterPlaster

ProsthesesProstheses

3232 5454

108108 5959

4 4 22

87%87% 00

MECRS service delivery modelMECRS service delivery modelAcute HospitalAcute Hospital

RRD fitted day 0RRD fitted day 0

Days 0-7 acuteDays 0-7 acute

RehabilitationRehabilitation

Day 7 onwardsDay 7 onwards Continue wearing Continue wearing

RRDRRD Day 21 fit shrinkerDay 21 fit shrinker Day 23 fit Rehab Day 23 fit Rehab

prosthesesprostheses

““Postoperative dressing and Postoperative dressing and management strategies for transtibial management strategies for transtibial

amputations: A critical review”amputations: A critical review”Douglas G.Smith et alDouglas G.Smith et al

Consensus on the most effective postoperative Consensus on the most effective postoperative management strategies for TTA is lacking management strategies for TTA is lacking however:however:

Rigid dressings have been shown to significantlyRigid dressings have been shown to significantly• ↓ ↓ edema compared to soft dressingsedema compared to soft dressings• ↓↓rehab times compared to soft dressingsrehab times compared to soft dressings• ↓↓time to initial gait training compared to soft time to initial gait training compared to soft

dressingsdressings

Compression TherapyCompression Therapy

A silicone liner is used for edema and volume A silicone liner is used for edema and volume control and for shaping of the residual limbcontrol and for shaping of the residual limb• allows the prosthetic treatment to start earlier.allows the prosthetic treatment to start earlier.

Three objectives are achieved in this phase:Three objectives are achieved in this phase:

1. Stretching of the soft tissue 1. Stretching of the soft tissue distallydistally

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

3. An even compression that 3. An even compression that decreases proximallydecreases proximally

Due to the Due to the decreasing decreasing thickness of the thickness of the liner walls.liner walls.

Compression TherapyCompression Therapy

Time of use and measure- Time of use and measure- ments are documentedments are documented

Size of the liner is changed Size of the liner is changed when necessary to maintain when necessary to maintain continuous compressioncontinuous compression

GuidelinesGuidelinesDay 1 Day 1 2 x 1h2 x 1hDay 2 Day 2 2 x 2h2 x 2hDay 3Day 3 2 x 3h2 x 3hDay 4 and further.. 2 x 4hDay 4 and further.. 2 x 4h

Compression TherapyCompression TherapyOedema controlOedema control

Graded compression assists with oedema Graded compression assists with oedema managementmanagement

The same level of compression is achieved The same level of compression is achieved regardless of who applies the linerregardless of who applies the liner• In traditional care, both the compression and In traditional care, both the compression and

the quality of the dressing vary, depending on the quality of the dressing vary, depending on who performs the treatment.who performs the treatment.

Improved pain control through the Improved pain control through the increased proprioception.increased proprioception.

Compression TherapyCompression TherapyImproved wound healingImproved wound healing

Reduction of oedemaReduction of oedema Provides occlusive environmentProvides occlusive environment

Considered standard treatment of leg ulcersConsidered standard treatment of leg ulcers Prevents tissue dehydration and cell deathPrevents tissue dehydration and cell death Provides barrier to bacteria Provides barrier to bacteria

Decreases risk of infectionDecreases risk of infection

Compression TherapyCompression Therapy

Further BenefitsFurther Benefits

Shaping of residuum to give optimal Shaping of residuum to give optimal shape for prosthetic fittingshape for prosthetic fitting• Thus reducing prosthetic complicationsThus reducing prosthetic complications

Facilitates early mobilization Facilitates early mobilization Silicone speeds up maturation of Silicone speeds up maturation of

residuum and helps smooth scarresiduum and helps smooth scar

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

Mr B – 4/2/02Mr B – 4/2/02

Mr B 12/2/04Mr B 12/2/04

Once the stitches Once the stitches were removed and were removed and there was no there was no infection found a infection found a silicone liner was silicone liner was used to assist with used to assist with the continuation of the continuation of healing.healing.

Mr B - 3/3/04Mr B - 3/3/04

Healing improved Healing improved as the “hardness” as the “hardness” of the distal end of the distal end reduced reduced

Patient reported Patient reported pain reduction.pain reduction.

Mr B – Today!Mr B – Today!

Launceston General Launceston General Hospital Pilot TrialHospital Pilot Trial

May 2003 May 2003 Prem Anandam Prem Anandam

Full pilot trial can be found on:Full pilot trial can be found on:www.monash.edu.au/rehabtech/www.monash.edu.au/rehabtech/

QUESTIONS?QUESTIONS?

For related Post Op references or any For related Post Op references or any further information please contact me further information please contact me

at APC prosthetics.at APC prosthetics.02-9890-812302-9890-8123

oror cameron@advcancedprosthetic.com.aucameron@advcancedprosthetic.com.au

ThankThank youyou

Thank YouThank You