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Post Op Management Options

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					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
                                         Orthopaedic
rehabilitation after                       surgeon
amputation requires a          Occupational
                                 therapist
                                                     Nurse
multi-disciplinary                        The
approach.                                Amputee
                                                      Physio-
                                Prosthetist
                                                     therapist
                                        Rehabilitation
                                         Consultant


                        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
      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:
    • 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
   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

                                 Plaster
         Criteria             Prostheses
   Admissions                32        54
   L.O.S                     108       59
   No. of sockets             4         2
   2nd definative             87%       0
    in 1st year
    MECRS service delivery model
Acute Hospital              Rehabilitation

   RRD fitted day 0      Day 7 onwards
                          Continue wearing
   Days 0-7 acute         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                        Time of use and measure-
Day   1    2x   1h                     ments are documented
Day   2    2x   2h
Day   3    2x   3h                    Size of the liner is changed
Day   4   and   further.. 2 x 4h       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.
          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
Thank You

				
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